Reference
(include title, author, journal title,
year of publication, volume and issue, pages) |
Evidence
level
(I-VII) |
Key
findings, outcomes or recommendations |
Ancora. G, Lago. P, Garetti. E, Merazzi. D, Levet. P.S, Bellieni. C.V, (July 2018) Evidence-based Clinical Guidelines on Analgesia and Sedation in Newborn Infants Undergoing Assissted Ventilation and Endotracheal Intubation, Acta Paediatrica, 108, pp 208-217.
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VII
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- Use premedication before endotracheal intubation for a more rapid, less painful, less traumatic and safe maneuver.
- Premed in both term and preterm infants facilitated procedures, reduced pain and stress and limited deterioration of vital parameters (such as heart rate, blood pressure oxygen saturation and intracranial pressure).
- Morphine is not the drug of choice for this procedure due to its delayed onset of action compared with fentanyl
- Supports Fentanyl 2-5 mcg/kg combined with a muscle relaxant.
- Atropine is useful for reducing bradycardias. (dosing 0.01-0.02 mg/kg)
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ANZCOR Guideline 13.5: Tracheal Intubation and Ventilation of the Newborn Infant. Updated Aug 2016. file:///C:/Users/Andrew/Downloads/anzcor-guideline-13-5-aug16.pdf |
VII |
- Laryngoscope and ETT size / depth of insertion
- Equipment required for intubation
- Verification of ETT in correct position (chest moves with each inflation, increase HR to above100/min, improving o2 sats
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Australian Neonatal Medicines Formulary (ANMF online) https://www.anmfonline.org/
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- Dose of Morphine for intubation of up to 200mcg/kg
- Dose of Suxemethonium for intubation- up to 3mg/kg, short-acting
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Barrington, K. (2011), Premedication for endotracheal intubation in the newborn infant. Paediatric Child Health 16(3): 159-164. |
V |
- Premedication reduces the adverse physiological responses of bradycardia, systemic hypertension, intracranial hypertension and hypoxia, as well as decreasing the pain and discomfort associated with the procedure.
- An optimal protocol for premedication for elective endotracheal intubation includes administration of a vagolytic agent, a rapid-acting analgesic, and a short-duration muscle relaxant.
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Better Safer Care. Victorian Agency for Health Information: Intubation. Updated 20th Aug 2019
https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn/intubation
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VII |
- Premeds should be considered in less urgent intubations
- Equipment required for intubation, including pictures
- ETT size and length
- Monitoring required during intubation procedure
- Supports the use of atropine, fentanyl and suxamethonium as premed for intubation
- Clinical signs of tracheal intubation
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BNF for Children, Medicines complete, Updated 13/2/24 https://www.medicinescomplete.com/#/content/bnfc/_131505096
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- Fentanyl dose for assisted ventilated for neonates 1-5 mcg/kg, then 1-3 mcg/kg as required to be administered over at least 30 secs.
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Chen.D.Y, Devsam.B, Sett.A, Perkins.E, Johnson.M.D, Tingay. D.G. 2023 Factors that determine first intubation attempt success in high-risk neonates, Paediatric Research, September 30. |
IV |
- Retrospective cohort study of patients included in the Neonatal Emergency Airway Registry (NEAR4NEOS), looking at intubation encounters between 2019 and 2022.
- Smaller lung volumes and higher metabolic needs, resulting in less physiological reserve.
- First attempt success rates in NICU reported to be between 37 and 54%
- Multiple attempts can result in increased risk of airway injury.
- Pre medications were routinely used
- Most intubations were direct laryngoscopy (91%) and CMAC was used in 4.5% of the intubations.
- An intubation stylet was used in 47% of intubations.
- LMA was used in 7% of intubations
- Experience of operator, rather than equipment was the greatest determinant of first attempt success.
- Known glottic airway grades can help during the selection of neonates suitable for less experienced practitioners.
