NRP Skills Stations Performance Skills Station OR Integrated Skills Station STATION: Assisting with and insertion of endotracheal tube (ETT) Equipment: NRP algorithm, MRSOPA table, medication chart, SpO 2 table Warm warmers, towels, blankets Clear Airway bulb and/or wall suction 10 or 12F suction catheters, suction tubing 5F or 6F for ETT suctioning meconium aspirator Auscultate stethoscope Oxygenate Air & oxygen sources, blender, oxygen tubing pulse oximeter & probes Ventilate t-piece, self-inflating, flow-inflating devices term & preterm masks 8F feeding tube & 10 or 20mL syringe Intubate laryngoscope, 0 & 1 blades ETT 2.5, 3, 3.5, 4 stylet End tidal CO 2 detector LMA (size 1) & 5mL syringe Other Mannequin, SpO2 & HR cue cards or metronome, air entry cue cards Clock with second hand tape Objectives: Brief: 1. Identify the newborn who requires endotracheal intubation during a resuscitation 2. Identify the appropriate equipment & sizes, how to check & prepare it 3. Demonstrate correct technique for performing/assisting with endotracheal intubation and administrating PPV 4. Demonstrate correct technique for suctioning from the trachea of a non-vigorous baby At this station you will learn the principles & techniques related performing/assisting with endotracheal intubation. You will be given a brief scenario and asked to perform a resuscitation just as you would in real life. The doll does not breathe spontaneously and does not have audible breath sounds unless you are giving PPV, nor does it have heart sounds or a palpable pulse but I would like you to actually perform assessments for these signs as you would on a real baby. I will provide you with verbal feedback about the status of the baby s breathing and tone. I will use the SpO 2 /HR flashcards (or metronome) to give you feedback about the heart rate and oxygen saturation when correct actions are performed. I will use the air entry cue cards when you listen for air entry. You will practice this skill with mask ventilation being performed by an assistant. We will pause from time to time for discussion; however please feel free to ask for help or stop and ask questions at any time. Alberta Perinatal Health Program Page 1 of 8
Action: ETT insertion Participant was able to: 1. Identify indications for endotracheal intubation indicated by * on NRP flowchart presence of meconium and infant is not vigorous improve efficacy of ventilation if mask ventilation is not effective improve efficacy of ventilation if mask ventilation is required for more than a few minutes facilitate coordination of chest compressions and ventilation and maximize efficiency of each ventilation improve ventilation in special conditions - extreme prematurity - surfactant administration - suspected diaphragmatic hernia 2. Check all equipment is in place (see equipment list) a) suction equipment bulb suction 10F, 12F for suctioning pharynx 5F or 6F for suctioning endotracheal tube meconium aspirator suction tubing suction set at 80-100 mm Hg when occluded b) laryngoscope straight blades preferred use 00 for extremely preterm infant extra batteries and bulb c) endotracheal tubes < 1000 grams = < 28 wks = 2.5 mm 1000 2000 grams = 28-34 wks = 3.0 mm 2000 3000 grams = 34-38 wks = 3.5 mm >3000 grams = - 38 weeks = 4.9 mm stylet inserted correctly CO 2 detector tape and scissors d) other equipment for PPV delivery self-inflating bag with O2 reservoir or T-piece resuscitator with tubing pulse oximeter and infant probe oxygen blender airways laryngeal mask with 5 ml syringe e) additional supplies: stethoscope clock/timer 3. Identifies anatomical structures on the intubation model 4. Demonstrates proper handling of the laryngoscope during intubation Alberta Perinatal Health Program Page 2 of 8
places laryngoscope in left hand stabilize infant s head and inserts blade carefully to base of tongue requests suction if needed lift blade and look for landmarks 5. Intubates (and uses the meconium aspirator) positions infant in sniffing position inserts tube from right side, does not insert tube down center of laryngoscope blade places endotracheal tube through vocal cords and suctions meconium using the meconium aspirator aligns vocal cord guide with vocal cords removes laryngoscope (and stylet) while firmly holding tube against baby's palate 6. Demonstrates intubation and leaves the tube in place holds tube against baby's palate with one hand and PPV device with other hand and resumes ventilation places CO2 detector on ET tube ensures O2 is running notes time taken to intubate (<30 sec) 7. Checks for correct placement of endotracheal tube observe tube passing through vocal cords mist in tube during exhalation CO 2 detector changed color symmetric chest movement with each breath listen for bilateral breath sounds (none over the stomach area) increasing heart rate increase in Spo 2 no gastric distention with PPV chest X-ray 8. Ensures correct depth of insertion, how to cut ETT and how to tape it in place depth of ET insertion in cm from upper lip using infant weight: 1 kg = 7 cm 2 kg = 8 cm 3 kg = 9 cm 4 kg = 10 cm cut ET tube diagonally can reinsert end piece hook up T-piece or self-inflating bag tape ET tube from both directions Alberta Perinatal Health Program Page 3 of 8
