The Neonatal Airway and Neonatal Intubation Matthew L. Paden, MD Pediatric Critical Care Fellow Emory University Children’s Healthcare of Atlanta

The Neonatal Airway The Neonatal Airway and Neonatal Intubationand Neonatal Intubation

Matthew L. Paden, MDMatthew L. Paden, MDPediatric Critical Care FellowPediatric Critical Care Fellow

Emory UniversityEmory UniversityChildren’s Healthcare of AtlantaChildren’s Healthcare of Atlanta

Goals of PresentationGoals of Presentation

Recognize differences between neonatal Recognize differences between neonatal and adult airwayand adult airway

Review neonatal intubation technique and Review neonatal intubation technique and equipmentequipment

Review common mistakes and Review common mistakes and complications of intubationcomplications of intubation

Examine syndromes commonly associated Examine syndromes commonly associated with difficult neonatal airwayswith difficult neonatal airways

Why do we care?Why do we care?

Prompt intubation of a distressed neonate Prompt intubation of a distressed neonate can be life-savingcan be life-saving Increasingly premature populationIncreasingly premature population

Residents are getting less training at thisResidents are getting less training at this RRC limitation of intensive care training RRC limitation of intensive care training

(1994) (1994) Revision of NRP protocols (2000)Revision of NRP protocols (2000)

Why do we care?Why do we care? Database of all neonatal intubations at UCSD Database of all neonatal intubations at UCSD

from 1992-2002from 1992-2002 9190 attempts recorded9190 attempts recorded

What did they find?What did they find? Successful intubation on each attemptSuccessful intubation on each attempt

• PGY1 33%, PGY2 40%, PGY3 40%PGY1 33%, PGY2 40%, PGY3 40% Total intubations attempted during residencyTotal intubations attempted during residency

• 1994 – 38(+/- 19), 2002 – 12(+/- 6)1994 – 38(+/- 19), 2002 – 12(+/- 6) Total intubations successful during residencyTotal intubations successful during residency

• 1994 – 24(+/- 14), 2002 – 4(+/-2)1994 – 24(+/- 14), 2002 – 4(+/-2) ConclusionConclusion

““Pediatric trainees are currently provided inadequate Pediatric trainees are currently provided inadequate experience to allow development of proficiency at experience to allow development of proficiency at neonatal intubation.” neonatal intubation.”

NN Finer, et al. Neonatal Intubation: Success of Pediatric Trainees. J Peds 2005;146:638-41.

The Neonatal AirwayThe Neonatal Airway

Compared to adults, Compared to adults, structures are…structures are… SmallerSmaller More anteriorMore anterior Epiglottis is floppierEpiglottis is floppier Larger tongueLarger tongue Larger occiputLarger occiput Narrowest portion of Narrowest portion of

airway is the cricoidairway is the cricoid

Airway AnatomyAirway Anatomy

EmbryologyEmbryology Larynx from 4Larynx from 4thth and 5 and 5thth

archesarches Primitive larynx altered Primitive larynx altered

by hypobranchial by hypobranchial eminence, epiglottis, eminence, epiglottis, arytenoidsarytenoids

Laryngeal lumen Laryngeal lumen obliterated and obliterated and recanalizedrecanalized

Indications for IntubationIndications for Intubation

In delivery roomIn delivery room Cardiorespiratory instabilityCardiorespiratory instability Meconium during birth, with a depressed Meconium during birth, with a depressed

infantinfant Prematurity requiring need for surfactant Prematurity requiring need for surfactant

therapytherapy Congenital malformationsCongenital malformations

Indications for IntubationIndications for Intubation

In NICUIn NICU Unable to protect airwayUnable to protect airway Hypercarbic respiratory failureHypercarbic respiratory failure Hypoxic respiratory failureHypoxic respiratory failure Therapeutic indicationTherapeutic indication

What do you need?What do you need?

