Chapter 33: Endotracheal Intubation and Extubation

I. INDICATIONS

1. Provide mechanical respiratory support.

2. Administration of surfactant.

3. Management of apnea.

4. Alleviate upper airway obstruction (subglottic stenosis).

5. Assist in the management of congenital diaphragmatic hernia to avoid bowel distention.

6. Administer medications (see Section III.R.) in the emergency setting.

7. Obtain aspirates for culture.

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

9. Selective bronchial ventilation.

II. EQUIPMENT

Correct endotracheal tube (ETT) (Table 33–1), a pediatric laryngoscope handle with a Miller blade (“No. 00” blade for extremely preterm infants, “No. 0” blade for preterm infants, “No. 1” blade for term infants), an ETT adapter, a suction apparatus, suction catheters, tape, scissors, tincture of benzoin, a malleable stylet (optional), personal protection equipment, a stethoscope, bag-and-mask apparatus, humidified oxygen/air source and blender, and pressure manometer should be available at the bedside. A colorimetric device or capnograph should be available to confirm the position of the tube. The mechanical ventilator set up should be ready. Cardiorespiratory monitoring is essential if not an emergent intubation.

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.

   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 similar except the lubricated nasotracheal tube is passed into the nostril and then pharynx and into cords following to the back of the throat. Small doses of intranasal 2% lidocaine gel can be used. Postextubation atelectasis maybe more frequent after nasal intubation, but one route of intubation does not seem to be preferable over the other.

2. Video laryngoscopy. A newer technique that uses a video laryngoscope (eg, GlideScope AVL Preterm/Small Child Video Laryngoscope; Verathon) to assist in the placement of the ETT. There is a high-resolution micro camera mounted on the blade that is connected to a small portable digital monitor. It is a form of indirect laryngoscopy that allows enhanced visualization of the glottis. It has also been used in teaching neonatal trainees with improvement in intubation success rates. A Cochrane review (2015) notes there was insufficient evidence to recommend or refute the use of video laryngoscopy for endotracheal intubation in neonates.

3. Pain/premedication

   1. Premedication is not necessary for an emergency intubation in the delivery room or after an acute deterioration in a neonatal intensive care unit. It is also not necessary in some cases of infants with upper airway anomalies (such as Pierre Robin sequence) or in infants in whom the instrumentation of the airway is presumed to be extremely difficult.

   2. If intravenous access is not available, the intramuscular route should be considered for premedications.

   3. Premedication can decrease pain and discomfort ...