Assisting with elective intubation of the neonate on the Butterfly Ward



    Neonates in Intensive Care often require intubation and mechanical ventilation. Elective intubation refers to the practice of inserting an endotracheal tube (ETT) for the purpose of providing mechanical ventilation in a non-emergency setting, i.e. the neonate is not requiring resuscitation. Nursing staff will be able to safely prepare a neonate for elective endotracheal intubation, provide assistance to the Medical Officer/Neonatal Nurse Practitioner during the procedure and correctly apply taping to secure both oral and nasal ETT’s.

    Definition of Terms

    • Colorimetric CO2 Detector: A connector that attaches between the ETT and the neopuff and will colour change to determine clearance of CO2. Butterfly currently uses Pedi-CapTM.
    • DOPE: A mnemonic that assists with troubleshooting when a ventilated neonate unexpectedly deteriorates (Displacement or Dislodgement, Pneumothorax and Ventilator or Equipment).
    • Elective endotracheal intubation: Non-emergent requirement for the neonate to receive respiratory support via an ETT i.e., where there is not an urgent need for resuscitation in a life-threatening situation. Indications for elective intubation include respiratory distress, hypoxia, hypercapnia, apnoea, respiratory depression due to medications, the need for endotracheal tube change, pre- or post-operative ventilation support.
    • External Laryngeal Manipulation (ELM): Pressure applied directly on the cricoid cartilage, by pressing backwards and gently cephalic to bring the larynx into view.
    • Premedication for elective endotracheal intubation:The administration of medications with rapid onset and short duration of action which will optimise intubation conditions, minimise the potential for intubation-related airway trauma and reduce adverse physiologic responses to intubation.
    • Role Allocation: The roles and responsibilities of each team member are clearly defined, to improve communication and optimise team performance.
    • Waveform Capnography: Can be placed between the ET tube and the neopuff or ventilation tubing to provide a waveform on the monitor which represents the exhalation of CO2


    Infants should have continuous cardiorespiratory monitoring, oxygen saturation and intermittent blood pressure monitoring (invasive or non-invasive). If desired, the QRS tone on the monitor can be activated and audible throughout the intubation procedure to alert the team of any changes to the patient’s condition.

    A full respiratory assessment includes auscultation of breath sounds in all lung fields, waveform capnography and review of a post-procedure chest x-ray to confirm ETT position and a post-intubation blood gas (usually 1 hour post).


    Role Allocation on Butterfly

    Ensures effective teamwork that allows for minimisation of human factors related risks and improves patient outcomes.  Roles should be allocated by the team leader, in collaboration with the scribe or nursing lead to ensure that the roles and skills/ knowledge are appropriately aligned. Each member of the allocated team needs to be easily identified and utilise closed loop communication throughout the event. Due to the high-risk nature of the neonatal intubation procedure, good leadership and followership is vital. Currently on Butterfly, role allocation stickers are to be used during patient deteriorations as well as planned and unplanned intubations.

    Key roles (minimum for procedure)

    • Leader
    • Airway lead
    • Airway support
    • Drug 1
    • Drug 2/ Circulation support
    • Scout
    • Scribe

    Additional roles (If staff available/ situation arises)

    • Nursing co-lead
    • Circulation support

    Equipment for intubation

    Prepare all equipment prior to commencement of the procedure. The equipment is stored within the Red Butterfly resuscitation trolleys (one trolley in each Pod 1 and 3, two trolleys in Pod 2).

    • Butterfly resuscitation trolley should be accessible next to the patient’s bedside and the top should be kept clear so the airway lead/ support can lay out the required intubation equipment.
    • A procedure (dressing) trolley can be used by the nursing staff when preparing medications.
    • An intravenous canula (IV) is necessary for the administration of the premedication agents and can be used for the administration of 10% glucose if the neonate remains nil orally for a period pre or post intubation.
    • Paediatric laryngoscope – check to ensure the light source is working and adequate for illumination.
    • Miller blade size 1 for full term infant (Mac curved blades are also available on the trolley).
    • Miller blade size 0 or 00 for preterm infant, or the blade specified by the Doctor who is to perform the procedure.
    • Uncuffed ETT internal diameter size appropriate for the neonate, and another one size smaller and larger (see below for recommended ETT sizes and length based on the neonate’s weight and gestational age).

