You are on page 1of 14

CYWHS Nursing & Midwifery Clinical Standards

Endotracheal Tube - intubation/ fixation/extubation - NICU


The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed
only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy
is the current endorsed version.
Document Number
Publication Date
Functional Group - Sub Group

cs2007_452
23 August 2007
Individual Health Care Care Planning and
Delivery

Summary

Some neonates require intubation to maintain a


patent airway, adequate ventilation and
oxygenation

Replaces

9.3.11Endotracheal tube intubation of the


neonate
9.3.17 Oral endotracheal intubation neonate
9.3.7 Endotracheal tube taping
9.3.19 Endotracheal tube - extubation

Lead Writer
Lead Writer Contact
Others Involved In Writing

Accreditation Action Group Responsible


Executive Director Responsible
Applies to
Review Date
Minimum Competency Level

MUH NICU
C Saunders (nicucm@cywhs.sa.gov.au)
T Cord-udy RM NICU, C Lyon CN PICU, C
Markwart CN NICU, L Mills CLC NICU, C
Woodward CN NICU, P Lowe CM NICU, S CTaylor CN NICU
Leadership and Management / Research
Regional Director - Nursing and Midwifery
NICU
8 May 2007
RN/RM

Key Words
Status
Endorsed by
Endorsement Date

For Endorsement
CSRG
8 August 2007

Board of Directors
Compliance with this clinical standard is mandatory

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 1/14

CYWHS Nursing & Midwifery Clinical Standard


Endotracheal Tube - intubation/ fixation/extubation - NICU
The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed
only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy
is the current endorsed version.
This Clinical Standard was printed on 23-Aug-07

Introduction
Some neonates require intubation to maintain a patent airway, provide adequate
ventilation and oxygenation. The nurses role is to prepare the patient, equipment
and medications and to assist the Medical Officer (MO) / Neonatal Nurse Practitioner
(NNP) with the procedure
Intubation is recognised as a painful procedure with adverse physiological responses
and the risk of trauma to the airways. Premedication is given for any non-urgent
intubation1, 2,3,4,5,6
Oro-tracheal intubation is the route of preference in an emergency and for
inexperienced operators 3,5,7,8
Fixation (taping) of an endotracheal tube is performed to ensure the intended position
of the tube is maintained and the risk of accidental extubation is minimised. Many
fixation devices and techniques are described in the literature 3, 8
Extubation is performed when the endotracheal tube is no longer required or a
replacement tube is necessary

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 2/14

Definition(s)
Endotracheal tube (ETT): oral/nasal, siliconised, latex free tube with a radiopaque
blue line. (Non-Murphy eye) 9
Murphy Eye: is a side vent near the distal end of an ETT to prevent complete
respiratory obstruction in the event that the open end of the ETT were to become
sealed by contact with the tracheal wall or occluded by a mass or mucous plug25
Intubation: insertion of an ETT into the trachea via the nose (naso-tracheal route) or
mouth (oro-tracheal route) using a laryngoscope1
Premedication: the use of sedatives, analgesics, neuromuscular blockers and
anticholinergics in isolation or combination to facilitate tracheal intubation. Optimises
intubation conditions and helps to minimise the adverse physiologic effects of
intubation 1, 6
Extubation: removal of the ETT
Cricoid cartilage: is the lowermost of the laryngeal cartilages12
Cricoid pressure: is the downward pressure applied to the cricoid cartilage using
the fore or middle finger to compress the oesophagus between the cricoid cartilage
and the anterior surface of the vertebral body3,12

Indications
INTUBATION1, 3,8,10
Any condition that requires a patent airway and/or artificial ventilation or
oxygenation

EXTUBATION
Blocked ETT
Elective change of ETT
Resolution of indication for intubation

Contraindications

The presence of cervical injuries is a contraindication to intubation with a


laryngoscope in older patients not a frequent problem in neonates 8
Muscle relaxation is contraindicated in situations known to be associated with
difficult intubation e.g. Pierre Robin sequence or when the operator is
inexperienced with these medications1,5

Equipment

Resuscitation trolley
Oxygen/air blender and/or oxygen flow meter connected to gas source
Infant resuscitation bag or Neopuff22 and appropriate size mask , connected
to blender/flow meter and function checked
Suction catheter size 8Fg connected (set to 15kpa)and function checked
Follow Link to Suction Neonate -NICU
cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007
Page 3/14

