endotracheal intubation
TRANSCRIPT
ENDOTRACHEAL ENDOTRACHEAL INTUBATIONINTUBATION
NEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHM
BIRTHBIRTHBIRTHBIRTH
• Term gestation?• Amnlotic fluid clear?• Breathing or crying?• Good muscle tone?u
• Term gestation?• Amnlotic fluid clear?• Breathing or crying?• Good muscle tone?u
• Provide warmth• Position clear airway* (as necessary)• Dry, stimulate, reposition
• Provide warmth• Position clear airway* (as necessary)• Dry, stimulate, reposition
Routine Care• Provide warmth• Clear airway if needed• Dry• Assess color
Routine Care• Provide warmth• Clear airway if needed• Dry• Assess color
Evaluate respiration heart rate and colorEvaluate respiration heart rate and color
Give supplementary oxygen
Give supplementary oxygen
Observational CareObservational Care
Provide positive-pressure ventilation*Provide positive-pressure ventilation* Post-resuscitation carePost-resuscitation care
• Provide positive-pressure ventilation*
•Administer chest compression
• Provide positive-pressure ventilation*
•Administer chest compression
Administer epinephrine and/ or volume*Administer epinephrine and/ or volume*
* Endotracheal intubation may be considered at several steps
* Endotracheal intubation may be considered at several steps
HR <60
HR <60 HR >60
Persistent cyanosis Effective
Ventilation, HR>100 & Pink
Pink Breathing, HR>100
but cyanosis
Breathing, HR>100 & Pink
Yes
No
Apneic or HR <100
Approximate Time
30 sec
30 sec
30 sec
Indications for Indications for intubationintubation
Meconium suctioning in non vigorous Meconium suctioning in non vigorous babybaby
Diaphragmatic herniaDiaphragmatic hernia Prolonged PPVProlonged PPV Ineffective B & MVIneffective B & MV ElectiveElective
< 1Kg< 1Kg with CCwith CC for medicationfor medication
Intubation equipmentIntubation equipment
Preparing laryngoscopePreparing laryngoscope
No. 1 for full termNo. 1 for full term No. 0 for preterm / LBWNo. 0 for preterm / LBW No. 00 for extremely preterm No. 00 for extremely preterm
(optional)(optional)
Selecting endotracheal Selecting endotracheal tubetube
Tube SizeTube Size WeightWeight Gest. AgeGest. Age
2.5 (ID mm)2.5 (ID mm) <1000 gm<1000 gm < 28 wks< 28 wks
3.0 (ID mm)3.0 (ID mm) 1000-2000 1000-2000 gmgm
28-34 wks28-34 wks
3.5 (ID mm)3.5 (ID mm) 2000-3000 2000-3000 gmgm
35-38 wks35-38 wks
4.0 (ID mm)4.0 (ID mm) >3000 gm>3000 gm > 38 wks> 38 wks
ID=Internal Diameter
Preparing endotracheal Preparing endotracheal tubetube
Shorten the tube to 13 cmShorten the tube to 13 cm Replace ET tube connectorReplace ET tube connector Insert stylet (optional)Insert stylet (optional)
Additional itemsAdditional items
TapeTape For securing the tubeFor securing the tube
Suction equipmentSuction equipment DeLee mucus trap or mechanical suctionDeLee mucus trap or mechanical suction
OxygenOxygen For free flow oxygen during intubationFor free flow oxygen during intubation For Use with the resuscitation bagFor Use with the resuscitation bag
Resuscitation Bag and MaskResuscitation Bag and Mask To ventilate the infant in between intubationTo ventilate the infant in between intubation To check tube placementTo check tube placement
Positioning the infantPositioning the infant
On a flat surface, head in midline On a flat surface, head in midline and neck slightly extendedand neck slightly extended
Optimal viewing of glottisOptimal viewing of glottis
Visualizing the Glottis with Visualizing the Glottis with LaryngoscopeLaryngoscope
Preparing for insertionPreparing for insertion Stand at the head end of the infantStand at the head end of the infant
Hold the laryngoscope in your left handHold the laryngoscope in your left handStabilize the infant’s head with right handStabilize the infant’s head with right hand
Introducing BladeIntroducing Blade Slide it over the tongue with the tip of the blade resting Slide it over the tongue with the tip of the blade resting
on the valleculaon the vallecula
Visualizing Glottis : Lift BladeVisualizing Glottis : Lift Blade Lift it slightly, thus lifting the tongue out of the way to Lift it slightly, thus lifting the tongue out of the way to
expose the pharyngeal areaexpose the pharyngeal area
Vocal cord guideVocal cord guide
Tip to lip distance Tip to lip distance (6+wt. in kg)(6+wt. in kg)
WeightWeight DistanceDistance
1 kg1 kg 7 cm7 cm
2 kg2 kg 8 cm8 cm
3 kg3 kg 9 cm9 cm
Confirming ET tube Confirming ET tube placementplacement
Correct placementCorrect placement ETCOETCO2 2 - the recommended method - the recommended method
SignsSigns Bilateral breath soundsBilateral breath sounds Equal breath soundsEqual breath sounds Rise of the chest with each ventilationRise of the chest with each ventilation No air heard entering stomachNo air heard entering stomach No gastric distentionNo gastric distention
Confirmation of tip position in Confirmation of tip position in tracheatrachea
Chest X-ray: tip at TChest X-ray: tip at T22
Tube in Rt. Main Tube in Rt. Main bronchusbronchus
Breath sounds only on right Breath sounds only on right chestchest
No air heard entering stomachNo air heard entering stomach No gastric distentionNo gastric distention
Action: Withdraw the tube, recheckAction: Withdraw the tube, recheck
Tube in esophagusTube in esophagus
No breath sounds heardNo breath sounds heard Air heard entering stomachAir heard entering stomach Gastric distention may be seenGastric distention may be seen No mist in tubeNo mist in tube No CONo CO2 2 in exhaled airin exhaled air
Action : Remove the tube, oxygen the infant Action : Remove the tube, oxygen the infant with a bag and mask, reintroduce ET tubewith a bag and mask, reintroduce ET tube
Three actions after Three actions after intubationintubation
1.1. Note the cm. Mark on the Note the cm. Mark on the tube at level of the upper liptube at level of the upper lip
2.2. Secure the tube to the infant’s Secure the tube to the infant’s faceface
3.3. Shorten tube 4 cm. from the Shorten tube 4 cm. from the lip marginlip margin
Complications of Complications of intubationintubation
HypoxiaHypoxia
BradycardiaBradycardia
ApneaApnea
PneumothoraxPneumothorax
Soft tissue injurySoft tissue injury
InfectionInfection
Minimizing hypoxia Minimizing hypoxia during intubationduring intubation
Providing free-flow Providing free-flow oxygen (Assistant’s oxygen (Assistant’s responsibility)responsibility)
Limiting each Limiting each intubation attempt to intubation attempt to 20 seconds20 seconds
LMA – its role in neonatal LMA – its role in neonatal resuscitationresuscitation
Effective for ventilation during Effective for ventilation during resuscitation in term and near term resuscitation in term and near term newbornsnewborns
Used by trained care providersUsed by trained care providers NOT TO BE USED IN:NOT TO BE USED IN:
In the setting of meconium stained amniotic In the setting of meconium stained amniotic fluidfluid
When chest compression is requiredWhen chest compression is required In VLBW babiesIn VLBW babies For delivery of medicationsFor delivery of medications