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The Neonatal Airway and Neonatal Intubation

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... with a depressed infant ... for help early if unable to intubate or for any congenital anomalies Continue to provide oxygen with bag valve mask ventilation ... – PowerPoint PPT presentation

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Title: The Neonatal Airway and Neonatal Intubation


1
The Neonatal Airway and Neonatal Intubation
  • Matthew L. Paden, MD
  • Pediatric Critical Care Fellow
  • Emory University
  • Childrens Healthcare of Atlanta

2
Goals of Presentation
  • Recognize differences between neonatal and adult
    airway
  • Review neonatal intubation technique and
    equipment
  • Review common mistakes and complications of
    intubation
  • Examine syndromes commonly associated with
    difficult neonatal airways

3
Why do we care?
  • Prompt intubation of a distressed neonate can be
    life-saving
  • Increasingly premature population
  • Residents are getting less training at this
  • RRC limitation of intensive care training (1994)
  • Revision of NRP protocols (2000)

4
Why do we care?
  • Database of all neonatal intubations at UCSD from
    1992-2002
  • 9190 attempts recorded
  • What did they find?
  • Successful intubation on each attempt
  • PGY1 33, PGY2 40, PGY3 40
  • Total intubations attempted during residency
  • 1994 38(/- 19), 2002 12(/- 6)
  • Total intubations successful during residency
  • 1994 24(/- 14), 2002 4(/-2)
  • Conclusion
  • Pediatric trainees are currently provided
    inadequate experience to allow development of
    proficiency at neonatal intubation.

NN Finer, et al. Neonatal Intubation Success of
Pediatric Trainees. J Peds 2005146638-41.
5
The Neonatal Airway
  • Compared to adults, structures are
  • Smaller
  • More anterior
  • Epiglottis is floppier
  • Larger tongue
  • Larger occiput
  • Narrowest portion of airway is the cricoid

6
Airway Anatomy
  • Embryology
  • Larynx from 4th and 5th arches
  • Primitive larynx altered by hypobranchial
    eminence, epiglottis, arytenoids
  • Laryngeal lumen obliterated and recanalized

7
Indications for Intubation
  • In delivery room
  • Cardiorespiratory instability
  • Meconium during birth, with a depressed infant
  • Prematurity requiring need for surfactant therapy
  • Congenital malformations

8
Indications for Intubation
  • In NICU
  • Unable to protect airway
  • Hypercarbic respiratory failure
  • Hypoxic respiratory failure
  • Therapeutic indication

9
What do you need?
  • Monitors - Cardiac and pulse oximetry
  • Suction - Yankauer or catheter
  • Machine - Laryngoscope, ventilator or bag/mask
  • Airway - Endotracheal tube
  • Intravenous - Peripheral or central line
  • Drugs -- Sedation/analgesia/paralysis/atropine

10
Laryngoscope Blades
  • Straight blades are placed under the epiglottis
    and used to lift anteriorly to expose the cords.
  • Curved blades are placed in the valecula and
    lifted anteriorly to expose the cords.

Miller
Macintosh
Wisconsin
11
Endotracheal Tubes
  • Endotracheal tubes are divided by the size of
    their internal diameter
  • For neonates endotracheal tube size roughly
    corresponds to 1/10th of gestational age rounded
    down to the nearest size.
  • For example
  • A 36 week premie would get a 3.5 ETT
  • A 28 week premie would get a 2.5 ETT

12
Intubation Procedure
  • Proper positioning
  • Equipment
  • Bed and patient at comfortable height
  • Suction and meconium aspirator readily available
  • Endotracheal tubes not under warmer
  • All equipment tested and working just prior to
    use
  • Patient
  • Shoulder roll
  • Head in sniffing position
  • Too much hyperextension can make visualization
    difficult

13
Intubation Procedure
  • Pre-oxygenate with 100 bag valve mask
    ventilation
  • Contraindicated in known congenital diaphragmatic
    hernia
  • Apply monitors
  • Give drugs
  • Remember minimum atropine dose
  • Ensure ability to bag/mask ventilate before
    paralysis

14
Intubation Procedure
  • Inserting the laryngoscope blade
  • Hold laryngoscope in left hand
  • While standing above the patient, insert the
    blade in the right side of the mouth WITHOUT
    trying to visualize the cords.

