Neonatal endotracheal intubation: indications and tube selection
THE CONTEXT
Only a small proportion of asphyxiated neonates require endotracheal intubation, a skill that needs consistent practice.
Indications
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Intubation is indicated when heart rate remains below 100 bpm despite 30 seconds of effective positive pressure ventilation, when prolonged bag-and-mask ventilation is required, or when bag-and-mask ventilation is ineffective.
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Other indications include the need for chest compressions, suspected diaphragmatic hernia, and airway blockage by thick secretions.
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Intubation may also be considered for administering epinephrine.
Tube characteristics and size
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The tube should have a uniform diameter without tapering near its tip, a vocal cord guide, and centimeter markings. Size depends on neonatal weight or gestation.
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A 2.5 mm internal diameter is listed for weight below 1000 g or gestation below 28 weeks.
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A 3.0 mm internal diameter is listed for 1000–2000 g or 28–34 weeks; 3.5 mm for 2000–3000 g or 34–38 weeks; and 4.0 mm for above 3000 g or above 38 weeks.
Depth, landmarks, and preparation
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Determine insertion depth using nasotragal length plus 1 cm.
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Place the black vocal cord guide at the level of the vocal cords to help position the tube tip above the tracheal bifurcation.
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Use a neonatal laryngoscope with a straight blade: size 0 for preterm neonates and size 1 for term neonates. Attach the appropriate blade and turn on the light before intubation.
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Keep the infant's head in the midline with the neck slightly extended, and hold the laryngoscope in the left hand.