Endotracheal Intubation Management RPAH PC2022 014

SLHD – Royal Prince Alfred Hospital
Procedure
Women and Babies: Endotracheal Intubation and Management
TRIM Document No. SD 22 / 103128 (POL/889)
Policy Reference No. RPAH_PC2022_014
Related MOH Policy N/A
Keywords Endotracheal intubation, Neonate
All nursing, midwifery and medical staff in RPA Newborn

Applies to
Care
Clinical Stream(s) Women’s Health, Neonatology and Paediatrics
Date approved by RPA

25/11/2022
General Manager
Date approved by Clinical

25/11/2022
Council
Date approved by RPA

23/11/2022
Policy Committee
Maria Daco, Transitional Nurse Practitioner; Professor Karen

Author
Walker CNC
Status Active
Review Date November 2027
Risk Rating M
Replaces RPAH_GL2016_040
Version History V.1
Current Version V.1 – 29/11/2022

Sydney Local Health District – Royal Prince Alfred Hospital Policy No: RPAH PC2022_014__
Date Issued: November 2022
Women and Babies: Endotracheal Intubation and Management
Contents
Contents ............................................................................................................................... 2
1. Introduction ................................................................................................................. 3
2. The Aims of This Procedure ....................................................................................... 3
3. Risk Statement ............................................................................................................ 3
4. Scope ........................................................................................................................... 3
5. Education and Training ............................................................................................... 4
6. Implementation ............................................................................................................ 4
7. Key Performance Indicators and Service Measures ................................................. 4
8. Procedure .................................................................................................................... 4
Communication prior to intubation .......................................................................... 4
Equipment .............................................................................................................. 4
Preparation............................................................................................................. 5
Intubation Procedure .............................................................................................. 6
8.4.1 Pre-intubation........................................................................................................... 6
8.4.2. Laryngoscopy and ETT Insertion ............................................................................. 7
8.5 Verify Correct ETT Placement ..................................................................................... 8
8.6 Securing the ETT ........................................................................................................ 9
8.6.1 Securing oral ETT .................................................................................................... 9
8.6.2 Securing nasal ETT ................................................................................................ 10
8.7 Reattempts ............................................................................................................... 11
8.8 Supraglottic Airway ................................................................................................... 11
9. Immediate Post Procedure Care ................................................................................. 11
9.1 Respiratory Assessment ........................................................................................... 11
9.2 Nursing Care ............................................................................................................. 11
9.3 Communication ......................................................................................................... 12
9.4 Documentation of Procedure..................................................................................... 12
9.5 Complications of Endotracheal Intubation17, 18 .......................................................... 12
10. Definitions ................................................................................................................... 12
11. Consultation ............................................................................................................... 13
12. Resources, Links and Tools ...................................................................................... 13
13. References .................................................................................................................. 13
14. National Safety and Quality Standard/s, 2nd ed ........................................................ 14
15 Appendix 1: Intubation Time Out ............................................................................. 14
Compliance with this Procedure is Mandatory

2
SLHD – RPA Women and Babies: Endotracheal Intubation and

Management
1. Introduction
Endotracheal intubation refers to the process of inserting an endotracheal tube (ETT) through
the vocal cords to the upper trachea in order to deliver positive pressure ventilation. In
neonates, endotracheal intubation may need to be performed in an emergency, as well as
elective settings.
Indications for emergency intubation include:

• When ventilation via facemask (or supraglottic airway) is unsuccessful or prolonged
despite correct technique 1
• In infants born without a detectable heart rate, intubation should be considered as soon
as possible after birth 1
• Infants with anatomical or surgical conditions exacerbated by non-invasive respiratory
support - including congenital diaphragmatic hernia and intestinal perforation1
• For infants with respiratory failure despite nasal continuous positive airway pressure
(nCPAP) or non-invasive pressure ventilation (NIPPV). (See guidelines CPAP and
Non-invasive Ventilation). Diagnosis of respiratory failure depends on the clinical
situation, but in general includes infants with:
o Pre-ductal SpO2 < 90% with FiO2 delivery of 0.6 to 0.8
o PaCO2 > 75 mmHg with pH < 7.2
Indications for elective intubation include:

