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  1. Indications

      1. To provide mechanical respiratory support.

      1. To obtain aspirates for culture.

      1. To assist in bronchopulmonary hygiene ("pulmonary toilet").

      1. To alleviate upper airway obstruction (subglottic stenosis).

      1. To clear the trachea of meconium.

      1. Selective bronchial ventilation.

      1. Diaphragmatic hernia.

      1. To administer medications in the emergency setting before intravenous access is established.

  2. Equipment. A correct endotracheal tube (Table 28–1), a pediatric laryngoscope handle with a Miller blade ("00" blade for extremely preterm infants, "0" blade for preterm infants, 1 blade for full-term infants; straight blades are preferred over curved blades), a bag-and-mask apparatus, an endotracheal tube adapter, a suction apparatus, tape, scissors, a malleable stylet (optional), personal protection equipment, and tincture of benzoin. A bag-and-mask apparatus with 100% oxygen should be available at the bedside. The mechanical ventilator should be checked and ready. Monitoring with electrocardiogram and pulse oximetry is essential if time permits.

  3. Procedure

      1. Oropharyngeal intubation is more commonly performed emergently and is described here. Nasotracheal intubation is more commonly performed in the elective setting or if anatomy precludes the oral route. The endotracheal tube should be precut to eliminate dead space (cut to 15 cm). Some newer tubes are marked "oral" or "nasal" and should be cut appropriately.

      1. Be certain that the light source on the laryngoscope is working before beginning the procedure. Place the stylet (if used) in the endotracheal tube. Flexible stylets are optional but may help guide the tube into position more efficiently. Be sure the tip of the stylet does not protrude out of the end of the endotracheal tube.

      1. Place the infant in the "sniffing position" (with the neck slightly extended); a small roll behind the neck may help with positioning. Hyperextension of the neck in infants may cause the trachea to collapse. The infant's head should be at the same level as the operator.

      1. Cautiously suction the oropharynx as needed to make the landmarks clearly visible.

      1. Preoxygenate the infant with a bag-and-mask device, and monitor the heart rate, color, and pulse oximeter. To limit hypoxia, limit each intubation attempt to ≤20 sec before reoxygenation.

      1. Hold the laryngoscope with your left hand. Insert the scope into the right side of the mouth, and sweep the tongue to the left side. Some practitioners move the tongue to the left by using the index finger of the right hand placed alongside the head. To perform this maneuver, stabilize the head and hold the mouth open.

      1. Advance the blade a few millimeters, passing it beneath the epiglottis.

      1. Lift the blade vertically to elevate the epiglottis and visualize the glottis (Figure 28–1). Note: The purpose of the laryngoscope is to lift the epiglottis vertically, not to pry it open. To better visualize the vocal cords, an assistant may place gentle external pressure on the thyroid cartilage.

      1. Pass the endotracheal tube along the right side of the mouth and down past the vocal cords during inspiration. It is best to advance the tube only 2–2.5 cm into the trachea to avoid placement in ...

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