- Endotracheal Intubation
- Laryngeal Mask Airway and the Airway Algorithm
Endotracheal Intubation
Move to an advanced airway when face mask PPV has failed corrective steps, when prolonged ventilation is expected, or when the clinical condition demands it immediately (congenital diaphragmatic hernia, CDH, being the clearest example).
Indications for advanced airway
- PPV via face mask remains ineffective after MR SOP corrective steps
- Chest compressions are required, as PPV via ETT is necessary for effective coordination
- Prolonged ventilation is anticipated beyond the immediate resuscitation period
- Specific conditions requiring immediate intubation (CDH, extreme prematurity)
- Tracheal suctioning is being considered for a depressed infant with meconium-stained amniotic fluid
ETT size selection
Correct tube size is determined by gestational age and estimated weight. Using a tube that is too small results in an inadequate seal and air leak; too large risks airway trauma. Current guidelines formally acknowledge a 2.0 mm tube for infants below 800 grams (Table 10):
Gestational age | Estimated weight | ETT size (mm ID) |
|---|---|---|
| Below 28 weeks | Below 1,000 g | 2.0-2.5 |
| 28-34 weeks | 1,000-2,000 g | 2.5-3.0 |
| 34-38 weeks | 2,000-3,000 g | 3.0-3.5 |
| Above 38 weeks | Above 3,000 g | 3.5 |
Insertion depth
Current guidelines changed the ETT reference point for insertion depth from the lip to the upper gum line, improving consistency across term and preterm infants and reducing the risk of right mainstem intubation. The formula for depth at the upper gum line is:
- Gestational age (weeks) ÷ 10 + 6 = insertion depth in cm at upper gum line
For example, a 28-week infant: 28 ÷ 10 = 2.8, then 2.8 + 6 = 8.8 cm at the upper gum line. This depth should be recorded and confirmed before securing the tube.
Laryngoscopy technique
Laryngoscopy is performed with the infant supine and the head in the neutral sniffing position. A straight blade laryngoscope is used, Miller 0 for preterm and small term infants, Miller 1 for larger term infants.
The blade is inserted along the right side of the mouth and advanced to the vallecula, then lifted anteriorly to visualise the vocal cords. The cords appear as a V-shaped opening. The ETT is passed through the cords under direct vision, with the vocal cord guide line (the black mark on the tube) positioned at the level of the cords.
The entire intubation attempt must be completed within 30 seconds. If successful placement has not been achieved within 30 seconds, the attempt should be abandoned, the infant ventilated with PPV via face mask for 30 seconds, and the attempt reattempted. Saturations and heart rate must be monitored throughout.
If intubation cannot be achieved within 30 seconds, stop, ventilate with face mask PPV, and reattempt. Never continue an attempt beyond 30 seconds in a deteriorating infant.
Confirming ETT placement
Don't secure the tube until you've confirmed placement four ways:
- CO₂ colorimetry: the primary confirmation method. The colorimetric detector changes from purple to yellow in the presence of exhaled CO₂. A colour change with each breath confirms tracheal placement. In infants with very low cardiac output, CO₂ may be insufficient to produce a colour change even with correct placement. In this case, clinical judgement is required.
- Bilateral breath sounds: auscultate in both axillae. Sounds should be equal bilaterally. Unilateral breath sounds suggest right mainstem intubation; no sounds suggest esophageal intubation.
- Chest rise: bilateral, symmetric rise with each breath.
- Improving heart rate: the most clinically significant indicator. A rising heart rate above 100 bpm confirms effective ventilation is being delivered.
Once placement is confirmed, the tube is secured using a tape bridge technique and the depth at the upper gum line is documented.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