• To deliver prophylactic surfactant via ETT in the delivery room to preterm infants born
<28 weeks gestation or if enrolled in the intubation arm of the EPINIST trial (see
EPINIST and guideline for Surfactant - Preterm)
• To administer surfactant and provide respiratory support in infants > 28 weeks with
respiratory distress syndrome (see guidelines for Surfactant - Preterm and Surfactant –
Term)
• To administer surfactant and provide respiratory support in infants with meconium
aspiration syndrome (see guideline Surfactant – Term)
• For infants requiring sedation for a medical procedure, such as laser treatment for
retinopathy of prematurity (N.B. Due to its level of difficulty, intubation for sedation for
laser treatment should be performed by a fellow or consultant)
2. The Aims of This Procedure

• Neonatal clinicians will recognise the need for intubation and safely intubate a neonate
• Strategies to prevent unplanned intubations will be implemented
3. Risk Statement
SLHD Enterprise Risk Management System (ERMS) Risk # 105 – Minimise adverse events
related to intubation procedure
• Safe intubation of newborn will prevent morbidity associated with intubation
• Appropriate management of an intubated neonate will prevent unplanned extubations

3
4. Scope
This procedure applies to all clinical staff in the Neonatal Intensive Care Unit (NICU) at RPA
Hospital
5. Education and Training

• Unit based delivery of in-service as required
• Neonatal intubation and ETT management education sessions
• Neonatal Resuscitation Skills workshop
• Nursing staff work packages
6. Implementation
• Procedure available on RPA Newborn Care SharePoint, Newborn Care Webpage and
SLHD Intranet
• Distribution of guideline via email to NICU staff
• Education for clinical staff including during orientation
7. Key Performance Indicators and Service Measures

• Audit of IMS+ related to intubation of the neonate
8. Procedure
Communication prior to intubation
• If required, call for assistance early (Neonatal Fellow or Consultant), and inform them
of the situation and need for intubation
• Ensure parents are aware for elective intubation and that their questions have been
answered
Equipment
• NeopuffTM with appropriately sized mask - connected to O2/air blender
• Suction catheters (long or short as per clinicians’ preference) - 6Fg, 8Fg or 10Fg
• Neonatal endotracheal tube – size appropriate for neonate (see section 8.3)
• Stylet (Optional for oral intubations. Not used in nasal intubation. Please ensure a new
stylet is used each time)
• Magill forceps (neonatal size)
• End-tidal CO2 detector (Pedi-CapTM)
• Neonatal stethoscope
• Lubrication jelly (for nasal intubations)
• Supplies for securing ETT (Comfeel dressing, LeukoplastTM brown tape, scissors,
CavilonTM skin preparation)
• Ventilator
• Laryngoscope handle with appropriately sized blade:
Size 00 Extremely low birthweight infants
Size 0 Preterm infants <32 weeks
Size 1 Term infants or larger preterm infants

4
Table 1. Laryngoscope blade size recommendations as per The Australian and New Zealand Committee on
Resuscitation (ANZCOR) 1
Preparation
Prepare pre-intubation medications where required
(see guideline Intubation and Sedation Medications in the Neonate)
• Medical staff print out the eANMF consensus group prescription sheet (from NICUS),
and prescribe medications on medication chart as per guideline
• Nursing staff prepare medications
• Insert intravenous cannula, or ensure intravenous cannula in situ is patent
• Calculate length to insert ETT (Table 2)
Corrected Current weight ETT size ETT mark at lip ETT mark at
gestation (kg) (cm) nostril (cm)
(weeks)
23 - 24 0.5 – 0.6 2.5 5.5 6.5
25 - 26 0.7 – 0.8 6.0 7.0
27 - 29 0.9 – 1.0 6.5 7.5
30 – 32 1.1 – 1.4 2.5 – 3.0 7.0 8.0
33 - 34 1.5 – 1.8 3.0 7.5 8.5
35 - 37 1.9 – 2.4 8.0 9.0
38 - 40 2.5 – 3.1 3.5 – 4.0 8.5 10
41 - 43 3.2 – 4.2 9.0 11
1,
Table 2: Recommended ETT length to the nearest 0.5 cm by corrected gestation and weight at time of intubation
2, 3
• Check Neopuff correctly set and functioning, with an appropriate size mask
o Neopuff flow set to 8L/min and adjust the O2/air blender to deliver the desired
oxygen concentration
• Set suction at -100mmHg
• Ensure fixation tapes prepared (Figure 1)
o Comfeel strips cut approximately the length
of infant’s cheek.
o Brown tape cut a little shorter than the ear to
ear length of the infant, and cut into two
‘trouser leg’ strips with the ends folded back
over the adhesive side to facilitate easy
removal
Figure 1. Fixation tapes
• If using for an oral intubation, insert a new stylet into ETT, ensuring stylet does not
pass beyond the tip of the ETT. Bend proximal end of stylet over the plastic adapter of