Suction catheter graduated wye size 5FG and 6FG available


Cardio respiratory monitor
Oximeter and or transcutaneous monitor
Stethoscope
Radiant warmer Follow Link to Overhead Radiant Heater
Sterile prem towel
Sterile scissors
Maternity sterile water swabs
Syringes/needles to draw up prescribed pre-medication
Appropriate medication label/s

Add for intubation

Laryngoscope handle and appropriate size straight blade for neonate,


function checked and ready for use

Google Images

Miller blades

Fibre-optic blades

Size 00 or 0 blade for premature neonate


Size 1 blade for term5,11,12
Magill forceps

CO2 (Carbon Dioxide) detector (Pedi-Cap) 3,10,12,16,21


ETT tube introducer (stylette) sterile (only open if requested). Used for oral
intubation. If used it should not protrude from the end of the ETT and should
be secured so that it cannot advance further into the ETT11,12

ETT9 Portex with a blue line

Google Images

Weight/tube size guidelines9


WEIGHT
< 500g
< 1000g
1000-2000g
2000-3000g
> 3000g

ORAL/NASAL 11,12
2.00mm
2.5mm
3.0mm
3.5mm
3.5-4.0mm

ORAL (Cole tube)


2.0mm
2.5mm
3.0mm

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 4/14

ETT tube length guide chart (on resuscitation trolley)

This chart indicates the position for a nasal tube at the nare based on the
crown to heel length of the neonate and is most useful when the weight is not
known. The depth of insertion for an oral tube at the centre of the upper lip is
1cm less than for a nasal tube

ENDO-TRACHEAL TUBE LENGTH CHART


Method of estimation of ideal Naso-Tracheal Tube Length (Pediatrics Vol 41 p 823,
June 1968)
(In emergency use 20% of crown-heel length)
This measurement is only a guideline from external nares to tracheal position
14

13

12

TUBE LENGTH - CMS

11

10

30

32

34

36

38

40

42

44

46

48

50

52

54

56

58

CROWN HEEL - CMS

Alternatively when the weight is known the following formula can be used

6cm + weight in kg for oral tube11,12


6cm + weight in kg plus 1cm for nasal tube

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 5/14

60

Ventilator function checked and ready for use


Securing Tapes (e.g. SLEEK, BDF, Elastoplast)
NeoBar endotracheal tube holder23
No sting barrier film wipe (e.g. Cavilon) optional
Silk 4/0 888 (oral taping only)
Naso-gastric tube for decompression of stomach post procedure Follow
Link to Naso/Oro gastric tube

Process

INTUBATION Medical Officer (MO)/Neonatal Nurse Practitioner (NNP)

Perform hand hygiene and observe standard precautions14,15


Inform parents of need for procedure at an appropriate time
Collect equipment
Ensure patent IV access
Discuss the provision of pre-medication with the MO/NNP and obtain written
order
Prepare medication20 (ready to be administered)
Ensure the neonate is maintained in a thermo-neutral environment. Use
radiant warmer if indicated Follow Link to Overhead Radiant Heater
Place prem towel on trolley and assemble equipment maintaining sterility of
the ETT
For nasal intubation

Cut the ETT to measured length plus 4cm3,8


Cut appropriate tapes for securing ETT

For oral intubation


o
o
o

Do not cut Oral tubes (can be trimmed after fixation to the NeoBar)
Cole tubes are not cut
Select appropriate size NeoBar fixation device

Ensure the infant resuscitation bag is connected to oxygen/air blender and flow
meter at 8 L/min.
Ensure NEOPUFF is connected to oxygen/air blender and flow meter at 8L/min
with PEEP and PIP pressures set and function checked Follow Link to Hand
Ventilation-Neopuff -Womens and Babies Division
NB Blended oxygen is given to maintain oxygen saturation within prescribed
limits12
Ensure 8FG suction catheter is attached to wall suction set at a pressure of 15-20
kPa Follow Link Suction Neonate and function checked
Increase sound volume of QRS complex on cardiac monitor to an acceptable
level for staff involved in procedure
Perform baseline observations
Aspirate the stomach and remove gastric tube if in situ
cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007
Page 6/14