15
Intubation Procedure
  • Take a step back
  • Lower your head to the level of the label
  • Slowly advance laryngoscope until you visualize
    the epiglottis
  • Use straight or curved blade appropriately

16
Intubation Procedure
  • Visualize the vocal cords
  • Meconium below cords?
  • Both moving if not paralyzed?
  • Structurally normal?
  • Pick up endotracheal tube and pass between vocal
    cords

17
Assessing Endotracheal Tube Placement
  • Direct visualization
  • End tidal CO2 monitoring
  • Chest rise
  • Auscultation
  • ETT vapor
  • Less reliable
  • Chest X-ray

18
Intubation Procedure
  • Secure endotracheal tube to lip with tape
  • Do not let go of tube until secure
  • Reassess that endotracheal tube is still in
    place.
  • Assess the neonate
  • Improving? More pink? Heart rate increasing?
  • Continue resuscitation proceed to B and C.

19
Common Problems
  • Esophageal Intubation
  • Blade placed too deep, cords not visualized
  • Tongue obscures visualization
  • Sweep tongue to one side with blade
  • More anterior lift
  • Tape on blade
  • Cannot see cords
  • Head is hyper-extended - reposition

20
Common Problems
  • Cannot intubate
  • Most neonates can be bag valve mask ventilated
    easily
  • Call early for anesthesiology assistance
  • Bag ventilating with oxygen can prolong life for
    a long time, repeatedly attempting and failing
    intubation will not.
  • Surgical airway

21
Difficult Neonatal Airways
  • Must always be prepared for something abnormal
  • Increasing awareness of problems beforehand
    because of neonatal ultrasound
  • Things you can see versus Things you may find

22
Difficult Neonatal Airways
  • Congenital malformations
  • Things you can see
  • Predictable from looking at the patient
  • Cleft lip and palate
  • Pierre Robin syndrome
  • Treacher Collins syndrome
  • Goldenhar syndrome
  • Apert and Crouzon Syndrome

23
Congenital Malformations
  • Cleft Lip and Palate
  • Most common congenital face malformation
  • Pierre Robin Sequence
  • Obstruction is usually at the nasopharyngeal level

24
Congenital Malformations
  • Apert and Crouzon
  • Maxillary hypoplasia
  • Nasopharyngeal airway compromise
  • Goldenhar syndrome
  • Unilateral anomalies
  • Higher incidence of airway anomalies

25
Congenital Malformations
  • Treacher Collins
  • Choanal atresia/stenosis more common
  • Downs Syndrome
  • Subglottic stenosis more common
  • Remember atlantoaxial instability

26
Difficult Neonatal Airways
  • Congenital Malformations
  • Things you may find
  • Laryngomalacia
  • Hemangioma or Lymphangioma
  • Tracheal web
  • Laryngeal atresia
  • Subglotic stenosis

27
Congenital Malformations
  • Laryngomalacia
  • A sequence between fully formed to atresia

28
Congenital Malformations
  • Laryngeal Web
  • Tracheal Atresia
  • Survive only if tracheoesophageal fistula or
    emergent trach

29
Congenital Malformations
  • Hemangioma or Lymphangioma
  • Only about 30 present at birth

30
Congenital Malformations
  • Subglottic Stenosis

31
In Review
  • Proper positioning is critical for successful
    neonatal intubation
  • Call for help early if unable to intubate or for
    any congenital anomalies
  • Continue to provide oxygen with bag valve mask
    ventilation
  • Practice makes perfect
  • It is estimated that you need to perform at least
    90 intubations to be able to intubate
    successfully on the first or second attempt at
    least 80 of the time

32
  • QUESTIONS?
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