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Management of the difficult airway, neonates

Where ventilation is adequate through bag-mask ventilation however intubation is proving difficult, it is important to remember that repeated intubation attempts can damage the airway and make bag-mask ventilation more difficult... Call a 2nd consultant. Consider try a different-sized laryngoscope blade which may improve the view of the cords. If familiar with the use of a bougie, consider inserting through the cords and ‘railroading’ the ETT over this.

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 Difficult Intubation In A Newborn

You never know when you will encounter difficult ventilation or intubation, even in a newborn. You must always be prepared with a plan and the equipment and people you need to carry out that plan.

 Improving neonatal intubation safety: A journey of a thousand miles

In this commentary we reviewed 4 elements of neonatal intubation; intubation success rates and complications, intubation training, intubation safety research, and the use of videolaryngoscopy. Understanding each of these elements has an important role in making intubation safer for the fragile neonates we care for.

 Neonatal Intubation and RSI

While brawn may overpower a neonate’s jaw muscles, it does not make intubation easier… as it is more complex than just getting past the mouth.

 Size compatibility of airway equipment in children, ETT and LMA

Tubes, LMAs and bougies...

Articles of Interest

Endotracheal Tube Intubation: Assisting (Neonatal)

Intubation attempts should take no longer than 30 seconds. If more than one intubation attempt is required, ventilation using a self-inflating resuscitation bag, flow-inflating resuscitation bag, or a T-piece resuscitator with a tight-fitting face mask should be performed before each subsequent attempt until the patient recovers.

Airway management in neonates and infants

Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants.

Episode 142 Neonatal Resuscitation

The goal is to establish an advanced airway in <40 seconds, as delays beyond this are associated with increased morbidity and mortality. Strongly consider using a supraglottic airway (SGA) rather than BVM and endotracheal intubation in neonates ≥34 weeks GA and ≥1.5kg requiring advanced airway management. A Cochrane review in 2018 found that SGA demonstrated comparable efficacy to endotracheal intubation. When compared to BVM, SGA was associated with shorter resuscitation and ventilation times, and less requirement for endotracheal intubation.

Intubation in neonatal resuscitation — Compelling necessity or incalculable risk?

In recent years, the emergency intubation of adult and pediatric patients has declined in priority since it does not appear to improve the patient outcome and, in fact, potentially has detrimental effects. This is also reflected in the European Resuscitation Council (ERC) Adult and Paediatric Advanced Life Support Courses (ALS and EPALS), where much more attention is being paid to focusing, for example, on sufficient mask ventilation. Amongst neonatologists and pediatric intensivists, there is a consensus that neonatal intubation in particular is extremely difficult and associated with numerous risks.

Making intubation safer for the most fragile babies

Even in our NICU, with most of this in place, over 10% of the very immature babies need more than 2 attempts to intubate, we have to find ways to do better than that, to reduce the number and the consequences of failed intubation attempts. During the study that I referred to, of the tiny baby team, we did not have a video-laryngoscope blade that worked for the extremely low birth weight baby, newer technology, and perhaps ever-more realistic high-fidelity mannequins, may help us to further reduce failure rates.

Neonatal endotracheal intubation: How to make it more baby friendly

Neonatal endotracheal intubation is commonly accompanied by significant disturbances in physiological parameters. The procedure is often poorly tolerated, and multiple attempts are commonly required before the airway is secured. Adverse physiological effects include hypoxemia, bradycardia, hypertension, elevation in intracranial pressure and possibly increase in pulmonary vascular resistance. Use of premedications to facilitate intubation has been shown to reduce but not eliminate these effects

Neonatal Intubation: Past, Present, and Future

Neonatal intubation is a lifesaving skill that has been performed by clinicians for over 200 years. Throughout history, the techniques used for neonatal intubation have improved and will continue to advance in the future. Although the incidence of neonatal intubation has decreased over time, the focus on neonatal intubation safety has increased. Current and future efforts to improve neonatal intubation success and safety are critical to improving neonatal outcomes.

Resuscitating the Neonate

Intubation is a skill integral to emergency medicine, but there are some aspects of intubating a neonate that differ from the more commonly encountered adult intubations. Note that full-term neonates have sizable occiputs and a small shoulder roll may be required to attain proper airway alignment given the profoundly anterior larynx. Uncuffed ET tubes, Miller blades, and size variations based on birth weight and gestational age are standard. Use of a stylet is optional. Neonates should not be paralyzed; remember that one may see closed or moving vocal cords. Be patient and wait for the neonate to breathe and open the cords before attempting to pass the tube. These babies have no reserve and will become hypoxic very quickly; intubation attempts should be no longer than 30 seconds in duration. Confirm placement as for an adult intubation.

The neonatal airway

When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.