The Neonatal Airway and Neonatal Intubation

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The Neonatal Airway and Neonatal Intubation

• Matthew L. Paden, MD
• Pediatric Critical Care Fellow
• Emory University
• Childrens Healthcare of Atlanta

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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

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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)

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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.
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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

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Airway Anatomy

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

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Indications for Intubation

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

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Indications for Intubation

• In NICU
• Unable to protect airway
• Hypercarbic respiratory failure
• Hypoxic respiratory failure
• Therapeutic indication

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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

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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
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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

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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

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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

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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.

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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

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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

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Assessing Endotracheal Tube Placement

• Direct visualization
• End tidal CO2 monitoring
• Chest rise
• Auscultation
• ETT vapor
• Less reliable
• Chest X-ray

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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.

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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

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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

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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

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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

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Congenital Malformations

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

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Congenital Malformations

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

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Congenital Malformations

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

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Difficult Neonatal Airways

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

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Congenital Malformations

• Laryngomalacia
• A sequence between fully formed to atresia

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Congenital Malformations

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

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Congenital Malformations

• Hemangioma or Lymphangioma
• Only about 30 present at birth

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Congenital Malformations

• Subglottic Stenosis

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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

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• QUESTIONS?