9. Lists complications associated with endotracheal intubation hypoxia bradycardia / apnea pneumothorax contusions or lacerations of tongue, gums or airway perforation of trachea or esophagus constructed endotracheal tube infection 10. Documentation of event times interventions (in order of occurrence) infant response to each intervention support for the family Reflective Learning Questions: These are sample questions for NRP Instructors to consider. Instructors can add additional questions. 1. What went well? 2. How do you determine if the newborn born with meconium-stained fluid requires tracheal suction? 3. What difficulties did you encounter in inserting ETT? 1. What are the indications for intubation? (meconium in the amniotic fluid and baby has depressed HR/breathing/tone *intubate as first step; if PPV isn t working despite corrective measures; if PPV is required beyond a few minutes; if compressions are needed to facilitate coordination with ventilation; special indications such as extreme prematurity, need for surfactant, suspected CDH. 2. How do you determine what size of ETT to use and how deep should it be inserted? <1 Kg <28 weeks 2.5 Can use the black vocal cord 1-2 Kg 28-34 3 marker(s) but be aware that the tip 2-3 Kg weeks 34-38 3.5 will be closer to the carina in prems OR use the weight in Kg + 6 = depth >3 Kg weeks >38 weeks 4 in cm ATL OR tip to lip 123 (weight in Kg)-789 3. Describe how to prepare the equipment (select blade size 0 = prem 1 = term & check light; prepare suction (80-100 mmhg) with 10F catheter & have 5 & 6F catheters to suction ETT, have mec aspirator; prepare PPV device & attach to Oxygen (flow 5-10L/min), manometer; prepare for oximetry, have ETCO 2 ready) 4. Describe the correct positioning for intubation & anatomic landmarks ( sniffing with the neck slightly extended & head in midline know valeculla, epiglottis, vocal cords, glottis) What happens with hyperextension? (airway too anterior, only see bottom of vocal cords) hyperflexion? (can only see posterior pharynx, airway to posterior) What if blade is in too far? Alberta Perinatal Health Program Page 4 of 8
(likely see esophageal walls) not far enough? (will only see tongue or posterior pharynx) what tricks can improve the view? (flex/extend, blade in/out, cricoid pressure) 5. Why do we insert the blade/ett into the right side of the mouth? (to keep the view unobstructed) 6. How do you know if the ETT is correctly placed? (gold standard: ETCO 2 color change AND improving heart rate; visualize the tube between the cords; mist in the tube with PPV; visible chest rise & stomach not distending; auscultation positive over chest not stomach) What if you don t see color change on the ETCO 2? (not in; inadequate PPV; DOPE, epinephrine in the ETT can turn the ETCO 2 yellow first step: direct visualization with laryngoscope to see if in) 7. What are the indications for intubation/aspiration for meconium and describe how it is done. (meconium stained amniotic fluid AND baby is not vigorous ie. HR < 100, depressed tone/breathing ** repeat if & only if mec was suctioned from below the cords, HR ok and you are fast!) 8. What are potential complications of intubation? (hypoxia/bradycardia, pneumothorax, contusions/lacerations of the tongue/gums/airway, perforation of the trachea/esophagus, obstruction of the endotracheal tube, infection) Alberta Perinatal Health Program Page 5 of 8
Action: Assisting with ETT insertion Participant was able to: 1. Identify indications for endotracheal intubation indicated by * on NRP flowchart presence of meconium and infant is not vigorous improve efficacy of ventilation if mask ventilation is not effective improve efficacy of ventilation if mask ventilation is required for more than a few minutes facilitate coordination of chest compressions and ventilation and maximize efficiency of each ventilation improve ventilation in special conditions - extreme prematurity - surfactant administration - suspected diaphragmatic hernia 2. Check all equipment is in place (see equipment list) a) suction equipment bulb suction 8F, 10F, 12F for suctioning pharynx 5F or 6F for suctioning endotracheal tube meconium aspirator suction tubing suction set at 80-100 mm Hg when occluded b) laryngoscope straight blades preferred use 00 for extremely preterm infant extra batteries and bulb c) endotracheal tubes < 1000 grams = < 28 wks = 2.5 mm 1000 2000 grams = 28-34 wks = 3.0 mm 2000 3000 grams = 34-38 wks = 3.5 mm >3000 grams = - 38 weeks = 4.9 mm stylet CO 2 detector tape and scissors d) other equipment for PPV delivery self-inflating bag with O2 reservoir or T-piece resuscitator with tubing pulse oximeter and infant probe oxygen blender airways laryngeal mask with 5 ml syringe e) additional supplies: stethoscope clock/timer scissors and tape 3. Demonstrate proper handling of the intubation equipment during procedure hands intubator functioning laryngoscope with appropriately sized blade provides intubator correctly sized ETT with sylet (correctly placed into ETT) has other equipment ready for use (meconium aspirator, suction Alberta Perinatal Health Program Page 6 of 8