5
the ETT to prevent inadvertent movement during intubation. Ensure ETT maintains
anatomical curve
• At least two ETT’s of the correct size should be placed on the prepared trolley with a
size below and above easily accessible to the proceduralist.
• Ensure appropriate monitoring (cardiorespiratory and pulse oximetry) in situ
• Check ventilator by infant bedside and confirm appropriate settings
Recommended initial ventilator settings for Dräger Babylog VN500

(As per Conventional Ventilation guideline)
Initial setting
Mode AC - PC +VG
Tidal volume VTe ≤ 1000 g = 4.5 mL / kg
> 1000 g = 4 mL / kg
Rate Resuscitation: 60 bpm
Back up: 40 bpm
Peak inspiratory 25 mmHg
pressure (PIP or
Pmax)
End expiratory 5 cmH2O
pressure (EEP)
Inspiratory time (Ti) 0.3 seconds
Expiratory time (Te) Automatically adjusted depending on rate
Intubation Procedure
Infants may be orally or nasally intubated. Neither route has been found to be superior in
terms of reducing tube malposition, accidental extubation, endotracheal obstruction, re-
intubation, infection or local trauma. 4 There is limited good quality evidence to recommend the
use of either cuffed or uncuffed endotracheal tubes in neonates. 4 In RPA Newborn care,
uncuffed neonatal ET tubes are used. A stylet may be used for oral intubations to make the
ETT more rigid and support tube advancement through the cords. However, there is limited
evidence to suggest that its use significantly improves the rate of successful orotracheal
intubations. 5
Moderate to very low-quality evidence suggests that video-laryngoscopy increases intubation

success in neonatal trainees.6 However, this method is not associated with a decrease in
intubation time or the number of attempts.6, 7 Moreover, the efficacy, safety, and cost-
effectiveness of its use have not yet been established.6
8.4.1 Pre-intubation
• Ensure privacy screens utilised and team ready for procedure
• Perform hand hygiene and don PPE as per infection guidelines
• Allocate roles
o Proceduralist who will intubate +/- senior clinician support
o Airway clinician to suction, apply cricoid pressure, tape ETT
o Medication administrator
o Scribe/monitor vitals
• Perform Intubation Time Out (see Appendix 1)

6
• Position the infant supine with head at the edge of the mattress – it may be necessary
to extend the mattress tray out to allow optimal access and position
• Ensure the infant is protected from excessive heat loss
• Aspirate intra-gastric tube (IGT) to prevent vomiting or aspiration during procedure.
The IGT can then be left in and used to guide/orientate, or removed to allow for an
unobstructed view at the discretion of the operator
• Administer pre-intubation medications if using (see Intubation and Sedation
Medications in the Neonate guideline for order of medications)
• Optimise ventilation with Neopuff, IPPV and increase oxygen and settings as required
to maintain saturations appropriate for gestation
8.4.2. Laryngoscopy and ETT Insertion

1. Once infant is muscle relaxed (if
using muscle relaxant
medication), hold laryngoscope
with left hand. Use fingers of
right hand to open the mouth
2. Gently insert laryngoscope
blade into the right corner of the
mouth and over tongue (Figure
2)8
3. Advance the blade to sweep
tongue out of view Figure 2. Modified from Cunningham FG, Leveno KJ,
4. Lift laryngoscope handle at a 45- Bloom SL, et al (eds). Williams Obstetrics. 23rd ed. New
degree angle in a forward and York, NY: McGraw-Hill; 2018
upward motion to obtain view of
the vocal cords. Do not rock
laryngoscope handle backward
as this can cause injury and
decrease space in the oral
cavity. Keeping wrist straight will
help prevent inadvertent rocking
5. As the blade is advanced into
the larynx and lifted, the
epiglottis will come into view
6. Suction as needed to optimize
view
7. Either position the laryngoscope
blade under the epiglottis to lift it
Figure 3: Blade under epiglottis9
directly (Figure 3)

