The Neonatal Airway and Neonatal Intubation

Matthew L. Paden, MD Pediatric Critical Care Fellow Emory University Children’s Healthcare of Atlanta

Goals of Presentation

 Recognize differences between neonatal and adult airway  Review neonatal intubation technique and equipment  Review common mistakes and complications of intubation  Examine syndromes commonly associated with difficult neonatal airways

Why do we care?

 Prompt intubation of a distressed neonate can be life-saving  Increasingly premature population  Residents are getting less training at this  RRC limitation of intensive care training (1994)  Revision of NRP protocols (2000)

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Why do we care?

Database of all neonatal intubations at UCSD from 1992-2002  9190 attempts recorded What did they find?

   Successful intubation on each attempt • PGY1 33%, PGY2 40%, PGY3 40% Total intubations attempted during residency • 1994 – 38(+/- 19), 2002 – 12(+/- 6) Total intubations successful during residency • 1994 – 24(+/- 14), 2002 – 4(+/-2) Conclusion  “Pediatric trainees are currently provided inadequate experience to allow development of proficiency at neonatal intubation.” NN Finer, et al. Neonatal Intubation: Success of Pediatric Trainees. J Peds 2005;146:638-41.

The Neonatal Airway

 Compared to adults, structures are…  Smaller      More anterior Epiglottis is floppier Larger tongue Larger occiput Narrowest portion of airway is the cricoid

Airway Anatomy

 Embryology  Larynx from 4 th and 5 th arches   Primitive larynx altered by hypobranchial eminence, epiglottis, arytenoids Laryngeal lumen obliterated and recanalized

Indications for Intubation

 In delivery room  Cardiorespiratory instability  Meconium during birth, with a depressed infant  Prematurity requiring need for surfactant therapy  Congenital malformations

Indications for Intubation

 In NICU  Unable to protect airway  Hypercarbic respiratory failure  Hypoxic respiratory failure  Therapeutic indication

What do you need?

M

onitors - Cardiac and pulse oximetry

S

uction - Yankauer or catheter

M

achine - Laryngoscope, ventilator or bag/mask

A

irway - Endotracheal tube

I

ntravenous - Peripheral or central line

D

rugs - Sedation/analgesia/paralysis/atropine

Laryngoscope Blades

 Straight blades are placed under the epiglottis and used to lift anteriorly to expose the cords.

 Curved blades are placed in the valecula and lifted anteriorly to expose the cords.

Miller Macintosh Wisconsin

Endotracheal Tubes

 Endotracheal tubes are divided by the size of their internal diameter  For neonates endotracheal tube size roughly corresponds to 1/10 th of gestational age rounded down to the nearest size.

 For example • • A 36 week premie would get a 3.5 ETT A 28 week premie would get a 2.5 ETT

Intubation Procedure

 Proper positioning   Equipment • • • • Bed and patient at comfortable height Suction and meconium aspirator readily available Endotracheal tubes not under warmer All equipment tested and working just prior to use Patient • Shoulder roll • Head in sniffing position  Too much hyperextension can make visualization difficult

Intubation Procedure

 Pre-oxygenate with 100% bag valve mask ventilation  Contraindicated in known congenital diaphragmatic hernia  Apply monitors  Give drugs   Remember minimum atropine dose Ensure ability to bag/mask ventilate before paralysis

Intubation Procedure

 Inserting the laryngoscope blade  Hold laryngoscope in left hand  While standing above the patient, insert the blade in the right side of the mouth WITHOUT trying to visualize the cords.

Intubation Procedure

 Take a step back  Lower your head to the level of the label  Slowly advance laryngoscope until you visualize the epiglottis  Use straight or curved blade appropriately

Intubation Procedure

 Visualize the vocal cords  Meconium below cords?

  Both moving if not paralyzed?

Structurally normal?

 Pick up endotracheal tube and pass between vocal cords

Assessing Endotracheal Tube Placement  Direct visualization  End tidal CO 2 monitoring  Chest rise  Auscultation  ETT vapor  Less reliable  Chest X-ray

Intubation Procedure

 Secure endotracheal tube to lip with tape  Do not let go of tube until secure  Reassess that endotracheal tube is still in place.

 Assess the neonate –   Improving? More pink? Heart rate increasing?

Continue resuscitation – proceed to B and C….

Common Problems

 Esophageal Intubation  Blade placed too deep, cords not visualized  Tongue obscures visualization  Sweep tongue to one side with blade  More anterior lift  Tape on blade  Cannot see cords  Head is hyper-extended - reposition

Common Problems

 Cannot intubate  Most neonates can be bag valve mask ventilated easily  Call early for anesthesiology assistance • “Bag ventilating with oxygen can prolong life for a long time, repeatedly attempting and failing intubation will not.”  Surgical airway

Difficult Neonatal Airways

 Must always be prepared for something abnormal  Increasing awareness of problems beforehand because of neonatal ultrasound  “Things you can see” versus “Things you may find”

Difficult Neonatal Airways

 Congenital malformations  “Things you can see”  Predictable from looking at the patient • • • • • Cleft lip and palate Pierre Robin syndrome Treacher Collins syndrome Goldenhar syndrome Apert and Crouzon Syndrome

Congenital Malformations

 Cleft Lip and Palate  Most common congenital face malformation  Pierre Robin Sequence  Obstruction is usually at the nasopharyngeal level

Congenital Malformations

 Apert and Crouzon   Maxillary hypoplasia Nasopharyngeal airway compromise  Goldenhar syndrome   Unilateral anomalies Higher incidence of airway anomalies

Congenital Malformations

 Treacher Collins  Choanal atresia/stenosis more common  Down’s Syndrome  Subglottic stenosis more common  Remember atlantoaxial instability

Difficult Neonatal Airways

 Congenital Malformations  “Things you may find” • • Laryngomalacia Hemangioma or Lymphangioma • • • Tracheal web Laryngeal atresia Subglotic stenosis

Congenital Malformations

 Laryngomalacia  A sequence between fully formed to atresia

Congenital Malformations

 Laryngeal Web  Tracheal Atresia  Survive only if tracheoesophageal fistula or emergent trach

Congenital Malformations

 Hemangioma or Lymphangioma  Only about 30% present at birth

Congenital Malformations

 Subglottic Stenosis

In Review

 Proper positioning is critical for successful neonatal intubation  Call for help early if unable to intubate or for any congenital anomalies  Continue to provide oxygen with bag valve mask ventilation  Practice makes perfect  It is estimated that you need to perform at least 90 intubations to be able to intubate successfully on the first or second attempt at least 80% of the time

 QUESTIONS?