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Foglia. E.E, Adnes.A, Sawyer.T, Glass.K.M, Singh.N, Jung.P, Quek.B.H, Johnson.L.C, Barry.J, Zenge.J, Moussa.A, Kim.J.H, DeMeo.S.D, Napolitano.N, Nadkarni.V, Nishisaki.A, January 2019, Neonatal Intubation Practice and Outcomes: An International Registry Study, Pediatrics, Vol.143 (1) |
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- Neonatal Emergency Airway registry (International) developed to collect data of neonatal intubations in aim to improve intubation safety.
- Data from 2607 intubation encounters collected in 10 centers between 2014 and 2017.
- Lower odds of adverse events were associated with video larygoscopy, paralytic premedications.
- Video larygoscopy may reduce oesphageal intubation.
- Unstable haemodynamics and increased number of intubation attempts were also associated with adverse effects.
- Oxygen desaturation represents a target for quality improvement during neonatal tracheal intubation.
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Government of Western Australia, North Metropolitan Health Services, Women and Newborn Health Service Neonatal Directive. Clinical Practice Guideline: Intubation, Updated 12th October 2017. |
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- Equipment preparation
- Procedure and team preparation. Role allocation and “walk through” plan.
- Nasal vs oral intubation
- ETT selection and depth/ size
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Higgs. A, McGrath.B.A, Goddard.C, Rangasami.J, Gale.R, Cook.T.M, 2018, Guidelines for the Management of Tracheal Intubation in Critically Ill Adults, British Journal of Anasthesia, Vol. 120:2 323-352. |
IV |
- Guidelines covering strategies during tracheal intubation in critically ill adults. Although the age group does not focus on neonates, the teamwork and human factor elements are still relevant.
- Discusses the importance of human factors and teamwork to minimize risk, such as good leadership and followership.
- It also discusses plans and management for difficult airways and patients with expected difficult airways.
- Examples of checklists for intubation
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Hodgson.K.A, Owen.L.S, Omar.C, Kamlin.F, Roberts.C.T, Newman.S.E, Francis.K.L, Biostat.M, Donath.S.M, Davis.P.G, Manley.B.J, 2022, Nasal High Flow Therapy During Neonatal Endotracheal Intubabtion, The New England Journal of Medicine, 386:17 (1627- 1637). |
II |
- Randomised controlled trial to compare nasal high flow therapy with standard care in neonates during endotracheal intubations at two tertiary Neonatal Intensive Care Units In Australia.
- 251 intubations for 202 infants, 124 randomised to high flow group and 127 randomised into standard care group.
- Results high flow therapy introduced during intubation procedure improved the likelihood of successful intubation in the first attempt without physiological instability in the infant.
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Kane.T, Tngay.D.G, Pellicano, Stefano.S, 2023, The Neonatal Airway. Seminars in Fetal and Neonatal Medicine. |
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- Paper highlighting the measures that can be taken to minimize risks and optimise the performance of the airway management team.
- If difficulties, position optimized before further attempts made
- Video laryngoscopy is rapidly becoming the standard of care for all intubations and recommended when difficulty is anticipated.
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Kirolos. S, O’Shea.J.E, 2020, Comparison of Conventional and videolarygoscopy Blades in Neonates, Archives Dis Child Fetal and Neonatal Ed, 105 (94-97). |
IV |
- Video laryngoscopy allows the airway view to be shared by intubator and supervisor and improves intubation success.
- Equipment required to prepare for video laryngoscopy intubation of a neonate. Miller blades 00, 0 and 1.
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Lexicomp, Victoria https://online.lexi.com.acs.hcn.com.au/lco/action/home
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- IV Fentanyl dose 1-4 mcg/kg for intubation
- Chest wall rigidity minimized when dose administered over at least 1 to 2 mins.