    Table 1 Recommended uncuffed ETT size (if cuffed ETT is desired, reduce size by 0.5mm):

     Tube size (internal diameter mm)  Weight (g)  Gestational age (weeks)
     2.5   < 1000   < 28 
     3.0 1000 - 2000 28 - 36 
     3.5  2000 - 3500  > 38 
     4.0  > 3500  > 38 

    Table 2 Recommended ETT length:

     Weight (kg)    ETT Length (cm)  
     Lips  Nares
      < 1  6.5 - 7  6.5 - 7.5
     1 - 2  7 - 8  7.5 - 9
     2 - 3  8 - 9  9 - 10.5
     3 - 4  9 - 10  10.5 - 12


    ETT Insertion Length

    Oral length = weight (kg) + 6cm

    Nasal length = 1.5 x weight (kg) + 6cm OR weight (kg) +7

    • Sterile intubation stylet (as requested)
    • Magill forceps for nasal intubation procedures
    • Water-soluble lubricant
    • Suction catheter attached to working suction unit
    • Appropriately sized and cut (oral or nasal) Leukoplast adhesive tape to secure ETT
    • Duoderm® pieces to protect skin prior to tape application
    • Cotton tie (Anchors the tube in position at specified measurement)
    • Ventilator set up with settings specified by medical lead, checked and ready for patient use.
    • Neopuff checked with a flow of 8 L/min and an oxygen blender should be used so appropriate levels of oxygen can be delivered throughout the procedure. Basic neopuff parameters should be set ready for patient use with an appropriate size face mask.
    • Cardiorespiratory monitor and oxygen saturation monitoring functioning (pre-ductal when relevant and QRS volume audible on request)
    • Stethoscope
    • Drugs for pre-medication drawn up and labelled
    • Waveform capnography (ETT CO2) or colorimetric CO2 detector (Pedi-CapTM)
    • Updated “Intubation and Resus Calculator” appropriate for the patient’s current working weight.

    Other Equipment

    Video Laryngoscopy

    The video laryngoscopy may be required or requested by the Airway lead, such as in the presence of a difficult airway or for teaching purposes.  The airway lead should take responsibility of checking the equipment required to use the device.  The RCH Butterfly Unit currently has Glideslope or CMAC devises available as required.

    High Flow Oxygen

    The airway lead may also request for high flow blended oxygen to be used during the initial stages of intubation as there is recent evidence that this may improve the physiological stability of the patient during the procedure. 

    Premedication action, dose, side effects

    In the setting of an elective intubation, premedications provide adequate analgesia, sedation and minimisation of the physiological effects of intubation. Intubation has been identified as a painful procedure and associated with physiologic side-effects including bradycardia, desaturation, increased blood pressure and increased intracranial pressure which may be associated with intraventricular haemorrhage.  Premedication administered to newborns for elective intubation reduces the time and number of attempts needed to complete the intubation procedure and minimises the potential for intubation-related trauma. 

    Patent IV access is required, and each medication should be followed by a saline flush to ensure that doses enter the circulation. An evidenced-based, protocol for premedication prior to elective intubation in neonates is to administer a vagolytic, an analgesic and a muscle-relaxant medication.  

    In emergency situations, it may be appropriate to intubate without premedication.

    Nursing staff on Butterfly ward have access to the “Intubation and Resus Calculator” to assist with dose and administration of medications for elective intubation. This is available on the shared Butterfly desktop computers.  Doses and volumes should always be checked when printed, as part of the safety shift checks and prior to administering to ensure that the calculations are correct. The neonate’s current working weight is utilised for dose calculation.


    Inhibits the parasympathetic response (bradycardia) induced by the placement of a laryngoscope and ETT and minimises oral secretions improving visibility of the vocal cords.