Position the neonate supine with arms gently restrained, chest exposed and head
towards the operator in a slightly extended sniffing position5,3,12
Place the laryngoscope, Magill forceps (if requested), ETT and suction catheter
within easy reach of operator and assistant (ready to hand to MO/NNP on
request)
If medication for intubation is ordered ensure MO/NNP is present and has
instructed medication to be given. NB Administer medications as per
Pharmacy guidelines
Intubation attempts should be limited to 20-30secs3,5
Hold the laryngoscope between the thumb and first finger of the left hand, using
other fingers to support the chin
Pass the laryngoscope blade into the right side of the mouth and position it
midline and to the left, deflecting the tongue

Google Images

Raise the laryngoscope blade gently to lift the epiglottis and reveal the visible
vocal cords, ensuring that excessive pressure is not placed on the neonates
upper gums

Gently suction any secretions from the larynx prior to inserting the ETT
Should the neonates condition deteriorate during the procedure the neonate
should be allowed to recover with hand ventilation as necessary3,5,12
Hold the prepared ETT in right hand and insert into
The ( L ) or ( R ) nare or orally and insert the ETT along the side of the
laryngoscope blade through the vocal cords and up to
The determined length for a Portex tube
To the shoulder for a Cole tube
Apply light pressure to the cricoid cartilage if requested3,12

Google Images

Google Images

Remove the laryngoscope blade carefully


Once intubated attach and gently ventilate with the infant resuscitation
bag/Neopuff22 to achieve adequate chest expansion and optimal oxygenation
Check correct tube position by

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 7/14

Attachment of a CO2 detector3,10,12,16,21


Auscultation of the chest for equal air entry
Observation of symmetric chest-wall movement and
Clinical improvement of colour and heart rate3,5

Maintain the position of the tube in the trachea and secure in place (Blue line of
ETT should be positioned towards the left ear)

NASAL TUBE FIXATION TAPING - RM/RN

Cut two lengths of SLEEK/BDF that are double the distance from the middle
of the upper lip to 1cm in front of the ear and double the width of the upper lip

Cut a split halfway along the length of each strip (trouser legs)

Cut one short, narrow piece of sleek that will fit across the nose

Clean face with maternity sterile water swabs ( to remove e.g. vernix) and allow
to dry
Apply no sting barrier film to the cheeks, upper lip and nose bridge and allow to
dry, becomes sticky to touch
The first trouser leg tape approaches from the side of the nose in which the ETT
is placed

Assess air entry after first tape is applied


The second trouser leg tape approaches from the other side of the face

The unsplit section is applied to the cheek


The upper leg is taped over the nose and across the opposite cheek
The lower leg is wrapped around the ETT, thereby effectively
anchoring the tube in the correct position

The lower leg is taped under the nose and across to the opposite
cheek
The upper leg is taped over the nose and then wrapped around the
ETT to further anchor the tube

To facilitate subsequent removal of tape from around the ETT fold over ends of
tape approximately 2mm8
A third trouser leg tape may be required in the case of a larger, more active
neonate. If so, this is applied in the same way as the first tape
The short, narrow piece of tape is positioned across the bridge of the nose to
further secure the applied tapes
cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007
Page 8/14

Care is taken to avoid creases in the skin or undue pressure on the skin, (e.g.
preventing eyes from closing), nares and septum
Assess air entry
Attach the ETT to the ventilator circuit ensuring the ventilator settings are as
prescribed by the MO/NNP
Insert nasogastric tube if required to aspirate air from the stomach Follow Link
to Naso/Oro gastric tube insertion
Settle neonate in a position which promotes optimal neurodevelopment
Record on the Neonatal Problem Sheet and Nursing Care Plan

Document procedure on the

ETT size
Length at which cut and taped
Date
Time

Vital signs and respiratory flow chart


Progress notes

Chest x-ray is required to confirm correct position of ETT


Clean and restock resuscitation trolley

NASAL TUBE RE-TAPING RM/RN

This is a two person procedure (one of whom must be a NICC trained nurse)
Check resuscitation equipment is available and function checked- Follow
Link to Hand Ventilation-Neopuff-Womens and Babies Division
Check the position documented in the case notes at which the ETT is to
be taped
Cut appropriate tapes AS ABOVE - Follow Link to NASAL TUBE
FIXATION TAPING

