Airway Management Flashcards
Purpose of Intubation in a Neonate
Assisted ventilation
Bronchial hygiene (suctioning and lavage)
Obtaining culture material
Continuous positive airway pressure
Relieving critical upper airway obstruction
Suspected diaphragmatic hernia
Administration of drugs
Decision to Intubate
- The decision to intubate a neonate and to initiate assisted ventilation is made in conjunction with the neonatologist/designate.
- If a neonate requires emergency airway management prior to discussion with the neonatologist/designate, intubation will be performed according to the established procedure and the consulting neonatologist/designate contacted as soon as possible.
Adjustment and Removal of Endotracheal Tubes
Endotracheal tubes may be adjusted by a Registered Nurse (RN) or Registered Respiratory Therapist (RRT) experienced in the procedure, if appropriate personnel, who are certified to reintubate, are present. The senior in-house physician or designate must be notified of such a procedure.
An RN or an RRT may remove the endotracheal tube if the tube is assessed to be occluded, or not in the trachea. In this situation, a care provider who is certified to intubate must be contacted immediately
Stabilization of an endotracheal tube must be performed by two trained care providers (eg. two RRTs, two RNs or one RRT and one RN).
Evaluation and Documentation of Intubation
- The person performing the intubation is responsible for follow-up evaluation of tube placement and documentation.
- A chest x-ray is required to confirm the endotracheal tube placement.
- Note: The placement of the ETT should be below the clavicles and above the carina, approximately T3 and mid-trachea.
Complications of Intubation
Trauma
Mucosal damage to the upper respiratory tract
Pressure necrosis to vocal cords
Perforation of the trachea
Oropharyngeal damage with nasal intubation
Complications of Intubation
Intubation of a bronchus or esophagus
Atelectasis
Pneumothorax
Perforation of the esophagus
Gross abdominal distention
Complications of Intubation
Other
Hypoxia and hypercarbia (hypercapnia)
Apnea
Infection
ETT Size Selection
Tube Size 2.5
- < 1000 g
- <28 week
Tube Size 3.0
- < 1000-2000 g
- 28-34 weeks
Tube Size 3.5
- < 2000-3000 g
- 34-38 weeks
Tube Size 3.5-4.0
- > 3000
- >38 weeks
Intubation Procedure
- If possible, connect the neonate to a cardiac monitor and activate the audible heart rate tone, or have a second care provider monitor the neonate’s heart rate by auscultation, cord palpation or peripheral pulse palpation.
- Ensure all equipment is prepared and at hand prior to beginning the procedure.
- Monitor vital signs and color continuously throughout the procedure.
- Contain the infant by bundling or other physical containment measures.
- Attend to the infant’s thermoregulation needs with the use of a radiant heat source to protect against heat loss.
- Position the neonate supine with the head in a “sniff” position; if necessary, use a small roll behind the shoulders.
- Ensure the head is neither hypoflexed nor hyperflexed.
- PPE
- Pre-oxygenate the neonate for at least 20 seconds before attempting to intubate.
- Suction the mouth prior to intubation to prevent aspiration of oral secretions and decrease risk of VAP
- Oxygen should be provided during intubation attempts by holding a free-flow source as
- close as possible to the neonate’s face, while not interfering with the actual intubation
attempt.
Following a Successful Intubation
- Following successful intubation, provide oxygen and ventilation as necessary and ensure CO2 detector is in place to confirm airway placement.
- Aspirate the stomach for accumulated air, if bag and mask ventilation is required for longer than two minutes during the procedure.
- During the evaluation chest x-ray, the head may be placed to the right, left, or midline but ensure that the chin is in a neutral position, as any deviation will affect ETT depth.
- Ensure there is no traction on the endotracheal tube.
- The intubating care provider is to review the x-ray and inform the bedside nurse of the position of the tube and indicate any necessary changes in tube placement
The intubating care provider is responsible for documentation of the procedure, including:
Events leading up to intubation.
Condition of infant before, during, and after the procedure.
Number of intubation attempts.
Size, route and position of the endotracheal tube.
Confirmation of tube placement on x-ray, including adjustments required and made.
Intubation Point of Emphasis
- The intubator maintains the position of the ETT during taping/securing of the tube.
- Verify the reference numbering on the tube at the level of the upper lip/gum before securing the ETT.
- Place the head in the neutral neck position before securing the ETT in place.
- Turn the blue line of the ETT to the left side of the mouth to ensure the bevel of the ETT is not occluded.
- Use a cotton swab applicator to paint the upper lip with liquid adhesive (or the bridge of the nose if nasally intubated) and allow to dry for about 10-15 seconds.
- Apply a pectin-based skin barrier (eg.Duoderm) to the area where tape is to be secured.
Note: This barrier is to remain on the skin and provide protection against epidermal stripping when the securing tape is removed
