Endotracheal Tube Management -NICU

 

Reviewed by Victoria Barnao & Mariam Buksh
June 2010
Clinical Guidelines Back Newborn Services Home Page
Overview Indications Complications
Equipment Process of Intubation Securing ETT
Extubation Related Docs References

Overview

This document covers the following topics:

Indications for Intubation

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

Equipment

Ensure the following equipment is available at the bedside:

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

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 infantís 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 infantís observation chart:
  • ETT size
  • Insertion depth
  • Date
  • Infantís 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:

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 infantís last feed before extubation. Consider withholding one feed following extubation, based on the infantís 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 infantís face Ė 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 infantís tolerance of extubation
16 Assess for and document any signs of nasal pressure injury.

Related documents

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