Ensure MO/NNP available if needed

Aspirate the stomach prior to the procedure. If a nasogastric tube is in


situ, aspirate and remove. If a transpyloric tube is in situ retain
Position the neonate supine and flat with arms gently restrained and chest
exposed
Increase ventilation and oxygen to settings utilised during endotracheal
suction to compensate for a probable increase in requirements during this
procedure Follow Link to Suction Neonate -NICU
Check air entry with the stethoscope for comparison with post procedure
auscultation
Consider giving Sucrose prior to procedure
Hold neonates head in the midline position whilst the position of the tube
is maintained securely by the assistant
Unwind the trouser legs from the ETT
Remove existing tapes with adhesive remover/water
Clean skin with sterile water swabs then dry
Observe the condition of the nares and skin
Ensure blue line of ETT is positioned towards the left ear
Apply tapes AS ABOVE - Follow Link to NASAL TUBE FIXATION
TAPING
Assess air entry

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 9/14

Document procedure on the

Vital signs and respiratory flow chart


Progress notes
Nursing care plan

If the ETT position has been altered this is recorded on the

Insert nasogastric tube if required and tape into position or retape


transpyloric tube - Follow link to Naso gastric Tube
Follow link to Transpyloric Tube
Gradually reduce ventilation settings to pre-procedure levels in
accordance with the neonates tolerance of the procedure
Settle neonate into a position that promotes optimal neurodevelopment

Neonatal problem sheet


Nursing care plan

Chest x-ray may be required to confirm position of ETT


Clean and restock resuscitation trolley

ORAL TUBE FIXATION RM/RN

Appropriate size NeoBar fixation device

Neotech Products

Using the disposable tape measure supplied with the NeoBar, measure from
the mid line of the septum of the upper lip to the tragus of the ear
The colour on the tape in front of the ear corresponds to the colour NeoBar size
required
If the tape borders between two colours, always use the larger NeoBar
Ensure skin is clean and dry
Apply no sting barrier film to area in front of ear and allow to dry, becomes sticky
to touch
Position NeoBar across centre of mouth NB NeoBar and ETT should not
contact lips and ensure the ETT is under the NeoBar
Remove clear liners from tabs and apply tabs in front of ear on bone NB warm
tabs with hands prior to applying for better initial adhesion
Hold in place for  60 seconds
Use 1cm BDF tape and with ETT under the bar

Wrap tape completely around ETT first

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 10/14

Then

Continue taping around both ETT and the platform

For emergency removal, carefully cut thin portion of the NeoBar with blunt
scissors, at junction of bar and tab

ORAL TUBE NEOBAR REPLACEMENT RM/RN

This is a two person procedure, (one of whom must be a NICC trained nurse)
Check resuscitation equipment is function checked
Check the position documented in the case notes at which the ETT is to be taped
Ensure MO/NNP available if needed

Document procedure on the

Vital signs and respiratory flow chart


Progress notes
Nursing care plan

If the ETT position has been altered this is recorded on the

Aspirate the stomach prior to the procedure. If a nasogastric tube is in


situ, aspirate and remove. If a transpyloric tube is in situ retain
Position the neonate supine and flat with arms gently restrained and chest
exposed
Increase ventilation and oxygen to settings utilised during endotracheal
suction to compensate for a probable increase in requirements during this
procedure Follow Link to Suction Neonate -NICU
Check air entry with the stethoscope for comparison with post procedure
auscultation
Hold neonates head in the midline position whilst the position of the tube
is maintained securely by the assistant
Unwrap the tape from the ETT and platform
Slowly peel back the tabs as you swab with adhesive remover/water
Clean skin with maternity sterile water swabs then dry
Observe the condition of the skin
Ensure blue line of ETT is positioned towards the left ear
Apply NeoBar AS ABOVE Follow Link to ORAL TUBE FIXATION
Assess air entry
Insert nasogastric tube if required and tape into position or retape
transpyloric tube - Follow link to Naso gastric Tube
o Follow link to Transpyloric Tube
Gradually reduce ventilation settings to pre-procedure levels in
accordance with the neonates tolerance of the procedure
Settle neonate into a position that promotes optimal neurodevelopment