equipment, bagger or T-piece resuscitator, stethoscope, CO2 detector, scissors, tapes) makes ETT tapes 4. Demonstrate skills associated with assisting with an intubation positions newborn s head monitor 30 second time frame for intubation provides suction (and catheter) as intubator requests attaches meconium aspirator device to suction tubing attaches meconium aspirator divide to endotracheal tube taps out heart rate (if no other audio HR from pulse oximeter available) applies cricoid pressure if requested remove mask from PPV device attach end-tidal CO2 detector attach PPV to CO2 detector resumes PPV hands off PPV device to intubator so that intubator is holding both the ETT and the PPV device provides ETT tapes to intubator 5. Record procedure notes time taken to intubate (<30 sec) records infant s response to procedure 6. List complications associated with endotracheal intubation hypoxia bradycardia / apnea pneumothorax contusions or lacerations of tongue, gums or airway perforation of trachea or esophagus constructed endotracheal tube infection 7. Documentation of event interventions (in order of occurrence) infant response to each intervention support for the family Reflective Learning Questions: These are sample questions for NRP Instructors to consider. Instructors can add additional questions. 1. What went well? 2. How do you determine if the newborn born with meconium-stained fluid requires tracheal suction? 3. What difficulties did you encounter in inserting ETT? 1. What are the indications for intubation? (meconium in the amniotic fluid and baby has depressed HR/breathing/tone *intubate as first step; if PPV isn t working despite corrective measures; if PPV is required beyond a few minutes; if compressions are needed to facilitate coordination with ventilation; special indications such as extreme prematurity, need for surfactant, suspected CDH. Alberta Perinatal Health Program Page 7 of 8
2. How do you determine what size of ETT to use and how deep should it be inserted? <1 Kg <28 weeks 2.5 Can use the black vocal cord 1-2 Kg 28-34 3 marker(s) but be aware that the tip 2-3 Kg weeks 34-38 3.5 will be closer to the carina in prems OR use the weight in Kg + 6 = depth >3 Kg weeks >38 weeks 4 in cm ATL OR tip to lip 123 (weight in Kg)-789 3. Describe how to prepare the equipment (select blade size 0 = prem 1 = term & check light; prepare suction (80-100 mmhg) with 10F catheter & have 5 & 6F catheters to suction ETT, have mec aspirator; prepare PPV device & attach to Oxygen (flow 5-10L/min), manometer; prepare for oximetry, have ETCO 2 ready) 4. Describe the correct positioning for intubation & anatomic landmarks ( sniffing with the neck slightly extended & head in midline know valeculla, epiglottis, vocal cords, glottis) What happens with hyperextension? (airway too anterior, only see bottom of vocal cords) hyperflexion? (can only see posterior pharynx, airway to posterior) What if blade is in too far? (likely see esophageal walls) not far enough? (will only see tongue or posterior pharynx) what tricks can improve the view? (flex/extend, blade in/out, cricoid pressure) 5. Why do we insert the blade/ett into the right side of the mouth? (to keep the view unobstructed) 6. How do you know if the ETT is correctly placed? (gold standard: ETCO 2 color change AND improving heart rate; visualize the tube between the cords; mist in the tube with PPV; visible chest rise & stomach not distending; auscultation positive over chest not stomach) What if you don t see color change on the ETCO 2? (not in; inadequate PPV; DOPE, epinephrine in the ETT can turn the ETCO 2 yellow first step: direct visualization with laryngoscope to see if in) 7. What are the indications for intubation/aspiration for meconium and describe how it is done. (meconium stained amniotic fluid AND baby is not vigorous ie. HR < 100, depressed tone/breathing ** repeat if & only if mec was suctioned from below the cords, HR ok and you are fast!) 8. What are potential complications of intubation? (hypoxia/bradycardia, pneumothorax, contusions/lacerations of the tongue/gums/airway, perforation of the trachea/esophagus, obstruction of the endotracheal tube, infection) Alberta Perinatal Health Program Page 8 of 8