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Neoresus: The Victorian Newborn Resusitation Project Learning Resourses (May 2020) Endotracheal Intubation:
https://www.neoresus.org.au/learning-resources/key-concepts/advanced-interventions/endotracheal-intubation/
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VII |
- Chest X-ray is the gold standard for verifying ET Tube placement, although a Pedicap TM will confirm placement in trachea (as opposed to the oseophagus)
- Charts for ETT size and length and chart for estimating depth of oral and nasal ETT tube
- Other signs of successful intubation: misting in the ETT, symmetrical chest movement
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Neonatal Formulary: Drug use in Pregnancy and the First Year of Life -8th Edition, Published 2020. https://academic.oup.com/book/35484
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- Dose of Atropine 20mcg/kg
- To be given prior to sedation/ analgesia and paralytic drugs used for non-emergency intubation
- Produces a vagal block that can abolish the sudden bradycardia caused by operative vagal stimulation
- Half-life in adults four Hours, longer in infants
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Newborn Services Guideline, Endotracheal Management- NICU. Updated 2019. http://www.adhb.govt.nz/newborn/Guidelines/Respiratory/Intubation/ETT.htm
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VII |
- Process for intubation explained (prepare and check equipment, position infant in supine position, Aspirate NGT/OGT, maintain warmth)
- Suggests atropine, fentanyl and Suxamethonium for neonatal intubation
- Suxamethonium should be given presence of significant hyperkalaemia.
- Suxamethonium se 1-3 mg/kg
- Fentanyl should be given as a slow push duce side effect of chest wall rigidity
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Paediatric Infant Perinatal Emergency Rettrieval (PIPER)- NEONATAL. Neonatal End Tidal Carbon Dioxide (EtCO2) Monitoring during Neonatal Retrieval. Guideline updated 2018 |
IV |
- ETCO2 monitoring is the monitoring standard ventilated term neonates
- Mixed reviews on how well it correlates with paCO2, relating to rapid rates and small volumes
- Provides rapid and ongoing confirmation of the position of the ETT in the trachea
- Intubated babies above 1kg
- Explanations of how to interpret waveforms displayed by ET CO2
- Oesophageal intubation- the capnogram will illustrate only small transient waveforms
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Paediatric Injectable Guidelines Online, The Royal Children’s Hospital https://pig.rch.org.au/monographs/
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- Information on administering atropine, Suxemethonium and Fentanyl.
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Royal Prince Alfred Hospital Procedure, 2022, Women and Babies: Endotracheal Intubation and Management Procedure, Updated November 2022. |
VII |
- Neopuff flow should be set to 8L/Min and blender should be adjusted to deliver desired amount of oxygen
- Suction should be set to -100mmHG
- Success of intubation can be supported with improvements in patient’s heart rate and oxygenation.
- ETT should be firmly held against the palate or at nares until tapes are securely in place.
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Safer Care Victoria, Best Practice Clinical Guidelines Victoria, Neonatal Intubation, 2015. |
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- Supports the use of Pedicap TM end tidal co2 connector for confirming correct ETT position, although gold standard is chest x-ray.
- Discusses clinical signs of correct ETT placement.
- Rule of six for estimating ETT depth.
- Doses of medications for intubation: Atropine 20mcg/kg, Fentanyl 5mcg/kg and Suxemethonium 2mg/kg
- Repeat dose of Suxemethonium may be required if first attempt at intubation unsuccessful.
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Sankaran.D, Zeinali.L, Chandrasekharan.P, Lakshminrusimha.S. Non-Invasive carbon dioxide monitoring in neonates: methods, benefits, and pitfalls. 2021 Journal of Perinatology 41:2580-2589. |
IV |
- ABG is the gold standard for assessment of gas exchange
- Fluctuations of co2 lead to changes in cerebral and pulmonary blood flow and are associated with brain injury
- Durin esophageal intubation, a change in waveform can be represented during ET co2 monitoring
- In a sample of 35 neonatal intubations, the Pedicap TM failed to colour change despite correct ETT placement
- ETT co2 monitoring missed esophageal intubation in 1in 40 instances.
- CO2 monitoring is an adjunct to clinical assessment prior to chest radiograph to determine correct ETT placement.
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Schmölzer GM, Roehr CC. Techniques to ascertain correct endotracheal tube placement in neonates. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD010221. DOI: 10.1002/14651858.CD010221.pub2. |
VI |
- There were no randomized or quasi-randomised controlled trials found in this review that addressed the variety of techniques currently in use to confirm correct tracheal tube placement.
