ENDOTRACHEAL INTUBATION POLICY

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Scott Mathews
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1 POLICY Indications: Ineffective ventilation with mask and t-piece, or mask and bag technique Inability to maintain a patent airway Need or anticipation of need for prolonged ventilation Need for endotracheal suctioning Route for instillation of certain medications (e.g. epinephrine, surfactant) To deliver mechanical ventilation manually or mechanically Applicability: Endotraceal intubation occurs within the Neonatal Program. Discipline Senior physician in attendance Physician responsible for airway management Registered Respiratory Therapist (RRT) Registered Nurse (RN) Pharmacist Responsibilities The senior physician in attendance directs the team during endotracheal intubation. Write orders, suction trachea during laryngoscopy, laryngoscopy, intubate and confirm tube placement by identifying that the endotracheal tube (ETT) black line is at the level of the infant s vocal cords. May delegate tasks such as ventilation or suctioning. Ensure all respiratory equipment is set up and operational; position and contain the infant in a developmentally supportive manner and to minimize heat loss; being the primary assistant in all airway management tasks, inclusive of bag-mask ventilation. Cross reference ETT position with table below for recommended ETT position. ETT stabilization. When able hold for chest x-ray. Prepare and administer pre-medication (scanning intubation drug orders to NICU Satellite Pharmacy, intravenous placement and drug administration); empty infant s stomach; infant monitoring and charting; position the infant, and thermoregulation. Bring the intubation drugs to the bedside and verifying dosages Recommended ETT poisition when infant s weight is known: ETT length at lips Actual weight (kg) (centimeters) Recommended initial ETT position at birth when weight is unknown ETT length at lips (centimeters) Corrected gestation (weeks) Page 1 of 5

2 PROCEDURE Gather Equipment 1. Mask (appropriate size) and t-piece or resuscitation bag attached to oxygen 2. Laryngoscope handle and correct size blade. Ensure blade attached securely to handle and light is bright. Blade Usage Description No. 00 Miller Extremely preterm (<1000 gm) Straight fiberoptic No. 0 Miller Preterm ( gm) Straight fiberoptic No. 1 Miller Term (>3000 gm) Straight fiberoptic No. 1 Macintosh No. 2 Macintosh No. 1 Oxford For anatomically challenged infants. Rarely used. Used for infants with large tongue. Rarely used in the Neonatal Program. Curved fiberoptic Curved fiberoptic (stored in RT room) Straight fiberoptic with larger blade at the bottom 3. Suction catheter ETT Size (mm) Suction Catheter Size Fr Fr Fr 3.5 to Fr 4. Suction set to 100 mm Hg 5. Endotracheal Tube Weight (gm) ETT Size (mm) < to > Carbon dioxide (CO 2 ) detector 6. Stethoscope 8. ETT holder (Neobar); skin barriers (Comfeel, Tegaderm) are optional 9. Stylet for oral intubation 10. Cloth tape RN x 2, RRT and Physician Preparation 1. Maintain/restore physiological stability by taking control of ventilation (mask-and-tpiece or bag ventilation) 2. Empty stomach Adequate ventilation can be provided by mask-and-tpiece or bag ventilation in most situations, allowing time for preparation and thus avoiding the need for a hectic intubation Page 2 of 5

3 Remove orogastric tube after emptying stomach to ensure face mask seal 3. Provide thermal support (warm blanket, radiant heater) 4. Obtain baseline vital signs, including blood pressure 5. Pre-medicate if the infant s condition permits Physician s order required Venous access required Pharmacist required to bring intubation drugs and verify drug doses Medication Administration Pre-medication is not used during intubation of infants in the delivery room or in emergencies Muscle relaxation provides the best possible intubating conditions and is recommended (may be contraindicated in critical airway) Caution regarding use of fentanyl: Rapid administration can cause chest wall rigidity / laryngeal spasm Chest wall rigidity can be treated with a muscle relaxant e.g. succinylcholine Physician must be present at bedside prior to drug administration and remain at the bedside until intubation completed Medication / Flush (administer in the exact order below) Route of Administration PIV, UVC, CVC Manual Push PICC IV Pump Onset of Action Duration Step 1: Clamp off current infusion at the T- connector Step 2: fentanyl 2 mcg/kg 3 minutes 3 minutes less than 1 minute 30 to 60 minutes Step 3: atropine 20 mcg/kg 3 minutes 3 minutes 1 to 2 minutes observe for increased heart rate Step 4: 0.9% NaCl 1 ml Step 5: succinylcholine 2 mg/kg Step 6: 0.9% NaCl 1 ml 30 seconds 1 minute rapid rapid 1 minute 1 minute 30 to 60 seconds 4 to 6 minutes Key: IV = intravenous mcg = microgram ml = milliliters kg = kilogram mg = milligram NaCl = Sodium Chloride Page 3 of 5

4 Procedure 6. Activate monitor QRS volume and OXY CRG 7. Provide containment, positioning infant s head, arms and legs midline; neck slightly extended 8. Provide mask-and-t-piece or bag ventilation to maintain/restore physiological stability, and preoxygenation 9. Attempt intubation when heart rate is > 100 beats per minute (bpm) and SpO 2 is 88 to 95% 10. Insert ETT to black mark level with vocal cords Select QRS volume and desired number Change monitor display to OXY CRG May use shoulder roll to extend neck Provide only enough oxygen to maintain acceptable saturation, taking care to avoid hyperoxia Avoid SpO 2 > 95% Abort the intubation attempt if SpO 2 < 70 to 80% or heart rate < 70 to 80 bpm. When using atropine, focus on SpO 2 as the heart rate may remain normal or near normal despite significant hypoxemia. Provide mask-and-t-piece or bag ventilation to restore physiological stability. If having difficulty, get help. Each physician should request assistance after two failed attempts (laryngoscopy) Check centimeter mark at lip corresponding with recommended initial ETT position table above 11. Attach CO 2 detector between ETT and t- piece or bagging system. Observe for cycling of colour (purple/yellow) with respiration 12. Observe restoration of normal heart rate Detection of CO 2 reliably indicates endotracheal intubation. 13. Auscultate and observe chest for breath sounds and chest movement Post Procedure 14. Secure ETT by taping to fixation device (Neobar) 15. X-ray with infant s head in a neutral position to confirm ETT placement 16. Adjust ETT position if necessary and tape securely. Document The ETT should align with the thoracic vertebrae T1 T2 Nursing Flowsheet; Physician s Progress s; Respiratory Therapy Ventilation Flowsheet Reason for intubation Number of attempts and by whom (an intubation attempt is defined as insertion of laryngoscope into infant s mouth) Page 4 of 5

5 Size of ETT Infant s tolerance of procedure DOCUMENTATION Nursing Flowsheet Physician s Progress s Respiratory Therapy Ventilation Flowsheet Patient Safety Learning System (PSLS) if patient concern or harm occurred as a result of intubation REFERENCES Kempley, S. T., Moreiras, J. W., & Petrone, F. L. (2008). Endotracheal tube length for neonatal intubation. Resuscitation, 77(3), Kumar, P., Denson, S.E., Mancuso, T.J., and Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. (2010), Clinical Report - Premedication for Nonemergency Endotracheal Intubation in the Neonate. Pediatrics, 125(3), Neonatal Program. Neonatal Drug Dosage Guidelines. Accessed October aspx Page 5 of 5

This interdisciplinary clinical support document provides guidelines for the safe establishment of an artificial airway.

PURPOSE This interdisciplinary clinical support document provides guidelines for the safe establishment of an artificial airway. POLICY STATEMENTS Endotracheal intubation will be performed by the Most