Neonatal problem sheet


Nursing care plan

Chest x-ray may be required to confirm position of ETT


Clean and restock resuscitation trolley

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 11/14

ORAL TUBE TAPING NB When a NeoBar is unable to be used e.g. hare


lip/cleft palate

4/0 silk 888 suture material


Elastoplast
Cut a piece of Elastoplast to fit across the upper lip
Cut BDF tapes - trouser leg NB SLEEK should not be used for this
method as the SLEEK can tear at the central connection point resulting in
an unsecured tube
Apply no sting barrier film to the cheeks, upper lip and allow to dry, becomes
sticky to touch
Place a piece of Elastoplast across the upper lip
The MO/NNP anchors the ETT by placing a suture through the ETT and then
through the lower edge of the Elastoplast
The first trouser leg is secured to one cheek and the top leg is taped across the
Elastoplast and opposite cheek
The bottom leg is wrapped around the ETT anchoring it in the correct position
Assess air entry after the first tape is applied
The second trouser leg is secured to the opposite cheek and the top leg is taped
across the upper lip
The bottom leg is wrapped around the ETT
An additional short, narrow piece of tape may be positioned across the upper lip
for reinforcement

EXTUBATION NNP/RM/RN
Nasal CPAP13, Oxygen therapy via Isolette, nasal cannula or head box is
function checked and ready for use (as ordered) Follow Link to Oxygen
Therapy

This is a two person procedure, (one of whom must be a NICC trained nurse)
Resuscitation trolley
Resuscitation bag/NEOPUFF function checked and ready for use
Perform chest physiotherapy only if ordered19 Follow Link to Chest
Physiotherapy
Suction ETT Follow Link to Suction Neonate - NICU
Reventilate for 5 minutes or until neonates vital signs are stable
Ensure MO/NNP is available
Cease feeds and commence IV fluids as prescribed Follow Link to Assembly,
Priming and Connection of Lines
Administer Respiratory stimulant17,20 or steroid18,20 if prescribed
Aspirate stomach and remove gastric tube if in situ. Retain transpyloric tube if in
situ
Gently remove tape/tabs from neonates face as described above
Remove the ETT and suction (using a size 8FG suction catheter) the

Nose
Nasopharynx
Mouth (avoid deep suctioning) Follow Link to Suction Neonate - NICU

Apply Neopuff with appropriate size mask and predetermined PEEP pressure
over the neonates nose and mouth - Follow Link to Hand Ventilation-Neopuff Womens and Babies Division
Give enough oxygen (if required) to maintain the neonate within prescribed
oxygen saturation limits
cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007
Page 12/14

Clean the face using sterile water swabs and dry


Commence alternative respiratory support as prescribed or assist with
reintubation
Monitor neonates respiratory effort and oxygenation
Position neonate prone if possible Follow Link to Positioning & Wrapping of
Neonates/Infants. Position to promote optimal neurodevelopment
Organise post extubation blood gas +/- chest x-ray as ordered
Feeds are not recommenced for at least four hours and until neonates condition
is reassessed by MO/NNP
Document procedure, date and time on the
Neonatal problem sheet (include the number of ventilated hours)
Vital signs and respiratory flow chart
Progress notes
Clean and restock resuscitation trolley

Associated Links
Overhead Radiant Heater
Hand Ventilation-Neopuff-Womens and Babies Division
Chest Physiotherapy
Naso/Oro gastric tube insertion
Neonate -NICU
Neonate NICU
Transpyloric Tube
Oxygen Therapy
Assembly, Priming and Connection of Lines
Positioning & Wrapping of Neonates/Infants

