cs2007_452
23 August 2007
Individual Health Care Care Planning and
Delivery
Summary
Replaces
Lead Writer
Lead Writer Contact
Others Involved In Writing
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
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
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
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
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Google Images
Miller blades
Fibre-optic blades
Google Images
ORAL/NASAL 11,12
2.00mm
2.5mm
3.0mm
3.5mm
3.5-4.0mm
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
13
12
11
10
30
32
34
36
38
40
42
44
46
48
50
52
54
56
58
Alternatively when the weight is known the following formula can be used
60
Process
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
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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
Maintain the position of the tube in the trachea and secure in place (Blue line of
ETT should be positioned towards the left ear)
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
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
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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
ETT size
Length at which cut and taped
Date
Time
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
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
Then
For emergency removal, carefully cut thin portion of the NeoBar with blunt
scissors, at junction of bar and tab
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
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
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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
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