Clinical Guidelines (Nursing)

Assisting with elective intubation of the neonate on the Butterfly Ward

  • Note: This guideline is currently under review.  


    Neonates in Intensive Care often require intubation and mechanical ventilation for a period of time. Elective intubation refers to the practice of insertion 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, assist a Medical Officer/Neonatal Nurse Practitioner during the procedure and correctly apply taping to secure both oral and nasal endotracheal tubes.

    Definition of terms 

    • Elective endotracheal intubation: non-emergent requirement for the neonate to receive respiratory support via an endotracheal tube i.e. not where there is an urgent need for resuscitation in a life-threatening situation. Indications for elective intubation include extreme prematurity, prolonged ventilation, respiratory support where there is cardiovascular compromise/instability, the need for endotracheal tube change, pre or post-operative ventilation support
    • Premedication for elective endotracheal intubation: the administration of medications with rapid onset and short duration of action which will significantly improve intubation conditions, minimise the potential for intubation-related airway trauma and reduce the adverse physiologic responses to intubation
    • Cricoid pressure: pressure applied directly on the cricoid cartilage to bring the larynx into view

      Elective Intubation Image


    Physical assessment

    • Initial acute
      • Infants should have continuous cardiorespiratory monitoring, oxygen saturation and intermittent blood pressure monitoring (invasive or non-invasive). The QRS tone on the monitor should be activated and audible throughout the procedure as a means of ascertaining the neonate’s heart rate for all personnel during the procedure
    • Ongoing assessment
      • Continuous cardiorespiratory monitoring, oxygen saturation and regular blood pressure monitoring should continue throughout and following the procedure
        Respiratory assessment including auscultation of breath sounds throughout the chest, and review of a post-procedure chest x-ray to confirm ETT position

    Investigations: biochemistry (blood gas results preceding the elective intubation and post intubation), Use of Pedicap® (exhaled CO2 detector) or End Tidal CO2 detector

    Procedures: chest x-ray confirming ETT position 

    Education needs: 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.

    Nutrition: The stomach should have any contents aspirated prior to the procedure if the neonate has been fed recently to prevent regurgitation and aspiration. An IV will be required to be in-situ 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 of time.


    Equipment for intubation

    Prepare all equipment before the procedure is started.
    • Paediatric laryngoscope – check to ensure the light source is working and adequate for illumination
    • Miller blade size 1 for full term infant
    • Miller blade size 0 for preterm infant, or the blade specified by the Doctor who is to perform the procedure
    • Endotracheal tube (ETT) internal diameter size appropriate for the neonate, and another a size smaller

    Table 1 Recommended ETT size:

     Tube size (internal diameter mm)

     Weight (g)

     Gestational age (weeks)



      <28 weeks



    28-36 weeks



     >38 weeks



     >38 weeks

    Table 2 Recommended ETT length:

     Weight (kg)  

     ETT Length (cm)  















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

    • May require sterile intubation stylet
    • Magill forceps for nasal intubation procedures
    • Water-soluble lubricant 
    • Suction catheter attached to working suction unit
    • Leukoplast adhesive tape to secure ETT
    • Duoderm® pieces to protect skin prior to tape application
    • Cotton tie (indicates depth to which ETT has been inserted, and anchors the tapes)
    • Working ventilator complete with circuit with humidifier and air/oxygen source
    • Neopuff checked and ready with appropriate size face mask
    • Cardiorespiratory monitor with QRS volume audible and oxygen saturation monitoring functioning
    • Stethoscope
    • Drugs for pre-medication drawn up and labelled
    • Exhaled or End-tidal CO2 detector for colorimetric analysis
    • Updated “Intubation and Resus Calculator”

    Premedication action, dose, side effects and nursing responsibilities

    Use of premedication prior to elective intubation to provide adequate analgesia and sedation should be used. 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 has also demonstrated a decrease in 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. An evidenced-based, optimal 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 online “Intubation and Resus Calculator” to assist with dose and administration of medications for elective intubation. Ensure the neonate’s weight is current when using dose calculators.

    For full medication monographs with dosing information, refer to Lexicomp Online resource (Pediatric and Neonatal Lexi-Drugs).

    Morphine or Fentanyl

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

    Morphine has a longer onset of action than Fentanyl: peak analgesic effect is obtained after 15 minutes for morphine in comparison to in less than 3 minutes for Fentanyl. If morphine is utilised as a premedication prior to intubation, staff must wait for the onset of action to be optimal prior to administering other premedications and proceeding with elective intubation.

    Morphine: Side effects include apnoea, hypotension and CNS depression.

    Fentanyl: side effects include apnoea, hypotension, CNS depression and chest wall rigidity. The risk of chest wall rigidity can be reduced by administering Fentanyl IV over 1 minute and can be treated with muscle relaxants.


