In this section
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.
Monitoring during procedure
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.
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.
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).
Table 1 Recommended uncuffed ETT size (if cuffed ETT is desired, reduce size by 0.5mm):
Table 2 Recommended ETT
Oral length = weight (kg) + 6cmNasal length = 1.5 x weight (kg) + 6cm
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.
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
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)
Confirmation of ETT position in the
Illustration of Oral and Nasal ETT strapping (link)
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.
Potential complications/complications of elective intubation include:
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.
Neonatal ehandbook topic “Intubation for neonates”:
RCH Nursing Guideline:
Emergency airway management clinical practice guideline
Evidence Table for this guideline can be accessed here.
Please remember to read the
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.