    Medication Dose Onset of action Side Effects

    IV 20 micrograms/kg


    Expected within 2 minutes. Half-life: > 4 hours. Caution should be used if re-administering atropine within several hours of a previous dose.   Tachycardia, arrhythmia, hyperthermia, flushing, Irritability, abdominal distention. For patients prone to SVT, atropine may precipitate arrhythmia and can block the effect of vagal manoeuvres.  


    Opioid analgesics, which provide sedation throughout the procedure, prevent systemic hypertension and reduce endocrine and endorphin responses to painful procedures.

    Opioid Dosing Effect Side Effects Instructions
    Fentanyl (1st line for Intubation)

    IV 5 micrograms/kg

    (use < 2.5 mcg/kg if cardiovascular instability/shock)


    Peak analgesic effect 3 mins

    Apnoea, hypotension, CNS depression and chest wall rigidity.

    Respiratory depression, urinary retention, constipation.

    Administer over at least 2 minutes (to reduce risk of chest wall rigidity). Chest wall rigidity can be treated with muscle relaxants.


    (alternative option)

    IV 0.2 mg/kg


    Peak analgesic effect 15 mins Side effects include apnoea, hypotension, and CNS depression. Respiratory depression, urinary retention, constipation. Need to ensure that analgesia has reached optimal effect prior to administering other premedications

    Muscle relaxants

    Utilised to reduce vocal cord adduction during intubation. Also has a benefit preventing the increase in intracranial pressure reported during endotracheal intubation and reduces duration of and number of intubation attempts.

    Medication Dosing Onset of Action Side Effects

    IV 3 mg/kg


    30-60 Seconds Hypertension/hypotension, tachycardia, arrhythmias, hyperkalaemia, bronchospasm, and malignant hyperthermia (contraindicated in the presence of hyperkalaemia and family history of malignant hyperthermia).


    The order in which intubation medications are administered is based on the onset and duration of action of the medication. Generally, the preferred order to administer the intubation medications are as follows; atropine first in order to reduce the risk of arrhythmias, followed by fentanyl and this is given slowly over 2 minutes to reduce risk of chest wall rigidity, followed by Suxamethonium, which is given immediately prior to intubation when the team is ready. 


    Link to Butterfly Pre-Intubation Checklist (following)

    The Leader and co-lead/ scribe should review the RCH Neonatal Intubation Checklist and Difficult Airway Algorithm (laminated copies are on all resus trolleys) and discuss preparation and plans A-D BEFORE the premedications are administered. The Butterfly neonatal intubation checklist should be read aloud in a challenge-response format by the team leader prior to every intubation, reassessing after any failed attempt. Prior to commencing the procedure, the leader needs to ensure that the team is fully prepared and aware of the plan, and everyone is comfortable in their roles.

    Emergency Airway Management CPG

    Emergency Airway Plan

    Nursing Responsibilities

    Airway support:

    • Position the neonate for optimal intubation: supine on a firm surface, head in a neutral position.
    • Ensure thermoregulation is maintained, e.g. neonate within hybrid incubator or nursed on a radiant warmer.
    • Ensure adequate pre-oxygenation is appropriate for gestational age and condition of neonate (SpO2 levels should be targeted between 91-95% unless pre-specified by the medical team for cardiac patients).
    • Ensure monitoring is continuous.
    • Gastric Content Aspiration: the stomach should have any contents aspirated prior to the procedure if the neonate has been fed recently to prevent aspiration. Confirm with the airway lead whether the gastric tube should remain in position or be removed prior to intubation.
    • Assist Medical staff or Neonatal Nurse Practitioner with intubation procedure.
    • Secure ETT when successfully placed (see illustration links below)
    • If intubation procedure fails, maintain face mask ventilation with Neopuff in appropriate oxygen concentration and ensure adequate chest excursion and vital signs until team are ready to repeat procedure.

    Nursing co-lead/ Scribe:

    • Ensure leader delegates the right people into the right roles and communicates the plan for intubation with the team.
    • Scribe should document all events throughout the procedure and position themselves, so they are able to work in collaboration with leader.

