What is the recommended technique for neonatal intubation?

Neonatal Intubation Technique

For neonatal intubation, use oral intubation with cuffed endotracheal tubes (with rigorous cuff pressure monitoring), employ direct laryngoscopy as the primary method, and avoid routine tracheal suctioning in nonvigorous infants born through meconium-stained amniotic fluid. 1

Route of Intubation

• Oral intubation is preferred over nasal intubation for neonates in intensive care settings 1
• Nasal intubation is more difficult technically and should be avoided, particularly by inexperienced operators 1
• Post-extubation atelectasis occurs more frequently following nasal intubation, especially in preterm infants of very low birth weight 1
• No significant differences exist between routes regarding tube malposition, accidental extubation, tube obstruction, infections, or local trauma 1

Endotracheal Tube Selection

• Cuffed endotracheal tubes are preferred in neonates to reduce the number of reintubations required for air leakage 1
• Cuffed tubes do not increase the incidence of post-extubation stridor or subglottic lesions when cuff pressure monitoring is rigorous 1
• The traditional dogma of using uncuffed tubes in children under 7-8 years is outdated and not evidence-based 1
• For infants weighing 1000-1199 g, use a 2.5 mm ETT rather than the 3.0 mm recommended by Neonatal Resuscitation Program, as this reduces adverse outcomes (severe oxygen desaturation: 35.2% vs 52.9%) 2
• For infants weighing 2000-2199 g, use a 3.0 mm ETT rather than the 3.5 mm NRP recommendation, as this reduces severe oxygen desaturation (41% vs 56%) 2

Laryngoscopy Technique

• Direct laryngoscopy remains the primary recommended method for neonatal intubation 3
• Video laryngoscopy provides better glottic visualization but takes approximately 5 seconds longer than direct laryngoscopy without improving first-attempt success rates 1
• Video laryngoscopy may be useful for training purposes or in cases of difficult airways 3
• When using video laryngoscopy, be aware that the blade design differs from conventional laryngoscopes (reduced vertical height, curved tip and body), requiring minor technique adaptations 4
• The appropriate lift maneuver should be used in 69% or more of attempts to optimize visualization 3

Procedural Considerations

• Limit each intubation attempt to 20 seconds, though successful attempts by experienced operators average 25-32 seconds 5
• Infants frequently deteriorate during intubation attempts, with heart rate and oxygen saturation falling by >10% in nearly half of attempts 5
• Success rates vary significantly by operator experience: residents 24%, fellows 78%, consultants 86% 5
• Use flow signals or exhaled CO2 detection to confirm tube position more quickly than clinical assessment alone 5

Pharmacologic Support

• Provide adequate sedation and analgesia for non-emergent intubations 1, 6
• Rapid-onset opioids such as fentanyl are preferable to morphine due to faster onset of action 1
• Thiopentone or methohexital can reduce apparent pain and provide smooth intubating conditions 1
• Infiltrate the insertion site with local anesthetic when time permits, using slow infiltration to reduce pain 1

Special Circumstances: Meconium-Stained Amniotic Fluid

• Do not perform routine immediate direct laryngoscopy with or without tracheal suctioning in nonvigorous infants born through meconium-stained amniotic fluid 1, 7
• Proceed immediately with appropriate resuscitation measures without routine laryngoscopy 1, 7
• Reserve intubation and tracheal suctioning only for cases with evidence of airway obstruction 1, 7
• Trained personnel and intubation equipment must be readily available at deliveries with meconium-stained fluid 1, 7
• Routine tracheal suctioning delays ventilation without improving outcomes (survival, HIE, or MAS rates) 1

Protective Measures During Intubation

• Lubricate the endotracheal tube before insertion 1
• Use low-adherent padding between gloved hands and the infant's skin 1
• Apply low-adherent tape underneath standard tape when securing tubes to the face 1
• Use water-based lubricant under face masks 1

Common Pitfalls to Avoid

• Attempting intubation without adequate preparation or monitoring equipment
• Using NRP-recommended ETT sizes without considering weight-specific data showing smaller tubes may be safer 2
• Prolonging intubation attempts beyond 20-30 seconds when the infant is deteriorating 5
• Performing routine tracheal suctioning in meconium-stained fluid cases, which delays critical ventilation 1, 7
• Using uncuffed tubes based on outdated age-based recommendations rather than evidence-based practice 1