MMonitors - Cardiac and pulse oximetryonitors - Cardiac and pulse oximetry

SSuction - Yankauer or catheteruction - Yankauer or catheter

MMachine - Laryngoscope, ventilator or achine - Laryngoscope, ventilator or bag/maskbag/mask

AAirway - Endotracheal tubeirway - Endotracheal tube

IIntravenous - Peripheral or central linentravenous - Peripheral or central line

DDrugs -- rugs -- Sedation/analgesia/paralysis/atropineSedation/analgesia/paralysis/atropine

Laryngoscope BladesLaryngoscope Blades

Straight blades are Straight blades are placed under the placed under the epiglottis and used to epiglottis and used to lift anteriorly to lift anteriorly to expose the cords.expose the cords.

Curved blades are Curved blades are placed in the valecula placed in the valecula and lifted anteriorly to and lifted anteriorly to expose the cords.expose the cords.

Macintosh

Miller

Wisconsin

Endotracheal TubesEndotracheal Tubes

Endotracheal tubes are divided by the size Endotracheal tubes are divided by the size of their internal diameterof their internal diameter

For neonates endotracheal tube size For neonates endotracheal tube size roughly corresponds to 1/10roughly corresponds to 1/10thth of of gestational age rounded down to the gestational age rounded down to the nearest size.nearest size. For example For example

• A 36 week premie would get a 3.5 ETTA 36 week premie would get a 3.5 ETT• A 28 week premie would get a 2.5 ETTA 28 week premie would get a 2.5 ETT

Intubation ProcedureIntubation Procedure

Proper positioningProper positioning EquipmentEquipment

• Bed and patient at comfortable heightBed and patient at comfortable height• Suction and meconium aspirator readily availableSuction and meconium aspirator readily available• Endotracheal tubes not under warmerEndotracheal tubes not under warmer• All equipment tested and working just prior to useAll equipment tested and working just prior to use

PatientPatient• Shoulder rollShoulder roll• Head in sniffing positionHead in sniffing position

Too much hyperextension can make visualization difficultToo much hyperextension can make visualization difficult


Pre-oxygenate with 100% bag valve mask Pre-oxygenate with 100% bag valve mask ventilationventilation Contraindicated in known congenital Contraindicated in known congenital

diaphragmatic herniadiaphragmatic hernia Apply monitorsApply monitors Give drugsGive drugs

Remember minimum atropine doseRemember minimum atropine dose Ensure ability to bag/mask ventilate before Ensure ability to bag/mask ventilate before

paralysisparalysis


Inserting the Inserting the laryngoscope bladelaryngoscope blade Hold laryngoscope in Hold laryngoscope in

left handleft hand While standing above While standing above

the patient, insert the the patient, insert the blade in the right side blade in the right side of the mouth of the mouth WITHOUT trying to WITHOUT trying to visualize the cords.visualize the cords.


Take a step backTake a step back Lower your head to Lower your head to

the level of the labelthe level of the label Slowly advance Slowly advance

laryngoscope until laryngoscope until you visualize the you visualize the epiglottisepiglottis

Use straight or curved Use straight or curved blade appropriatelyblade appropriately


Visualize the vocal Visualize the vocal cordscords Meconium below Meconium below

cords?cords? Both moving if not Both moving if not

paralyzed?paralyzed? Structurally normal?Structurally normal?

Pick up endotracheal Pick up endotracheal tube and pass tube and pass between vocal cordsbetween vocal cords

Assessing Endotracheal Tube Assessing Endotracheal Tube PlacementPlacement

Direct visualizationDirect visualization End tidal COEnd tidal CO2 2 monitoring monitoring

Chest riseChest rise AuscultationAuscultation ETT vaporETT vapor

Less reliable Less reliable Chest X-rayChest X-ray


Secure endotracheal tube to lip with tapeSecure endotracheal tube to lip with tape Do not let go of tube until secureDo not let go of tube until secure

Reassess that endotracheal tube is still in Reassess that endotracheal tube is still in place.place.

Assess the neonate –Assess the neonate – Improving? More pink? Heart rate Improving? More pink? Heart rate

increasing?increasing? Continue resuscitation – proceed to B and Continue resuscitation – proceed to B and

C….C….

