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Assisting with elective intubation of the neonate on the Butterfly Ward

  • Introduction

    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, providing 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 

    • 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 extreme prematurity, 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 optimise intubation conditions, minimise the potential for intubation-related airway trauma and reduce adverse physiologic responses to intubation.
    • External Laryngeal Manipulation (ELM): pressure applied directly, by pressing backwards and gently cephalic, on the cricoid cartilage to bring the larynx into view.
    • Role Allocation:The roles and responsibilities of each team member are clearly defined, to improve communication and optimise team performance.
    • DOPE: A mnemonic that assists with troubleshooting when a ventilated unexpectedly deteriorates (Displacement or Dislodgement, Pneumothorax and Ventilator or Equipment failure).


    Monitoring during procedure 

    • 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.
    • 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 in all lung fields, 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 team work that allows for minimisation of human factors and improves patient outcomes.  Roles should be allocated by the team leader, although this can be done 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. 

    • Key roles
      • 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

    The Leader and co-lead/ scribe should review the RCH Intubation Algorithm (laminated copies are on all resus trolleys) and discuss preparation and plans A-D BEFORE the premedications are administered. 
    Emergency Airway Management CPG.

    Equipment for intubation

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

    • 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 a 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 weeks
     3.0 1000 - 2000 28 - 36 weeks
     3.5  2000 - 3500  > 38 weeks
     4.0  > 3500  > 38 weeks

    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

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

    • Sterile intubation stylet (as requested)
    • Magill forceps for nasal intubation procedures
    • Water-soluble lubricant
    • Suction catheter attached to working suction unit
    • Appropraietely sized and cut (oral or nasal) Leukoplast adhesive tape to secure ETT
    • Duoderm® pieces to protect skin prior to tape application
    • Cotton tie (Achors the tube in position at specified)
    • Ventilator set up, checked and ready for patient use
    • Neopuff checked and set to basic parametors ready for patient use with an appropriate size face mask
    • Cardiorespiratory monitor with QRS volume audible and oxygen saturation monitoring functioning (pre-ductal when relevant)
    • Stethoscope
    • Drugs for pre-medication drawn up and labelled
    • Exhaled or End-tidal CO2 detector for colorimetric or waveform analysis
    • Updated “Intubation and Resus Calculator” appropriate for the patients current working weight

    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.
    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 online “Intubation and Resus Calculator” to assist with dose and administration of medications for elective intubation. Ensure 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.

    Dose: 20 micrograms/kg 

    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.

    Morphine or Fentanyl

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

    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.

    Morphine has a longer onset of action than Fentanyl: peak analgesic effect is obtained after 15 minutes for morphine in comparison to 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

    Dose: Fentanyl 5 micrograms/kg (administer over 1 minute) (use < 2.5 mcg/kg if cardiovascular instability/shock)

    Morphine 0.2 mg/kg

    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.


    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). If repeated doses of Suxamethonium are required, reduce the dose to 1-2mg/kg.

    Dose: Suxamethonium 3 mg/kg (1-2 mg/kg for repeated doses)

    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 between 91-95% for preterm infants and >95% for full term infants,
      pre-specified targets by the medical team for cardiac patients). 
    • Ensure monitoring is continuous and audible for heart rate and SpO2 so that staff are alerted to a change in heart rate.  
    • Gastric Content Aspiration: the stomach should have any contents aspirated prior to the procedure if the neonate has been fed recently to prevent aspiration.
    • Assist Medical staff or Neonatal Nurse Practitioner with intubation procedure. 
    • Secure ETT when successfully placed.
    • 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.

    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 work in collaboration with leader 

    Drug 1 and 2

    • Check and draw up the premedication and label clearly.
    • Ensuring patent IV access is available. 
    • The medications should be prepared on a dressing trolley and in a position that does not obstruct but allows communication with the leader.
    • 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 muscle-relaxant of choice.

    Confirmation of ETT position in the trachea

    • 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, or in extremely small babies whom tidal volume is too small for change to be detected.
    • End tidal CO capnography with both a numeric value and a waveform display should 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 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 linked Illustration of Oral and Nasal ETT strapping PDF 

    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. 


    Ensure ETT is documented as an LDA. 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. Ensure MAR is completed with all doses administered signed for.  

    Ongoing management

    Potential complications/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 appropriate sized neonatal face mask

    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


    Neonatal ehandbook topic “Intubation for neonates”: 
    RCH Nursing Guideline:

    RCH CPG:  Emergency airway management clinical practice guideline

    Evidence table

    The Evidence Table for this guideline can be accessed 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 Health16(3): 159-164.  retrieved 07/10/15
    • 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.
    • 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.
    • 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.
    • 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.


    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 July 2020.