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29: Endotracheal Intubation and Extubation

I. INDICATIONS

  1. Provide mechanical respiratory support.

  2. Obtain aspirates for culture.

  3. Assist in bronchopulmonary hygiene (“pulmonary toilet”).

  4. Alleviate upper airway obstruction (subglottic stenosis).

  5. Clear the trachea of meconium.

  6. Perform selective bronchial ventilation.

  7. Assist in the management of congenital diaphragmatic hernia (to avoid bowel distention).

  8. Administer medications (“NEAL” or “LANE” see Section III.O) in the emergency setting while intravenous access is established.

  9. Administration of surfactant.

  10. Management of apnea.

II. EQUIPMENT

Correct endotracheal tube (ETT) and suction catheter (Table 29–1), 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 [Miller blades] are preferred over curved blades [Macintosh blade] because of better visualization), an ETT adapter, a suction apparatus, suction catheters, tape, scissors, tincture of benzoin, a malleable stylet (optional), personal protection equipment, bag-and-mask apparatus with 100% oxygen, and pressure manometer 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. A colorimetric device or capnograph to confirm the position of the tube. Suctioning equipment and catheters.

Table 29–1.GUIDELINES FOR ENDOTRACHEAL TUBE SIZE, DEPTH OF INSERTION, AND SUCTION CATHETER SIZE BASED ON WEIGHT AND GESTATIONAL AGE
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Table 29–1.GUIDELINES FOR ENDOTRACHEAL TUBE SIZE, DEPTH OF INSERTION, AND SUCTION CATHETER SIZE BASED ON WEIGHT AND GESTATIONAL AGE
Weight (g) Gestational Age (wk) Endotracheal Tube Size, Inside Diameter (mm)

Depth of Insertion (tip of tube to upper lipa in cm)
<1000 <28 2.5 6 (if <750 g)–7
1000–2000 28–34 3.0 7–8
2000–3000 34–38 3.5 8–9
>3000 >38 3.5–4.0 9 (3000 g) –10 (4000 g)

a“Tip to lip.”

Data from guidelines from Kattwinkel J. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove, IL: American Heart Association/American Academy of Pediatrics; 2011.

III. PROCEDURE

  1. Orotracheal versus nasotracheal intubation

    1. Orotracheal intubation. More commonly performed emergently and is described here. It is easier and quicker than nasotracheal intubation. The orotracheal tube should be precut to eliminate dead space (cut to 15 cm).

    2. Nasotracheal intubation. More commonly performed in the elective setting or if anatomy precludes the oral route. Nasotracheal intubation can be used in overly active infants or in those infants who have copious secretions. It offers tube stability but can be associated with an increase in postextubation atelectasis and a risk of nasal damage. In nasotracheal intubation the procedure is the same except the lubricated nasotracheal tube is passed into the nostril, then pharynx and into cords following to the back of the throat. Small doses of 2% lidocaine gel can be used.

    3. Cochrane review. Did not find any differences in the effect of nasal versus oral intubation.

  2. Pain/premedication

    1. Premedication is not necessary in the case of an emergency intubation in the delivery room or ...

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