References
1. Lodha A, Ohlsson A, Shah V. Premedication for endotracheal intubation in
neonates. (Protocol) Cochrane Database of Systematic Reviews 2003, Issue
4. Art. No.: CD004499. DOI: 10.1002/14651858.CD004499. Level 1
2. Shah V, Ohlsson A. The effectiveness of premedication for endotracheal
intubation in mechanically ventilated neonates: a systematic review. Clinics
in Perinatology. 2002; 29(3):535-554 Level 11
3. Merenstein GB, Gardner SL; Handbook of neonatal intensive care. 6th edition.
2006; 67-69,610-612 Level 111-2
4. Dempsey EM, Al Hazzani F, Faucher D and Barrington KJ; Facilitation of
neonatal endotracheal intubation with mivacurium and fentanyl in the
neonatal intensive care unit; Arch. Dis. Child. Fetal Neonatal Ed. 2006; 91;
F279-F282; originally published online 7 Feb 2006;
DOI:10.1136/adc.2005.087213 Level IV
5. Neonatal Handbook, NETS Victoria, Neonatal Handbook Editorial Board,
Enquiries: Ellen Bowman & Simon Fraser.
6. DeBoer SL, Peterson LV; Sedation for Nonemergent Neonatal Intubation,
Neonatal Network, October 2001; 20(7): p.19-23
7. Spence K, Barr P. Nasal versus oral intubation for mechanical ventilation of
newborn infants. Cochrane Database of Systematic Reviews 1999, Issue 2.
Art. No.: CD000948. DOI: 10.1002/14651858.CD000948. Level 1
8. MacDonald MG, Ramasethu J; Atlas of procedures in neonatology 3rd edition
2002; Lippincott Williams and Wilkins; 253-269
cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007
Page 13/14

9. Smiths Medical Australasia Pty. Ltd. Brisbane, QLD, Australia. [monograph


on the internet] [cited on line 3/7/2007] http://www.smiths-medical.com
10. DeBoer S, Seaver M; End-tidal CO2 verification of endotracheal tube
placement in neonates, Neonatal Network, May/June 2004; 23(3): p. 29-38
Level IV
11. The Australian Resuscitation Council Online; Section 13, Neonatal
Guidelines. February 2006. [monograph on internet] [cited on line
3/07/2007]http://www.resus.org.au
12. Kattwinkel J, editor. Lesson 5 Endotracheal intubation. In: Textbook of
Neonatal Resuscitation. 5th ed. Elk Grove Village, IL: American Academy of
Pediatrics and American Heart Association; 2006. p. 5-1 to 5-42
13. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure
immediately after extubation for preventing morbidity in preterm infants.
Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.:
CD000143. DOI: 10.1002/14651858.CD000143. Level 1
14. Child, Youth, Womens Health Service. Standard and Additional Precautions.
Procedure PR2006_055; Adelaide (Australia): 2007
15. Child, Youth, Womens Health Service. Hand Hygiene and Hand Care for
Staff who have hands on Patient Care. Procedure PR2006_056; Adelaide
(Australia): 2007
16. O'Donnell CPF, Kamlin COF, Davis PG and Morley CJ; Endotracheal
Intubation Attempts During Neonatal Resuscitation: Success Rates, Duration,
and Adverse Effects Pediatrics, 2006; 117(1); 16-21 [monograph on internet]
[cited on line 3/07/2007]http://www.pediatrics.org
17. Henderson-Smart DJ, Davis PG. Prophylactic methylxanthines for extubation
in preterm infants. Cochrane Database of Systematic Reviews 2003, Issue 1.
Art. No.: CD000139.DOI: 10.1002/14651858.CD000139. Level 1
18. Davis PG, Henderson-Smart DJ. Intravenous dexamethasone for extubation
of newborn infants. Cochrane Database of Systematic Reviews 2001, Issue
4. Art. No.: CD000308. DOI: 10.1002/14651858.CD000308. Level 1
19. Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity in babies
being extubated from mechanical ventilation. Cochrane Database of
Systematic Reviews 2202, Issue2. Art. No.: CD000283.
DOI:10.1002/14651858.CD000283. Level 1
20. Neonatal Medication Manual. Womens and Childrens Hospital 2006
21. Pedi-Cap Tyco Healthcare Group LP. Nellcor Puritan Bennett Division. USA
22. Fisher and Paykel Healthcare. [monograph on interent] [cited on line
28/06/2007]http://www.fphcare.com
23. NeoBar Endotracheal Tube Holder [monograph on internet] [cited on line
28/06/2007 http://www.neotechproducts.com
24. Anaesthesia & Analgesia. 2005; 100:1854-1855 2005 International
Anaesthetic Research Society. doi: 10.12/01.ANE.000015290.42078.91

Disclaimer

Copyright

cs2007_452 ETT - NICU CSRG Endorsed 08/08/2007


Page 14/14