Endotracheal Tube Management -NICU

Reviewed by Victoria Barnao & Mariam Buksh

June 2010

Overview	Indications	Complications
Equipment	Process of Intubation	Securing ETT
Extubation	Related Docs	References

Overview

This document covers the following topics:

Assisting with intubation
Securing an endotracheal tube
Endotracheal tube suctioning
Extubation

Indications for Intubation

To assist ventilation in respiratory insufficiency

To aid airway management

Pre or post-operative respiratory support

Emergency	Elective
Failure of mask airway control	Extreme prematurity
Congenital or structural airway abnormalities	Prolonged ventilation
Diaphragmatic hernia	Endotracheal tube change
Prolonged resuscitation	Unstable airway
Administration of surfactant	Respiratory support in neonatal sepsis / necrotising enterocolitis
Severe meconium aspiration syndrome
Apnoea of prematurity

Complications

Pharyngeal, oesophageal and tracheal trauma or perforation
Cardiorespiratory instability during intubation attempts
Intubation of right mainstem bronchus
Accidental extubation
Blockage of endotracheal tube with secretions
Nosocomial respiratory infection
Erosion of nares or septum (nasal intubation)
Palatal groove formation, acquired cleft palate, and defective primary dentition (oral intubation)
Acquired subglottic stenosis

Equipment

Ensure the following equipment is available at the bedside:

Emergency trolley
Laryngoscope
Appropriate size endotracheal tubes (ETT)¹

Tube Size (internal diameter)	Weight (g)	Gestational Age
2.5	<1000	<26
3.0	1000-2000	27-34
3.5	2000-3000	35-40
3.5-4.0	>3000	>38

Appropriate stylet or introducer (only if required for oral intubation))
Hydrocortisone cream
Magill’s forceps
Exhaled carbon dioxide detector (Pedi-Cap)²
Stethoscope
Appropriate sized suction catheters, including size 10Fr for oropharyngeal suction
Neopuff infant resuscitator or self-inflating Laerdal bag and appropriate size mask
Source of compressed air/oxygen with blender
Scissors
Duoderm base tapes - cut to appropriate size for infant
Leukoplast “trouser legs” - cut to appropriate size for infant
Ventilator - set up and checked
Cardio-respiratory and saturation monitor
Premedication for intubation

Process for Intubation

Nurse Responsibilities

Step	Action
1	Explain procedure and rationale to family. Suggest that although optional for them to stay during procedure we would advise that they wait outside.
2	Ensure standard precautions are adhered to
3	Prepare and check all equipment
4	Prepare infant in a supine position using muslin wrap to promote containment.
5	Maintain infant warmth
6	Ensure continuous monitoring of heart rate and saturation during procedure.
7	Ensure suction equipment functioning
8	Aspirate NG/OG tube if insitu
9	Assist medical staff/NS-ANP with airway maintenance/ventilation as required
10	Administer medications when requested by medical staff (ensure IV flushed fully to clear all medication from line)
11	During the procedure you may be asked to apply: suction, cricoid pressure, or gently push endotracheal tube.
12	Assess infant’s tolerance of intubation attempt and inform medical staff/NS-ANP (Observe heart rate & saturation)
13	Attach Neopuff to ETT
14	Verify tube position with Pedi-Cap (yellow indicates carbon dioxide detected on exhalation)
15	Examine chest for bilateral synchronous movement. Auscultate chest and ensure bilateral air entry detected
16	Consider need to decompress stomach if prolonged bag mask ventilation required
17	Assist with securing the ETT (see images below)
18	Connect infant to ventilator
19	Ensure a NG/OG tube inserted and connected to free drainage
20	Ensure chest x-ray obtained to confirm correct tube placement
21	Check blood gas within 1 hour of intubation if infant stable or earlier as requested by medical staff or NS-ANP
22	Document on the infant’s observation chart: ETT size Insertion depth Date Infant’s tolerance of the procedure Ventilator settings
N.B	If possible for reintubation, consider leaving the existing ETT insitu for the medical person inserting the new ETT to use as a guide.

Process for endotracheal tube security

Endotracheal tube security is continually assessed and tapes are replaced as required (this is a two person procedure).

For nasal intubation: See images 1-6

The first length of leukoplast (image 1-3) is applied to the base tape on the side of the nose that the ETT has been inserted into, with the V of the tape butting against the nostril. The first securing length of tape goes across the upper lip and onto the base tape on the opposite side.

The second portion of the tape is then wrapped around and slightly up the tube at the requested depth of insertion. Ensure that the edge of the nostril is not pinched between the tape and ETT

1	2	3

The second length of leukoplast (image 3-6) is applied to the base tape on the opposite side of the face butting up against the free nostril and the first portion of the tape is secured up and over the nose.

The second portion of the tape is then wrapped around the tube up and over the first piece of the tape and up the tube slightly.

4	5	6

For oral intubation:

Follow the same procedure attaching the trouser legs to the corner of the mouth
The portion not attaching to the ETT is secured along the top or below the lips
Monitor the ETT closely as they are often more mobile with oral intubations.

Process for extubation

Unplanned extubation

1. Ring the emergency bell
2. Remove the tube (if indicated i.e. unable to achieve air entry)
3. Maintain airway
4. Suction if necessary
5. Bag the infant

Planned extubation

Decision for extubation is made by medical staff and this is generally performed by the bedside nurse at a time negotiated with registrar or NS-ANP.

Step	Action
1	Explain procedure and rationale to family
2	Ensure that the resuscitation trolley is available at the bedside.
3	Prepare and check all equipment is functioning.
4	Prepare infant in a supine position using muslin wrap to promote containment.
5	Consider loading infant with Caffeine prior to extubation as required
6	Allow for at least an hour after infant’s last feed before extubation. Consider withholding one feed following extubation, based on the infant’s condition.
7	If there has been a large volume of secretions, endotracheal tube may be suctioned 10-15 minutes prior to planned extubation, including oropharyngeal suctioning. (see suctioning policy)
8	Allow infant to recover and re-establish lung volume and functional residual capacity after suctioning. Consider switching OFF the VG at this time, being mindful of peak inspiratory pressure setting.
9	Ensure CPAP or other respiratory support, including bag and mask ventilation with Laerdal bag or Neopuff ready to be applied to infant after extubation
10	Remove the endotracheal tube after gently removing the securing tapes from the infant’s face – DO NOT APPLY SUCTION OR NEGATIVE PRESSURE TO THE ENDOTRACHEAL TUBE AS IT IS BEING REMOVED
11	Suction oropharynx and/or nares as necessary
12	Apply respiratory support as planned and position infant comfortably
13	If possible registrar/NS-ANP to remain on NICU for 30 minutes following extubation
14	Check blood gas within one hour after extubation if infant stable or earlier as requested by medical staff or NS-ANP
15	Document date, time and infant’s tolerance of extubation
16	Assess for and document any signs of nasal pressure injury.

References

1	Wylie, J. Neonatal Endotracheal Intubation. Archives of Disease in Childhood - Education and Practice 2008; 93:44-49
2	Wylie, J., Waldemar, A.C. The role of carbon dioxide detectors for confirmation of endotracheal tube position. 2006; 33 (1), 111-119