Common ProblemsCommon Problems

Esophageal IntubationEsophageal Intubation Blade placed too deep, cords not visualizedBlade placed too deep, cords not visualized

Tongue obscures visualizationTongue obscures visualization Sweep tongue to one side with bladeSweep tongue to one side with blade More anterior liftMore anterior lift Tape on bladeTape on blade

Cannot see cordsCannot see cords Head is hyper-extended - repositionHead is hyper-extended - reposition

Common ProblemsCommon Problems

Cannot intubateCannot intubate Most neonates can be bag valve mask Most neonates can be bag valve mask

ventilated easilyventilated easily Call early for anesthesiology assistanceCall early for anesthesiology assistance

• ““Bag ventilating with oxygen can prolong life for a Bag ventilating with oxygen can prolong life for a long time, repeatedly attempting and failing long time, repeatedly attempting and failing intubation will not.”intubation will not.”

Surgical airwaySurgical airway

Difficult Neonatal AirwaysDifficult Neonatal Airways

Must always be prepared for something Must always be prepared for something abnormalabnormal

Increasing awareness of problems Increasing awareness of problems beforehand because of neonatal beforehand because of neonatal ultrasoundultrasound

““Things you can see” versus “Things you Things you can see” versus “Things you may find”may find”


Congenital malformationsCongenital malformations ““Things you can see”Things you can see” Predictable from looking at the patientPredictable from looking at the patient

• Cleft lip and palateCleft lip and palate• Pierre Robin syndromePierre Robin syndrome• Treacher Collins syndromeTreacher Collins syndrome• Goldenhar syndromeGoldenhar syndrome• Apert and Crouzon SyndromeApert and Crouzon Syndrome

Congenital MalformationsCongenital Malformations

Cleft Lip and PalateCleft Lip and Palate Most common Most common

congenital face congenital face malformationmalformation

Pierre Robin Pierre Robin SequenceSequence Obstruction is usually Obstruction is usually

at the nasopharyngeal at the nasopharyngeal levellevel


Apert and CrouzonApert and Crouzon Maxillary hypoplasiaMaxillary hypoplasia Nasopharyngeal Nasopharyngeal

airway compromiseairway compromise

Goldenhar syndromeGoldenhar syndrome Unilateral anomaliesUnilateral anomalies Higher incidence of Higher incidence of

airway anomalies airway anomalies


Treacher CollinsTreacher Collins Choanal Choanal

atresia/stenosis more atresia/stenosis more commoncommon

Down’s SyndromeDown’s Syndrome Subglottic stenosis Subglottic stenosis

more commonmore common Remember Remember

atlantoaxial instabilityatlantoaxial instability


Congenital MalformationsCongenital Malformations ““Things you may find”Things you may find”

• LaryngomalaciaLaryngomalacia• Hemangioma or Hemangioma or

LymphangiomaLymphangioma• Tracheal webTracheal web• Laryngeal atresiaLaryngeal atresia• Subglotic stenosisSubglotic stenosis


LaryngomalaciaLaryngomalacia A sequence between A sequence between

fully formed to atresiafully formed to atresia


Laryngeal WebLaryngeal Web

Tracheal AtresiaTracheal Atresia Survive only if Survive only if

tracheoesophageal tracheoesophageal fistula or emergent fistula or emergent trachtrach


Hemangioma or Hemangioma or LymphangiomaLymphangioma Only about 30% Only about 30%

present at birthpresent at birth


Subglottic StenosisSubglottic Stenosis

In ReviewIn Review

Proper positioning is critical for successful Proper positioning is critical for successful neonatal intubationneonatal intubation

Call for help early if unable to intubate or for any Call for help early if unable to intubate or for any congenital anomaliescongenital anomalies Continue to provide oxygen with bag valve mask Continue to provide oxygen with bag valve mask

ventilationventilation

Practice makes perfectPractice makes perfect It is estimated that you need to perform at least 90 It is estimated that you need to perform at least 90

intubations to be able to intubate successfully on the intubations to be able to intubate successfully on the first or second attempt at least 80% of the timefirst or second attempt at least 80% of the time

QUESTIONS?QUESTIONS?

Documents

The Neonatal Airway and Neonatal Intubation Matthew L. Paden, MD Pediatric Critical Care Fellow Emory University Children’s Healthcare of Atlanta