Management of the Neonatal Airway Based upon American Academy for Pediatrics (AAP) Guidelines Presented by: Michael R. Jackson RRT-NPS CPFT & the NRP Instructors* of the NICU Respiratory Care Service * AAP Certified Instructors of the Newborn Resuscitation Program

32 weeks & under

Oral airway Used for: Micrognathia (pictured here) Pierre Robin Choanal atresia airway may cause gagging

Oral airway Predict size measure from ear to corner of mouth Placed right side up in the oropharynx (no need to rotate into place as with adult oral airways) Choanal Atresia

Lesson 3: Insertion of Orogastric Tube Measuring correct length © 2000 AAP/AHA

Pressure/Volume ratlung

Nasopharangeal Tube for CPAP Nasal tubes more easily secured in position than oral tube Are associated with nasopharangeal irritation, swelling, mucous plugging Greater movement in airway with head motion than oral tubes Require greater (~1cm) insertion depth than oral tube

Nasotracheal Tube for Ventilation Nasal tubes more easily secured in position than oral tube Are associated with nasopharangeal irritation, swelling, mucous plugging Greater movement in airway with head motion than oral tubes Require greater (~1cm) insertion depth than oral tube

DuoDerm Nare protection from CPAP prongs Nasal seal for CPAP prongs

Leone TA, Rich W, Finer NN, Neonatal Intubation Success of Pediatric Trainees, J Pediatr 2005;146: Preferred number of experiences to achieve competency is 45. Opportunities have diminished since we stopped intubating active meconium babies. Rates of Intubation Success

AAP Newborn Resuscitation: Endotracheal Intubation Indications l Meconium present and baby is not vigorous l Prolonged positive-pressure ventilation required l Bag-and-mask ventilation ineffective l Chest compressions necessary l Epinephrine administration necessary l Special indications: prematurity, surfactant administration, diaphragmatic hernia © 2000 AAP/AHA

ETTUBEETTUBE

Neck mass by ultrasound During EXIT* procedure *ex utero intrapartum treatment

Surfactant & Tube position

90 degree ETT to airway entrance Blue line of ETT superior

Equipment and Supplies l Equipment should be clean, protected from contamination. Wear gloves l Sterile disposable endotracheal tubes with uniform diameters preferred. Size is based on gestational age. l Stylette is optional © 2000 AAP/AHA ETT Size Wt. Gest. (mm) (kg) (wks) (mm) (kg) (wks) 2.5 < 1 < < 1 < – –

Lesson 5: Preparation of Laryngoscope: Supplies Select blade size –No 0 for preterm newborns –No 1 for term newborns l Check laryngoscope light l Connect suction source to 100 mm Hg l Use large suction catheter (greater than or equal to 10F) for secretions l Small suction catheter for ET tube © 2000 AAP/AHA

Anatomic Landmarks © 2000 AAP/AHA Flash intubation

Positioning the Newborn Prepare for Intubation © 2000 AAP/AHA l Prepare resuscitation bag and mask l Turn on oxygen l Get stethoscope l Cut tape or prepare endotracheal tube stabilizer Flash intubation

Lesson 5: Endotracheal Intubation Step 1: Preparation for Insertion l Stabilize head l Provide free-flow oxygen © 2000 AAP/AHA

Lesson 5: Endotracheal Intubation: Holding the Laryngoscope © 2000 AAP/AHA

Lesson 5: Endotracheal Intubation Step 2: Insert Laryngoscope l Slide blade over right side of tongue l Push tongue to left side of mouth l Advance blade tip to vallecula © 2000 AAP/AHA

Lesson 5: Endotracheal Intubation Step 3: Lift Blade l Lift blade up & away l keep 60 degrees to baby’s chest l Visualize pharyngeal area l Do not use rocking motion © 2000 AAP/AHA 60

Visualize Landmarks l Vocal cords appear as vertical strips or as inverted letter “V” l Downward pressure on cricoid may help bring glottis into view l May need to suction secretions © 2000 AAP/AHA

Pass tube from right side of mouth (not down blade – which would obstruct view) Hold tube in right hand Insert until cord guide is at cords Wait for cords to open l Limit attempt to 20 seconds

Tube Location in Trachea © 2000 AAP/AHA

Remove Laryngoscope l Use a finger to hold the tube against the hard palate l Remove laryngoscope (and stylet, if used) © 2000 AAP/AHA

Signs of correct tube position l Chest rise with each breath l Breath sounds over both lung fields l No gastric distention with ventilation l Vapor condensing on inside of tube during exhalation l Carbon dioxide detector will change color (or reads more than 2%-3% during exhalation)

Depth of insertion Weight (kg)(cm from upper lip) * Predicted Tube Location in Trachea Tip-to-lip measurement © 2000 AAP/AHA

The fulcrum for movement of this lever arm is the upper cervical spine. Fulcrum for movement of this lever arm is the upper cervical spine Vocal Cord Vocal Cord Epiglottis Thy. Cartilage Epiglottis FLEXION NEUTRAL EXTENSION

ETCO2 display On/off Respiratory Rate Display 1 Place sensor & turn unit on. Place sensor & turn unit on. (unit will self-test) Confirm position by · CO2 value (ideally > 20) · CO2 waveform on monitor

Figure 1. Sensitivity = 94%, Specificity = 98%, P P Value = 98%, N P Value = 94% _ _ _ False positive (tube in esophagus) technical error. False negative (tube in trachea CO2 reading low) severe bronchospasm, hyperventilation, technical error, huge leak around ett, cardiopulmonary arrest.

Where is the tube?

esophageal intubation

Every few years, another BPD baby requires a trach at Brigham & Women’s Hospital.

Bivona 3.0 TTS Custom FlexTend cuff Water port Pilot balloon stylette Airway connect

Suction at least a few mm past the length of trach tube –pre- measure distance to suction Trach Suction Trach Feeding Assess ability of patient to coordinate suck, swallow & breathe Test swallowing ability ~ 5 days after tracheostomy- (maybe earlier)

Changing a trach tube Humidification Remove stitches On new trach tube Remove tracheostomy tube Insert new tube same size Monitor # of “noses”used per day Check if patient is aspirating saliva Frequent coughing may be a clue