7
8. Cricoid pressure can be applied

to assist in visualising the glottis.
This is done by placing light
pressure on the cricoid cartridge
to push the vocal cords into view
9. Identify vocal cords. (N.B. Vocal
cords are often anteriorly located
in preterm babies)
Figure 4 Modified from www.lhsc.on.ca
10.Once vocal cords identified,

receive ETT in right hand
11.Insert the ETT in from the side of
the mouth to allow visualisation
as it passes through the cords
12.Insert to the end of black mark at
the tip of the ETT
13.If used, carefully hold the ETT in
place while an assistant removes
the stylet (check stylet intact).
14.Attach Pedi-cap to assist in
confirming endotracheal
intubation (see section 8.5) Figure 5. Modified from Cunningham FG, Leveno KJ, Bloom
SL, et al (eds). Williams Obstetrics. 23rd ed. New York, NY:
McGraw-Hill; 2018
8.5 Verify Correct ETT Placement

• Verification of successful endotracheal intubation include: 1, 10, 11
o Direct visual confirmation of the ETT going through the vocal cords
o Chest movement with each inflation
o Improvement in heart rate (if the heart rate was low at time of intubation)
o Improvement in oxygenation (as demonstrated by pulse oximetry)
o Mist condensation on inside of ETT during exhalation
o Auscultation with a stethoscope of breath sounds over both lung fields
o Detection of exhaled CO2 with an end tidal CO2 detector.
▪ Successful endotracheal intubation using a CO2 detector is confirmed if
the window changes to gold/yellow during expiration (Figures 6-9).
▪ Extremely low birthweight infants, or those that have poor gas exchange
may not have sufficient flow to generate adequate CO2 response even
when ETT is correctly placed. If other signs of correct endotracheal
intubation are evident, recommend using CO2 detector with caution to
avoid unnecessary extubation and re-intubation)
• Once successful intubation confirmed, adjust ETT to pre-calculated length
• Continue to Neopuff, or attach the ETT to a ventilator
NB: The ETT should be firmly held against the palate or at the nares until the tapes
have been secured in place

8
Connecting the Pedi-Cap
Figure 6. Pedi-Cap Figure 7. Connection to ETT Figure 8. Connection to Figure 9. Gold colour change
Neopuff indicating correct placement
8.6 Securing the ETT

Securing the ETT at the correct position (T2 on x-ray) is essential to ensure effective
ventilation and prevent accidental extubation. There are numerous methods of securing an
ETT, however, there is insufficient data to determine the best method to secure an ETT in
neonates.12 At RPA Newborn Care, the current practice is to maintain skin integrity with
Comfeel and secure the ETT using two or three strips of brown tape cut in ‘trouser legs’ – see
diagrams below.
8.6.1 Securing oral ETT

1. Apply Cavilon (use with caution in babies
under 27 weeks) on the infant’s lower
cheeks
2. Once Cavilon is dry, place the Comfeel
strips on the lower cheeks
3. Starting from the cheek proximal to the
ETT, tape the trouser legs on the infant’s
cheek, over the Comfeel avoiding the ear
(Figure 10)
4. Secure the upper trouser leg above the
infant’s top lip and on to the other
cheek
Figure 10.
5. Confirm centimetre marking of ETT at

the lips
6. Tape the lower trouser leg around and
up the ETT Figure 11)
7. The ETT should be secured tightly in the
corner of the mouth
Figure 11

9
8. The second set of trouser legs should

be taped on the opposite cheek, with the
lower trouser left on the infant’s chin
to the other cheek
9. Tape the upper trouser leg up and
around the tube (Figure 12)
Figure 12
8.6.2 Securing nasal ETT
1. Apply Cavilon on the infant’s cheeks.

