Neonatal intubation

General considerations

• Anatomical differences of neonates (compared to adults/big kids):
  • Large occiput--> may need shoulder roll to get ear to sternal notch aligned
  • Relatively larger tongue, small mouth
  • More anterior larynx
  • Larger/floppier epiglottis
  • Short trachea--> easy to mainstem tube, easy for accidental tube dislodgement

• Cuffed vs uncuffed ETT: controversial but cuffed tubes now genearlly considered acceptable

Endotracheal Intubation

Age	Weight(kg)	Cuffless	Cuffed	Depth(cm)	Blade
Preterm	<1kg	2.5	-	6-7	Miller 0
Preterm	1-2.5	3.0	-	7-9	Miller 0
Neonate	2.5-4	3.0	-	10	Miller 0
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• ETT tube size:
  • Full term newborn - 3.5-4 uncuffed
  • Preemie- gestational age in weeks/10 (e.g. 24-25wker gets a 2.5)
• Blade:
  • Preemie <1.5kg: 00
  • Full term newborn: 0
  • Neonate/infant: 1
• ETT depth
  • Newborn/neonate: uncuffed ETT x 3 (cm at lip)
  • Preemie: weight in kg +1 (cm at lip)
• LMA size
  • Weight in kg/20 + 1
• Apneic O2 by NC for newborn/neonate: 5L/m
• Routine vent settings
  • FiO2 100%--> wean
  • PEEP 4-5
  • TV 8-10cc/kg
  • RR 25-35
  • I-time 0.5s

Drugs

• Atropine premedication
  • Controversial
  • Neonates VERY prone to bradycardia with myriad stimuli, including the vagal stimulation of laryngoscopy
  • May not be needed routinely but should at least have handy in case of bradycardia
  • 0.01-0.03 mg/kg IV/IO

• Sedation
  • Ketamine not approved for <3mo
  • Fentanyl 1mcg/kg
  • Etomidate 0.3mg/kg
• Paralytic- consider double dose in shock
  • Rocuronium 1.2mg/kg
    • Preferred as may not yet be aware of preexisting conditions that would make sux contraindicated
  • Succinylcholine 1.5mg/kg

See Also

• Neonatal resuscitation, newborn resuscitation
• Pediatric jet ventilation
• The difficult airway