What is the proper procedure for neonatal intubation?

Neonatal Intubation Procedure

I cannot provide video content, but I can provide you with the comprehensive procedural guidelines for neonatal intubation based on the most current evidence.

Indications for Intubation

Intubate when the heart rate remains below 60 beats per minute despite 30 seconds of adequate positive pressure ventilation with supplemental oxygen. 1, 2

Additional indications include:

• Ineffective or prolonged bag-mask ventilation that fails to improve heart rate or oxygenation 2
• When chest compressions are required during resuscitation 1, 2
• Special circumstances such as congenital diaphragmatic hernia 1, 2
• Extremely low birth weight infants requiring prolonged respiratory support 1

Pre-Intubation Preparation

Premedication for Non-Emergent Intubations

For non-emergent intubations, always use premedication including analgesia, sedation, and paralysis. 2, 3

The evidence strongly supports this approach:

• Paralytic use increases odds of first-attempt success by 2.41 times 3
• Combined paralytic and videolaryngoscopy increases odds of first-attempt success by 4.07 times 3
• Premedication reduces bradycardia, desaturation, and physiologic instability during the procedure 3, 4
• Infants receiving premedication are intubated twice as fast with fewer changes in baseline heart rate 4

Note: Rocuronium is the paralytic of choice, dosed at 0.6 mg/kg IV for intubation, with onset in approximately 1 minute 5

Equipment Selection

Use videolaryngoscopy as the preferred tool for neonatal intubation. 2, 6

The evidence is compelling:

• Videolaryngoscopy increases first-attempt success from 41% to 66% when the instructor can view the screen 6
• With premedication, success rates improve from 44% to 72% using videolaryngoscopy 6
• This benefit is particularly important given that junior doctors have success rates below 50% with traditional laryngoscopy 7

Intubation Technique

Positioning and Approach

• Position the infant in a "sniffing" position to open the airway 1
• Use the most experienced operator available 2
• For infants with epidermolysis bullosa, apply water-based lubricant under the face mask and lubricate the endotracheal tube 1

Timing Considerations

Limit each intubation attempt, though the optimal duration remains debated:

• The Neonatal Resuscitation Program traditionally recommends 20-second attempts 7
• However, successful intubations by experienced operators average 25-32 seconds 7
• Residents average 49 seconds for successful attempts 7

Critical pitfall: Infants frequently deteriorate during intubation attempts, particularly when heart rate and oxygen saturation are already low before the attempt 7. Monitor continuously and be prepared to abort and provide bag-mask ventilation.

Physiologic Monitoring During Intubation

Monitor for deterioration, which occurs in nearly half of intubation attempts 7:

• Heart rate drops of >10% from baseline 7
• Oxygen saturation drops of >10% from baseline 7
• Deterioration is more likely when HR and SpO2 are already compromised before the attempt 7

Confirmation of Tube Placement

Use exhaled CO2 detection as the most reliable method to confirm endotracheal tube placement. 1, 2

The confirmation hierarchy:

1. Primary confirmation: Detection of exhaled CO2 confirms tracheal placement in patients with adequate cardiac output 1, 2
2. Negative CO2: Strongly suggests esophageal intubation 1, 2
3. Clinical signs: A prompt increase in heart rate is the best clinical indicator of successful intubation 1

Important: CO2 detection is effective even in very low-birth-weight infants 1. Clinical assessment alone takes longer to determine tube position than using flow signals or CO2 detection 7.

Alternative Airway Devices

Laryngeal Mask Airway

Consider the laryngeal mask airway when bag-mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible. 1, 2

Specific recommendations:

• Effective for infants weighing >2000g or ≥34 weeks gestation 1
• Reduces failure to improve by 105 per 1,000 infants compared to face masks 8
• Reduces need for endotracheal intubation by 41 per 1,000 infants 8
• Achieves heart rate >100 bpm 66 seconds faster than face masks 8

Limitations: Not evaluated for meconium-stained fluid, during chest compressions, or for emergency medications 1

CPAP as Alternative to Intubation

For spontaneously breathing preterm infants with respiratory distress, start with CPAP at approximately 5 cm H2O rather than routine intubation. 9

This approach:

• Reduces the need for mechanical ventilation 9
• Decreases surfactant use and duration of ventilation 1
• Improves outcomes overall 9

Special Populations

Preterm Infants

For preterm infants requiring intubation 5:

• Initial dose: 0.6 mg/kg rocuronium (or 0.45 mg/kg depending on anesthetic technique) 5
• Onset time is shortest in infants 28 days to 3 months 5
• Duration of clinical relaxation is shortest in children >2 years 5

Critical note: Rocuronium is not recommended for rapid sequence intubation in pediatric patients 5

Infants with Epidermolysis Bullosa

Implement preventative measures for all intubations in infants with suspected or confirmed epidermolysis bullosa. 1

Specific precautions:

• Lubricate the endotracheal tube and scopes 1
• Use low-adherent padding between gloved hands and the infant's skin 1
• Apply low-adherent taping underneath standard tape to secure tubes to the face 1
• Use water-based lubricant under the face mask 1

Common Pitfalls to Avoid

1. Attempting intubation without premedication in non-emergent situations: This increases failure rates, physiologic instability, and infant distress 3, 4, 10

2. Using traditional laryngoscopy when videolaryngoscopy is available: This significantly reduces first-attempt success rates, especially for less experienced operators 6

3. Relying solely on clinical assessment for tube confirmation: Use CO2 detection for faster and more reliable confirmation 1, 7

4. Persisting with prolonged attempts when the infant is deteriorating: Be prepared to abort and provide bag-mask ventilation 7

5. Not having the most experienced operator available perform the procedure: Experience dramatically improves success rates (86% for consultants vs 24% for residents) 7