Once dry, tape the Comfeel strips on the
cheeks
2. Starting on side proximal to the ETT,
tape the trouser legs to the infant’s
cheek over the Comfeel avoiding the
ear.
3. Secure the lower trouser leg under the
nose and on to the other cheek. (Figure
13).
Figure 13
4. Secure the ETT by winding the upper

trouser leg around and up the tube
achieving maximum surface area
coverage (Figure 14).
5. Do not reduce ETT lumen by winding
too tightly.
Figure 14

10
Sydney Local Health District – Royal Prince Alfred Hospital Policy No: RPAH_PD20xx_0xx
Date Issued: xxx 2022
6. Tape the second set of trouser legs on

the infant’s opposite cheek and secure
the upper trouser leg over the top of
the nose and on to the other cheek
(Figure 15).
7. Secure the ETT by winding the lower
trouser leg around and up the tube
Figure 15
8. For larger and/or more active babies a

third set of trouser legs is used to secure
the ETT to the bridge of the nose and
glabella (Figure 16).
9. The third set of trouser legs can be
taped to the bridge of nose. The ETT is
then secured by winding both trouser
legs individually up and around the
ETT
Figure 16
.
8.7 Reattempts
• Consider suspending the procedure if prolonged (> 30 secs) or if there is sustained
drop in the heart rate and/or SpO2 and restabilise with O2 via Neopuff until the infant
recovers
• Administer additional medications if required
• Junior medical staff and nurse practitioners should have a maximum of two attempts at
intubation before a more experienced clinician performs the procedure
8.8 Supraglottic Airway

In an emergency setting, a supraglottic airway
should be considered in infants >34 weeks or 2000g
if tracheal intubation is unsuccessful or unfeasible 1
At RPA Newborn Care the i-gel Newborn size 1

uncuffed supraglottic airway is used.
9. Immediate Post Procedure Care
9.1 Respiratory Assessment

• Auscultate for equal breath sounds and assess work of breathing of the infant

11
• Order chest x-ray to confirm correct ETT position. The ETT tip should be at T2 – T3,
above the carina
Please refer to the Conventional Ventilation guideline for ongoing ventilation settings,
management and troubleshooting of the ventilator.
9.2 Nursing Care

Nursing care is aimed at ensuring safety and preventing adverse events including
unplanned extubation.
• Nursed 1:1 and nurse must remain at the infant’s bedside at all times
• Two clinicians are required during any positioning/handling, with one nurse
responsible for the airway 13, 14
• Ensure standardized taping as per this guideline 13, 14, 15
• Ensure the infant’s head is in a neutral position for x-rays with the ETT in alignment
with the trachea13,
• Confirm and document correct ETT measurement at nostril/lip14
• Re-tape ETT if position needs adjustment, do not nurse on a stretch with tension on
the tapes
• An IGT must be in situ
• Obtain arterial/capillary blood gases as required
• Ensure optimal sedation of the infant if prescribed13, 14,16
9.3 Communication
• Ensure parents have been updated following the procedure and address any
question or concerns
9.4 Documentation of Procedure

• Document procedure on eMR. Including:
• Pre-intubation medication used
• Time and route of intubation
• ETT size and measurement of ETT at the lips or nares
• Position of ETT tip on x-ray
• Update Respiratory and other relevant sections on NICUS
• The following information should be documented in the infant’s eMR or NICU chart:
o Initial ventilator settings post intubation and assessment of infant after
intubation
o Any changes to ventilator settings or to infant’s condition
▪ If ventilation settings changed, document the clinician who
ordered the change, the change(s) made, and the time
o Notification of the parents regarding the procedure
o Update Respiratory, Medications and other relevant sections on eMR
9.5 Complications of Endotracheal Intubation17, 18

• Incorrect placement – (oesophageal, bronchial intubation)
• Airway trauma (laceration or bleeding of the vocal cords, perforation of the airway)
• Oesophageal trauma from inadvertent oesophageal intubation
• Vomiting and aspiration of gastric contents
• Haemodynamic instability: Hypertension, tachycardia, bradycardia, arrhythmia

12
• Loss of skin integrity. This can result from excessive oral/nasal secretions, pulling of
tape with movement, or pressure from a poorly positioned and/ or taped ETT
• ETT obstruction (e.g. tenacious secretions)
• Unplanned extubation
10. Definitions
EPINIST Extremely Preterm Infant Non-Invasive Surfactant Trial

ETT Endotracheal tube
IGT Intra-gastric tube
IPPV Intermittent positive pressure ventilation
MIST Minimally Invasive Surfactant Therapy
nCPAP Nasal continuous positive pressure ventilation
NICUS Neonatal Intensive Care Unit Study Group
PPE Personal protective equipment
11. Consultation
Neonatologists, RPA Newborn Care
Neonatal Nursing and Midwifery Clinicians, RPA Newborn Care
RPA Guideline Committee
12. Resources, Links and Tools