- The gold standard test to confirm ETT position is chest radiography.
- Additional use of clinical signs, respiratory function monitors or exhaled CO2 detectors to assess correct ETT placement is based on evidence from observational studies and case reports.
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Scott. D. N, Else. MD, Pete. G, Kovatsisi, MD, (April 2020) A Narrative of Oxygenation During Pediatric and Airway Procedures, Pediatric Anesthesiology Vol 130 (4) 831-840. |
VII |
- Children have a high rate of oxygen consumption for body mass as compared to adults. They also have a tendency to alveolar collapse and reduction in functional residual capacity under anaesthesia.
- The National Emergency Airway Registry for Neonates reported an incidence of 42% in non-difficult and 75% in difficult intubations.
- Apneic oxygenation- technique to delay the onset of hypoxemia after cessation of ventilation.
- Adequate pre-oxygenation minimizes the partial pressure of nitrogen in the alveoli thereby maximizing for movement of oxygen from the airspace into the blood.
- THRIVE- Transnasal Humidified Rapid Insufflation Ventilatory Exchange.
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Still.L, O’Shea.J, Kirolos.S, Grant.J, Reviewed 18 May 2022, Neonatal Intubation Guideline, West of Scotland Neonatology. |
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- Supports the use of an intubation pause to ensure that the equipment, the patient and the team are fully prepared for the procedure.
- Video laryngoscopy facilitates successful intubation
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Sakhuja. P, Finelli. M, Howes, J, Whyte. H. (2016) Article: Is it time to review guidelines or ETT positioning in the NICU? SCEPTIC Survey of Challenges Encountered in Placement of Endotracheal Tubes in Canadian NICUs, International Journal of Pediatrics, Vol 2016 1-8. |
VI |
- Cross-sectional survey of a sample of healthcare professional involved in neonatal intubations
- 207 responses and 85.5% completed
- 93% used premeds
- 91%- Mid trachea is the best position for ETT in a neonate
- 51%- T2-T3 was the ideal position of an ETT on x-ray
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South Australian Neonatal Medication Guidelines, Suxemethonium, Updated 2022. https://www.sahealth.sa.gov.au/wps/wcm/connect/08057a004cd7f8c8bb95bba496684d9f/Suxamethonium_Neo_v4_0.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-08057a004cd7f8c8bb95bba496684d9f-ojf-Vax |
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- 2mg/kg dose for intubation, repeated as required.
- Common side effects: Muscle twitching, bradycardias (particularly with repeated doses), increased intracocular, intracranial and intragastric pressures. excessive salivation
- Infrequent: Tachycardia, arrhythmias, hypertension, bronchospasm, jaw rigidity, prolonged neuromuscular and hyperkalaemia.
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Trung. L, Kim. J.H, Kateria. A.C, Finer. N. N, Marc-Aurele. K, (March 2020) Haemodynamic Effects of Premedication for Neonatal Intubation: An Observational Study. Arch Dis Child Fetal Neonatal Ed, 105 (2): 123-127. |
IV |
- Pilot prospective Observational study on level 3 NICUs collecting HR, o2 sats, regional cerebral oxygenation, co2 and BP (35 infants of all gestational ages
- 30% of infants dropped their BP by 20% or above after premed for elective intubation.
- Premedication has been shown to:
- Improve intubation conditions
- Minimize pain/ traumatic injury
- Decrease time to successful intubation
- Decrease number of attempts
- Improve physiological stability
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Yamada. N.K, Kamlin. C.O.F, Halamek. L.P, (2018) Optimal Human and System Performance During Neonatal Resuscitation, Seminars in Fetal and Neonatal Medicine, 23 306-311. |
IV |
- Working with colleagues as a member of a coordinated team is an integral part of healthcare delivery in general and in neonatal resuscitation.
- Strategies that decrease cognitive and technical workload could lead to a reduction in resuscitation errors.
- Continuous display of data necessary to guide neonatal resuscitation as well as a combination of visual and auditory prompts.
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