    Increases the heart rate, blocks the vagal response that placement of a laryngoscope and ETT may induce and minimises oral secretions improving visibility of the vocal cords.

    Onset of action: Expected within 2 minutes. Half-life: > 4 hours. Caution should be used if re-administering atropine within several hours of a previous dose.

    Side effects: Tachycardia. In patients prone to SVT, atropine may precipitate arrhythmia and can block the effect of vagal manoeuvres.

    Ensure IV that medication is to be administered through is patent, not extravasated. Administration of this medication precedes administration of muscle-relaxant. Flush with saline following Atropine dose to ensure dose enters circulation. Ensure medication actions are available prior to administering muscle-relaxant.

    Muscle relaxants

    Prevent the increase in intracranial pressure reported during endotracheal intubation, and reduce duration of and number of intubation attempts and hence reduces hypoxia. Muscle relaxants used for intubation are are either Suxamethonium or Pancuronium.



    Onset of action: 30- 60 seconds

    Duration of action: 4-6 minutes

    Side effects: Hypertension/hypotension, tachycardia, arrhythmias, hyperkalaemia, bronchospasm, and malignant hyperthermia (contraindicated in the presence of hyperkalaemia and family history of malignant hyperthermia). 



    Onset of action 1-3 minutes
    Duration of action 40-60 minutes (if utilised as a premedication for elective intubation staff must be confident they can maintain the neonate’s airway and ventilation if intubation is unsuccessful). Effects can be reversed with Neostigmine administration.
    Side effects: Mild histamine release, hypertension, tachycardia, bronchospasm, excessive salivation 

    Nursing responsibilities

    Position the neonate for optimal intubation: supine on a firm surface, head in a neutral position.

    Ensure thermoregulation is maintained e.g. neonate within incubator or nursed on a resuscitaire overhead heater.

    Ensure oxygenation is appropriate for gestational age and condition of neonate (SpO2 between 91-95% unless cardiac patient then as per cardiology team). Ensure monitoring is continuous and audible for heart rate and SpO2 so that staff are alerted to a change in heart rate.

    Checking and drawing up the medications, ensuring patent IV access is available. Administration of premedication agents should take into account their onset and duration of action. Thus the opioid is administered first, with sufficient time elapsing to ensure action is optimal, prior to administering Atropine, then the muscle-relaxant of choice.

    Assist Medical staff or Neonatal Nurse Practitioner with intubation procedure.

    If intubation procedure fails, maintain face mask ventilation with Neopuff in appropriate oxygen concentration and ensure adequate chest excursion and vital signs until staff are ready to repeat procedure.

    To confirm ETT position in the trachea, the following is confirmed by medical staff or Neonatal Nurse Practitioner, at the time of intubation:

    • Confirmation of position by direct laryngoscopy
    • Observation of passage of ETT through the vocal cords
    • Pedi-Cap® turns yellow on exhalation. (Manufacturer states 6 initial inflations may be required prior to Pedi-Cap® 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.
    • End tidal COcapnography with both a numeric value and a waveform display can be utilised if available
    • 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 obtained 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: 
    Illustration of Oral and 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. 


    Within EMR, ensure:

    • ETT is documented as an LDA (record the date and time of intubation, the ETT size, depth and insertion site - oral or nasal, and in which nostril
    • MAR is completed with medications administered prescribed and signed as administered
    • Neonate’s tolerance of intubation procedure
    • Ventilation settings

    Ongoing management

    Potential complications/complications of elective intubation include:

    • Hypoxaemia
    • 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 appropriate sized neonatal face mask

    Education of parents including reason for intubation, requirement for respiratory support, 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

    • For difficult intubation, refer to Emergency Intubation flow chart for escalation process
    • Infection control: potential for acquired infection through instrumentation, breach of immune defence systems and ongoing procedural requirements (ETT suction). Ensure hand hygiene 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

    Companion documents


    Neonatal ehandbook topic “Intubation for neonates” a useful reference with diagrams/pictures clearly outlining anatomical structures.

    Evidence table

    The evidence table for this guideline can be found here.


    • Kumar, P., Denson, S.E., Mancuso, T.J. and Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine, (2010) Pediatrics; 125(3); 608-616. 
    • Nemergut, M.E., Yaster, M., Colby, C.E. (2013) Sedation and analgesia to facilitate mechanical ventilation. , 40; 539-558 
    • Barrington, K. (2011), Premedication for endotracheal intubation in the newborn infant. Paediatric Child Health 16(3): 159-164.  retrieved 07/10/15 

    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Jacquie Whitelaw, Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. First published April 2017.