Women and Babies: Surfactant in Term Infants RPAH_GL2016_025:
Women and Babies: Surfactant in Preterm Infants RPAH_GL2018_000
Neonatal Non-invasive Ventilation SLHD_GL2018_043
13. References
1. ANZCOR Guideline 13.5: Tracheal intubation and ventilation of the newborn infant.
Australian Resuscitation Council 2016. [Cited June 29, 2022]. Available from:
https://resus.org.au/the-arc-guidelines/
2. Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal
intubation. Resuscitation 2008; 77:369-73.
3. Coldiron JS. Estimation of nasotracheal tube length in neonates. Pediatrics.
1968;41:823-8.
4. 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. Accessed 29 June 2022.
5. Dariya V, Moresco L, Bruschettini M, Brion LP. Cuffed versus uncuffed endotracheal
tubes for neonates. Cochrane Database of Systematic Reviews 2022, Issue 1. Art. No.:
CD013736. DOI: 10.1002/14651858.CD013736.pub2. Accessed 29 June 2022.
6. Hu, X., Jin, Y., Li, J., Xin, J., Yang, Z. (2020). Efficacy and safety of videolaryngoscopy
versus direct laryngoscopy in paediatric intubation: A meta-analysis of 27 randomized
controlled trials. Journal of Clinical Anaesthesia, Vol 66, Article number 109968.
7. Lingappan, K., Arnold, J. L., Fernandes, C. J., & Pammi, M. (2018). Videolaryngoscopy
versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database of
Systematic Reviews, (6).

13
8. Cunningham, F. G., Leveno, K. J., Bloom, S., Gilstrap, L., & Cunningham, F. G.
(2010). Williams Obstetrics (23rd Edition). New York, USA: McGraw-Hill Professional
Publishing.
9. Linday Johnson. “Neonatal Teacheal Intubation” Lindsay Johnson for
OPENPediatrics. https://www.youtube.com/watch?v=lGTaA_UdIXw. November
23, 2016. Accessed September 29, 2022
10. Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide
detector role in endotracheal intubation in newborns. J Perinatol. 1999;19(2):110-3
11. Neonatal resuscitation in the Delivery Room – Endotracheal Intubation. UpToDate.
Accessed 20 September 2022. Available from:
https://www.uptodate.com.acs.hcn.com.au/contents/neonatal-resuscitation-in-the-
delivery-
room?search=neonatal%20intubation&sectionRank=1&usage_type=default&anchor=H
19&source=machineLearning&selectedTitle=1~150&display_rank=1#H19
12. Lai M, Inglis GDT, Hose K, Jardine LA, Davies MW. Methods for securing endotracheal
tubes in newborn infants. Cochrane Database of Systematic Reviews 2014, Issue 7.
Art. No.: CD007805. DOI: 10.1002/14651858.CD007805.pub2. Accessed 29 June
2022.
13. Crezee KL, DiGeronimo RJ, Rigby MJ, Carter RC, Patel S. Reducing Unplanned
Extubations in the NICU Following Implementation of a Standardized Approach. Respir
Care. 2017;62(8):1030-1035. doi:10.4187/respcare.04598, 10.4187/respcare.04598
14. Mahaseth, M., Woldt, E., Zajac, M. E., Mazzeo, B., Basirico, J., & Natarajan, G. (2020).
Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The
Elusive Benchmark. Pediatric quality & safety, 5(6), e337.
https://doi.org/10.1097/pq9.0000000000000337
15. Fontánez-Nieves, T., Frost, M., Anday, E. et al. Prevention of unplanned extubations in
neonates through process standardization. J Perinatol 36, 469–473 (2016).
https://doi.org/10.1038/jp.2015.219
16. da Silva PSL, Reis ME, Farah D, Andrade TRM, Fonseca MCM. Care bundles to
reduce unplanned extubation in critically ill children: a systematic review, critical
appraisal and meta-analysis. Arch Dis Child. 2022 Mar;107(3):271-276. doi:
10.1136/archdischild-2021-321996. Epub 2021 Jul 20. PMID: 34284999.
17. Divatia, JV, Bhowmick, K. Complications of Endotracheal intubation and other airway
management procedures. Indian Journal of Anaesthisia 2005;49(4): 308-318.
18. Page, NE, Giehl, M, Luke, S. Intubation complications in the critically ill child. AACN
Clinical Issues Advance Practice in Acute Critical Care 1998;9(1): 25-35.
14. National Safety and Quality Standard/s, 2nd ed

