Endotracheal intubation of the newborn

How should endotracheal intubation of the newborn be performed? 

Perform the tracheal intubation by the oral route, using an uncuffed endotracheal tube and a laryngoscope with a straight blade (size 0 for premature, size 1 for term). If a stylet is used, it should not protrude beyond the end of the tube.

Cricoid pressure may be needed. After the endotracheal tube is passed through the vocal cords, check the position by observing symmetrical chest wall movement, listen for breath sounds at the axilla, and note the absence of breath sounds over the stomach.

Confirm the absence of gastric inflation, watching for condensation in the endotracheal tube during exhalation, and note the improvement in heart rate, color, and activity of the newborn.

A prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation. Confirm tube placement with a CO monitor.

Exhaled CO detection is effective for confirmation of endotracheal placement in infants, including very low birth weight infants. Confirmation of tube placement by radiograph is also recommended. 

The guide for the proper size of the endotracheal tube follows:

Endotracheal tube size=Gestational age in weeks/10

The proper depth of insertion can be estimated by using the following calculation:

Insertion depth at lip in cm=Weight in kg + 6cm

Sources

Kattwinkel J, Perlman JM, Aziz K, et al: Part 15: Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S909-S919.

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