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Intubation and Securing An Endotracheal Tube


Dr. Reynolds
When a baby is unresponsive and not breathing, it’s important to act quickly to restore spontaneous and effective respirations. Intubation is a life-saving procedure to help a baby breathe, and it provides an additional route for medication administration such as 1:10,000 epinephrine.

As you prepare to intubate, be sure to follow these steps carefully:
  1. Confirm that your silk tape is prepared according to the “Three Y Method.”
  2. Coordinate with the equipment team member responsible for handing equipment to you, the team leader.

    This equipment person should be standing on your right side.
  3. Determine whether or not you will use a stylet inside the endotracheal tube to facilitate intubation.

    If you choose to use a stylet, make the “hockey stick bend” to your personal preference. Decide with the equipment person who is to remove the stylet. Typically, the person intubating takes it out in order to avoid accidental extubation of the recently inserted endotracheal tube.
  4. Tell the team to prepare for intubation while providing positive pressure ventilation with the flow-inflating bag and mask.
  5. Place the flow-inflating bag to the right side of the bed.
  6. Taking the laryngoscope in your left hand, open the baby’s mouth with your right hand, sweeping the tongue to the left, allowing you to see the vocal cords.
  7. If you are unable to see the vocal cords due to the presence of amniotic fluid, ask the equipment person for the suction catheter in order to suction the hypopharynx.
  8. Once you have a clear view of the baby’s vocal cords, ask the equipment person for the endotracheal tube.

    To avoid contaminating the tip and lower third of the endotracheal tube, the equipment person should be careful not to let the tube contact any surfaces. When the equipment person transfers the tube to you, he should be careful to place the upper third of the E.T. tube on the distal interphalange joint, or DIP, of your right index finger. Knowing exactly how it will be placed will allow you to keep your eyes entirely on the vocal cords during intubation.
  9. If suction is needed, the equipment person should tap the suction tube on the DIP joint of your right index finger, ensuring 8–10 cm of suction length. When you say “on,” the equipment person should cover the suction hole, uncovering it when you say “off.”
  10. While this is happening, the cardiac team member, standing to your left, should monitor the baby’s heart rate, tap it out, and call out the rate loud enough for the entire team to hear.

    If the heart rate is less than 100, or less than 60 during the intubation attempt, the baby may not be tolerating the procedure. In this case, it’s strongly recommended you interrupt the intubation attempt and provide positive pressure ventilation using the flow-inflating bag and mask. The cardiac person must track the amount of time it takes to intubate, alerting the team if the intubation attempt takes longer than 30 seconds.
  11. Ask the cardiac person to apply cricoid pressure using just one finger if you’re having trouble seeing the baby’s vocal cords.
  12. Ask the medication nurse to hold the baby’s head steady if, during the intubation process, the baby’s head is moving too much.
  13. Ask the equipment person to pull on the right corner of the baby’s mouth to provide more room for the endotracheal tube to be inserted.
  14. Once you have passed the endotracheal tube through the vocal cords, insert your left index finger into the baby’s mouth, holding the E.T. tube firmly against the baby’s hard palate.
  15. Place your left middle finger under the chin while placing your left thumb on the baby’s forehead.

    This will stabilize the endotracheal tube in the baby’s mouth until it can be secured in place by tape or other E.T. tube securing devices.
  16. Because your left hand is holding the endotracheal tube in place, the equipment person must remove the mask from the flow-inflating bag in order to attach the end-tidal carbon dioxide detector.
  17. The equipment person should then attach both the flow-inflating bag and the carbon dioxide detector to the endotracheal tube. The equipment person must not let go of the bag until you have taken control of it.
  18. Provide a safe transfer of control after the flow-inflating bag and carbon dioxide detector are attached to the endotracheal tube.

    The equipment person should hold on to the bag and ask you, “Do you have the bag?” You should then grasp the bag and respond, “I have the bag.”
  19. You should then adjust the endotracheal tube. Calculate the insertion depth by adding 6 cm to the baby’s weight in kilograms.

    For example, if the baby is 3 kilograms, the tube should be inserted to 9 cm on the baby’s lips or gums using the endotracheal tube’s distance markings.
  20. The cardiac person should use their stethoscope to listen for the baby’s breath sounds on the lateral aspects of the chest.

    It’s important to listen to each side individually to determine if both lungs are being ventilated equally. If not, the tube should be slowly pushed in or pulled out, until breath sounds are equal bilaterally.
  21. While providing positive pressure ventilation through the endotracheal tube, look for symmetric chest rise, mist in the tube, and an end-tidal carbon dioxide detector color change from purple, which indicates a possible problem, to yellow, which indicates tracheal placement of the E.T. tube.

    It’s important to note that, in rare instances, when a baby has a very slow heart rate, or even no heart rate at all, the baby’s heart will not be pumping blood filled with carbon dioxide from the body to the lungs, and the end-tidal CO2 detector will not change from purple to yellow even if you have successfully intubated the trachea.
  22. The equipment person will then clean the baby’s face using the alcohol pads and the 2 x 2 gauze pads.

    Wipe away all of the amniotic fluid, blood, meconium, and vernix from the baby’s cheeks and mustache area, making sure these are completely clean and dry. This is important because tape will not stick to wet skin or alcohol.
  23. The equipment person will place the intersection of the first “Y” cut tape at the right side corner of the baby’s mouth.

    The straight section of the tape should reach the tragus of the baby’s right ear. One of the legs of the tape should be placed over the baby’s mustache area, taking care not to tape the upper lip. Tightly wrap the second leg around the endotracheal tube, beginning just outside the baby’s mouth. It’s critical for the first complete tape circle to be tightly wrapped around the endotracheal tube.

    Because your left index finger is still inside the baby’s mouth, pinning the endotracheal tube against the hard palate, the equipment person doing the taping will need to work around your fingers. Continue to hold the endotracheal tube in position with your left index finger until the second “Y” of tape is secured to the tube.
  24. The equipment person then places the intersection of the second “Y” cut tape at the left side corner of the baby’s mouth.

    The straight section of the tape should reach the tragus of the baby’s left ear. After both “Y” cut tapes have been secured, the person providing positive pressure ventilation can remove their finger from the inside of the baby’s mouth.
  25. The cardiac person should then use the stethoscope again to listen to the baby’s breath sounds on the lateral aspects of the chest.
Following these steps will increase the likelihood of a timely intubation and resuscitation of the newborn.