Clinical Governance Standard
Partnering with Consumers Standard
Preventing and Controlling Healthcare-Associated Infection Standard
Medication Safety Standard
Comprehensive Care Standard

Communicating for Safety Standard

14
15 Appendix 1: Intubation Time Out
Intubation Time Out Checklist

Initial Preparation
 Fellow/Consultant aware
 Parents aware (elective intubation)
 Pre-intubation medications charted
Equipment Safety Checks
 Cardiorespiratory and pulse oximetry monitoring in situ
 Neopuff correctly set and functioning, with an appropriate size mask
 Suction equipment ready for use
 Intubation equipment checked and ready for use
 All staff in PPE
 Medication: doses correctly drawn; second doses available if needed
Assignment of Roles
 Proceduralist and back-up clinician identified
 Airway nurse – assist with suction, provide cricoid pressure, tape ETT
 Medication administrator
 Scribe/monitor patient vitals
Patient Assessment
 Patient positioned appropriately
 IV access in situ/checked
 Feed withheld/gastric contents aspirated
Final Checks
1. Confirm patient identification
2. Discuss anticipated complications including difficult airway scenario
3. Team members present and ready
4. Administer medications and prepare to intubate

15

Endotracheal Intubation Management RPAH PC2022 014

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endotracheal Intubation Management RPAH PC2022 014

Uploaded by

Copyright:

Available Formats

SLHD – Royal Prince Alfred Hospital

Policy Reference No. RPAH_PC2022_014

Related MOH Policy N/A

Keywords Endotracheal intubation, Neonate

All nursing, midwifery and medical staff in RPA Newborn

Clinical Stream(s) Women’s Health, Neonatology and Paediatrics

Date approved by RPA

Date approved by Clinical

Date approved by RPA

Maria Daco, Transitional Nurse Practitioner; Professor Karen

Review Date November 2027

Version History V.1

Current Version V.1 – 29/11/2022

Women and Babies: Endotracheal Intubation and Management

Compliance with this Procedure is Mandatory

SLHD – RPA Women and Babies: Endotracheal Intubation and

Indications for emergency intubation include:

Indications for elective intubation include:

2. The Aims of This Procedure

Compliance with this Procedure is Mandatory

5. Education and Training

7. Key Performance Indicators and Service Measures

Size 00 Extremely low birthweight infants

Size 0 Preterm infants <32 weeks

Size 1 Term infants or larger preterm infants

Compliance with this Procedure is Mandatory

23 - 24 0.5 – 0.6 2.5 5.5 6.5

25 - 26 0.7 – 0.8 6.0 7.0

27 - 29 0.9 – 1.0 6.5 7.5

30 – 32 1.1 – 1.4 2.5 – 3.0 7.0 8.0

33 - 34 1.5 – 1.8 3.0 7.5 8.5

35 - 37 1.9 – 2.4 8.0 9.0

38 - 40 2.5 – 3.1 3.5 – 4.0 8.5 10

41 - 43 3.2 – 4.2 9.0 11

Compliance with this Procedure is Mandatory

Recommended initial ventilator settings for Dräger Babylog VN500

Moderate to very low-quality evidence suggests that video-laryngoscopy increases intubation

Compliance with this Procedure is Mandatory

8.4.2. Laryngoscopy and ETT Insertion

Compliance with this Procedure is Mandatory

8. Cricoid pressure can be applied

Figure 4 Modified from www.lhsc.on.ca

10.Once vocal cords identified,

8.5 Verify Correct ETT Placement

Compliance with this Procedure is Mandatory

Connecting the Pedi-Cap

8.6 Securing the ETT

8.6.1 Securing oral ETT

5. Confirm centimetre marking of ETT at

Compliance with this Procedure is Mandatory

8. The second set of trouser legs should

8.6.2 Securing nasal ETT

1. Apply Cavilon on the infant’s cheeks.

4. Secure the ETT by winding the upper

Compliance with this Procedure is Mandatory

6. Tape the second set of trouser legs on

8. For larger and/or more active babies a

8.8 Supraglottic Airway

At RPA Newborn Care the i-gel Newborn size 1

9. Immediate Post Procedure Care

9.1 Respiratory Assessment

Compliance with this Procedure is Mandatory

9.2 Nursing Care