The Neonatal Airway

The Neonatal Airway

and Neonatal Intubation

Goals of Presentation

Recognize differences between neonatal

and adult airway

Review neonatal intubation technique and

equipment

Review common mistakes and

complications of intubation

Examine syndromes commonly associated

with difficult neonatal airways

Why do we care?

Prompt intubation of a distressed neonate

can be life-saving

Increasingly premature population

Residents are getting less training at this

RRC limitation of intensive care training

(1994)

Revision of NRP protocols (2000)

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

from 1992-2002 9190 attempts recorded

What did they find? Successful intubation on each attempt

• PGY1 33%, PGY2 40%, PGY3 40%

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

Total intubations successful during residency • 1994 – 24(+/- 14), 2002 – 4(+/-2)

Conclusion “Pediatric trainees are currently provided inadequate

experience to allow development of proficiency at neonatal intubation.”

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

The Neonatal Airway

Compared to adults,

structures are…

Smaller

More anterior

Epiglottis is floppier

Larger tongue

Larger occiput

Narrowest portion of

airway is the cricoid

Airway Anatomy

Embryology

Larynx from 4th and 5th

arches

Primitive larynx altered

by hypobranchial

eminence, epiglottis,

arytenoids

Laryngeal lumen

obliterated and

recanalized

Indications for Intubation

In delivery room

Cardiorespiratory instability

Meconium during birth, with a depressed

infant

Prematurity requiring need for surfactant

therapy

Congenital malformations

Indications for Intubation

In NICU

Unable to protect airway

Hypercarbic respiratory failure

Hypoxic respiratory failure

Therapeutic indication

What do you need?

Monitors - Cardiac and pulse oximetry

Suction - Yankauer or catheter

Machine - Laryngoscope, ventilator or

bag/mask

Airway - Endotracheal tube

Intravenous - Peripheral or central line

Drugs --

Sedation/analgesia/paralysis/atropine

Laryngoscope Blades

Straight blades are

placed under the

epiglottis and used to

lift anteriorly to

expose the cords.

Curved blades are

placed in the valecula

and lifted anteriorly to

expose the cords.

Macintosh

Miller

Wisconsin

Endotracheal Tubes

Endotracheal tubes are divided by the size

of their internal diameter

For neonates endotracheal tube size

roughly corresponds to 1/10th of

gestational age rounded down to the

nearest size.

For example

• A 36 week premie would get a 3.5 ETT

• A 28 week premie would get a 2.5 ETT

Intubation Procedure

Proper positioning

Equipment • Bed and patient at comfortable height

• Suction and meconium aspirator readily available

• Endotracheal tubes not under warmer

• All equipment tested and working just prior to use

Patient • Shoulder roll

• Head in sniffing position Too much hyperextension can make visualization difficult


Pre-oxygenate with 100% bag valve mask ventilation

Contraindicated in known congenital diaphragmatic hernia

Apply monitors

Give drugs

Remember minimum atropine dose

Ensure ability to bag/mask ventilate before paralysis


Inserting the

laryngoscope blade

Hold laryngoscope in

left hand

While standing above

the patient, insert the

blade in the right side

of the mouth

WITHOUT trying to

visualize the cords.


Take a step back

Lower your head to

the level of the label

Slowly advance

laryngoscope until

you visualize the

epiglottis

Use straight or curved

blade appropriately


Visualize the vocal

cords

Meconium below

cords?

Both moving if not

paralyzed?

Structurally normal?

Pick up endotracheal

tube and pass

between vocal cords

Assessing Endotracheal Tube

Placement

Direct visualization

End tidal CO2 monitoring

Chest rise

Auscultation

ETT vapor

Less reliable

Chest X-ray


Secure endotracheal tube to lip with tape

Do not let go of tube until secure

Reassess that endotracheal tube is still in place.

Assess the neonate –

Improving? More pink? Heart rate increasing?

Continue resuscitation – proceed to B and C….

Common Problems

Esophageal Intubation

Blade placed too deep, cords not visualized

Tongue obscures visualization

Sweep tongue to one side with blade

More anterior lift

Tape on blade

Cannot see cords

Head is hyper-extended - reposition

Common Problems

Cannot intubate

Most neonates can be bag valve mask

ventilated easily

Call early for anesthesiology assistance

• “Bag ventilating with oxygen can prolong life for a

long time, repeatedly attempting and failing

intubation will not.”

Surgical airway

Difficult Neonatal Airways

Must always be prepared for something

abnormal

Increasing awareness of problems

beforehand because of neonatal

ultrasound

“Things you can see” versus “Things you

may find”


Congenital malformations

“Things you can see”

Predictable from looking at the patient

• Cleft lip and palate

• Pierre Robin syndrome

• Treacher Collins syndrome

• Goldenhar syndrome

• Apert and Crouzon Syndrome

Congenital Malformations

Cleft Lip and Palate

Most common

congenital face

malformation

Pierre Robin

Sequence

Obstruction is usually

at the nasopharyngeal

level


Apert and Crouzon

Maxillary hypoplasia

Nasopharyngeal

airway compromise

Goldenhar syndrome

Unilateral anomalies

Higher incidence of

airway anomalies


Treacher Collins

Choanal

atresia/stenosis more

common

Down’s Syndrome

Subglottic stenosis

more common

Remember

atlantoaxial instability

http://campos-davis.com/infoweek/dsaweighing.html



“Things you may find”

• Laryngomalacia

• Hemangioma or

Lymphangioma

• Tracheal web

• Laryngeal atresia

• Subglotic stenosis


Laryngomalacia

A sequence between

fully formed to atresia


Laryngeal Web

Tracheal Atresia

Survive only if

tracheoesophageal

fistula or emergent

trach


Hemangioma or

Lymphangioma

Only about 30%

present at birth


Subglottic Stenosis

In Review

Proper positioning is critical for successful

neonatal intubation

Call for help early if unable to intubate or for any

congenital anomalies

Continue to provide oxygen with bag valve mask

ventilation

Practice makes perfect

It is estimated that you need to perform at least 90

intubations to be able to intubate successfully on the

first or second attempt at least 80% of the time

QUESTIONS?

http://www.mssm.edu/msjournal/69/v69_1&2_078_082.pdf

The Neonatal Airway

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