    Drug 1 and 2:

    • Ensuring patent IV access is available.
    • Check and draw up the premedication and label clearly.
    • The medications should be prepared on a dressing trolley and in a position that does not obstruct but allows communication with the leader and the rest of the team.
    • Administration of premedication agents
    • When administering each medication, saline flushes should also be administered, and the doses should be called outload and provide confirmation that they have been given.

    Key Communication points:

    • All team members need to ensure that they have an element of awareness throughout the procedure, so they can adapt to any changes to the original plan.
    • A time-out should be performed prior to commencing the procedure. This should include reading the Butterfly pre-intubation checklist, ensuring a shared mental model among all members of the team and provide the opportunity to voice any safety concerns.
    • Team briefs can be repeated if an alternative plan needs to be made or following any unsuccessful intubation attempts.
    • A post intubation debrief may be helpful for quality improvement purposes, as well as supporting all team members involved.

    Confirmation of ETT position in the trachea:

    • Confirmation of position by direct laryngoscopy by observing of passage of ETT through the vocal cords.
    • Continuous waveform capnography (ET CO2) is the best objective method of confirmation of tracheal intubation. 
    • Colorimetric capnography (Pedi-CapTM) can be used as an alternative method of confirmation of tracheal intubation.
    • Pedi- CapTM turns yellow on exhalation. (Manufacturer states 6 initial inflations may be required prior to Pedi-CapTM colour changing). No colour change indicates that the ETT is not in the trachea, or may not colour change in the clinical setting where cardiac output is low or the lungs are under ventilated, or in extremely small babies whom tidal volume is too small for change to be detected.
    • Breath sounds are auscultated equally under both left and right axillae.
    • Symmetrical excursion of the chest wall occurs on inflation.
    • Heart rate and SpO2 improve post intubation appropriately.
    • Chest X-ray is subsequently obtained (after securing ETT) showing ETT within the trachea at appropriate depth (below the level of the vocal cords, well above the carina).

    Assist with securing ETT by taping method suitable for route of insertion: 

    See attached: Illustration of Oral & Nasal ETT strapping 

    Common principles to be considered regardless of ETT location and taping method include the use of Duoderm ® as a skin protective layer, and that if string is used to assist marking ETT insertion depth, the knot needs to be tied so that it lies on the underside of the ETT and does not press into the upper lip or upper aspect of the nostril and cause pressure damage.

    Ensure a naso-gastric or oro-gastric tube is re-inserted and connected to free drainage post-procedure to ensure the stomach is drained of any air inadvertently instilled. 

    Ongoing Management 

    Post-Intubation Checklist

    • Correct tube position (equal air entry, symmetrical chest rise and fall, capnography)
    • ETT secure
    • Ventilations settings checked against medical orders
    • Nasogastric tube inserted and aspirated
    • Chest x-ray ordered
    • Plan for timing of blood gas set
    • Ongoing analgesia and sedation as required
    • Clarify any additional changes to current management
    • Baby warm and positioned comfortably
    • Family updated
    • Documentation completed within EMR.
    • Post procedure debrief completed and any concerns discussed

    Potential complications of elective intubation include:

    • Hypoxaemia
    • Hyper/hypocapnoea
    • Oesophageal intubation
    • Right main bronchus intubation
    • Pneumothorax

    Management of complications/troubleshooting (DOPE)

    • Displacement of the ETT (into right main bronchus or out of trachea) or disconnected tubing: inspect all connections from the ETT back to the ventilator or Neopuff. Observations of neonate for alteration in vital signs (heart rate and SpOdeterioration), observe for equal, bilateral chest movement and auscultate for equal, bilateral air entry.
    • Obstruction with mucus plug or with kinked ETT or respiratory tubing: auscultate chest for air entry, inspect tubing, and suction ETT.
    • Pneumothorax: observe neonate for equal chest movement on right and left, auscultate for equal, bilateral air entry, inform medical staff immediately and prepare neonate for transillumination of the chest/chest x-ray and potential thoracentesis and/or insertion of a chest drain.
    • Equipment failure: Ensure there is a checked and functioning Neopuff ready with appropriately sized neonatal face mask.
    • In the instance of a difficult intubation the Emergency Airway Management Plan should be followed.


    Ensure ETT is documented as an LDA within EMR. Record the date and time of intubation, the ETT size, insertion site (oral or nasal and in which nostril), insertion depth, neonate’s tolerance of the procedure and the ventilator settings. If a cuffed ETT is used, ensure that the inflation is also recorded within the LDAS’s and assessed as per guideline. Ensure MAR is completed with all doses administered signed for.  

    All interventions during procedure documented by scribe using either the resus navigator or the alternative resus worksheet. If alternative paper worksheet used, ensure that a copy is uploaded to EMR. 

    Family Support 

    Parents will require an appropriate explanation as to why their baby requires intubation and ongoing respiratory support. Parents can also be assured their baby’s comfort will be maintained and pain relieved by use of premedication agents. Discuss with the Doctor/Nurse Practitioner whether the parent(s) can remain with their baby throughout the procedure, and then with the family.

    Ongoing education of parents following the procedure should include safety aspects they need to be mindful of when interacting with their baby, how they can still interact with and assist with their baby’s care.

    Special Considerations

    • Infection control: potential for acquired infection through instrumentation, breach of immune defence systems and ongoing procedural requirements (ETT suction). Ensure hand hygiene and appropriate PPE (where indicated) is attended and that equipment remains sterile/clean until utilised.
    • Potential adverse events: Impeded future tooth formation from excessive pressure being placed on the alveolar ridge during oral intubation
    • Mucosal injury and bleeding

    Companion Documents


    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Allison Kendrick, Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2024. 

    Evidence Table 

    Reference (include title, author, journal title, year of publication, volume and issue, pages)

    Evidence level


    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. 

    • 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)
    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
      Australian Neonatal Medicines Formulary (ANMF online)

      • Dose of Morphine for intubation of up to 200mcg/kg
      • Dose of Suxemethonium for intubation- up to 3mg/kg, short-acting  
      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.
      Better Safer Care. Victorian Agency for Health Information: Intubation. Updated 20th Aug 2019

      • 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
      BNF for Children, Medicines complete, Updated 13/2/24

      • 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.  
      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.
        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)
        • 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.

          Government of Western Australia, North Metropolitan Health Services, Women and Newborn Health Service Neonatal Directive.  Clinical Practice Guideline: Intubation, Updated 12th October 2017.   
          • Equipment preparation
          • Procedure and team preparation. Role allocation and “walk through” plan.
          • Nasal vs oral intubation
          • ETT selection and depth/ size
          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
          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.  
          Kane.T, Tngay.D.G, Pellicano, Stefano.S, 2023, The Neonatal Airway. Seminars in Fetal and Neonatal Medicine.   
          • 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.
            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.
            Lexicomp, Victoria
            • IV Fentanyl dose 1-4 mcg/kg for intubation
            • Chest wall rigidity minimized when dose administered over at least 1 to 2 mins. 
            Neoresus: The Victorian Newborn Resusitation Project Learning Resourses (May 2020) Endotracheal Intubation:


            • 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

              Neonatal Formulary: Drug use in Pregnancy and the First Year of Life -8th Edition, Published 2020.

              •  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
                Newborn Services Guideline, Endotracheal Management- NICU. Updated 2019.

                •  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
                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
                Paediatric Injectable Guidelines Online, The Royal Children’s Hospital
                •  Information on administering atropine, Suxemethonium and Fentanyl. 
                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.
                Safer Care Victoria, Best Practice Clinical Guidelines Victoria, Neonatal Intubation, 2015.  
                • 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.
                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. 

                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.
                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.
                Still.L, O’Shea.J, Kirolos.S, Grant.J, Reviewed 18 May 2022, Neonatal Intubation Guideline, West of Scotland Neonatology.   
                •  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

                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
                South Australian Neonatal Medication Guidelines, Suxemethonium, Updated 2022.  
                •  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. 
                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
                 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.