The Neonatal Airway

and Neonatal Intubation

Matthew L. Paden, MD
Pediatric Critical Care Fellow
Emory University
Children’s Healthcare of Atlanta
 Goals of Presentation
 Recognize differences between neonatal
and adult airway
 Review neonatal intubation technique and
equipment
 Review common mistakes and
complications of intubation
 Examine syndromes commonly associated
with difficult neonatal airways
 Why do we care?
 Prompt intubation of a distressed neonate
can be life-saving
 Increasingly premature population
 Residents are getting less training at this
 RRC limitation of intensive care training
(1994)
 Revision of NRP protocols (2000)
 Why do we care?
 Database of all neonatal intubations at UCSD
from 1992-2002
 9190 attempts recorded
 What did they find?
 Successful intubation on each attempt
• PGY1 33%, PGY2 40%, PGY3 40%
 Total intubations attempted during residency
• 1994 – 38(+/- 19), 2002 – 12(+/- 6)
 Total intubations successful during residency
• 1994 – 24(+/- 14), 2002 – 4(+/-2)
 Conclusion
 “Pediatric trainees are currently provided inadequate
experience to allow development of proficiency at
neonatal intubation.”
NN Finer, et al. Neonatal Intubation: Success of
Pediatric Trainees. J Peds 2005;146:638-41.
 The Neonatal Airway
 Compared to adults,
structures are…
 Smaller
 More anterior
 Epiglottis is floppier
 Larger tongue
 Larger occiput
 Narrowest portion of
airway is the cricoid
 Airway Anatomy
 Embryology
 Larynx from 4th and 5th
arches
 Primitive larynx altered
by hypobranchial
eminence, epiglottis,
arytenoids
 Laryngeal lumen
obliterated and
recanalized
 Indications for Intubation
 In delivery room
 Cardiorespiratory instability
 Meconium during birth, with a depressed
infant
 Prematurity requiring need for surfactant
therapy
 Congenital malformations
 Indications for Intubation
 In NICU
 Unable to protect airway
 Hypercarbic respiratory failure
 Hypoxic respiratory failure
 Therapeutic indication
 What do you need?
Monitors - Cardiac and pulse oximetry
Suction - Yankauer or catheter
Machine - Laryngoscope, ventilator or
bag/mask
Airway - Endotracheal tube
Intravenous - Peripheral or central line
Drugs --
Sedation/analgesia/paralysis/atropine
 Laryngoscope Blades
 Straight blades are
placed under the
epiglottis and used to Miller
lift anteriorly to
expose the cords.
 Curved blades are
placed in the valecula Macintosh
and lifted anteriorly to
expose the cords.

Wisconsin
 Endotracheal Tubes
 Endotracheal tubes are divided by the size
of their internal diameter
 For neonates endotracheal tube size
roughly corresponds to 1/10th of
gestational age rounded down to the
nearest size.
 For example
• A 36 week premie would get a 3.5 ETT
• A 28 week premie would get a 2.5 ETT
 Intubation Procedure
 Proper positioning
 Equipment
• Bed and patient at comfortable height
• Suction and meconium aspirator readily available
• Endotracheal tubes not under warmer
• All equipment tested and working just prior to use
 Patient
• Shoulder roll
• Head in sniffing position
 Too much hyperextension can make visualization difficult
 Intubation Procedure
 Pre-oxygenate with 100% bag valve mask
ventilation
 Contraindicated in known congenital
diaphragmatic hernia
 Apply monitors
 Give drugs
 Remember minimum atropine dose
 Ensure ability to bag/mask ventilate before
paralysis
 Intubation Procedure
 Inserting the
laryngoscope blade
 Hold laryngoscope in
left hand
 While standing above
the patient, insert the
blade in the right side
of the mouth
WITHOUT trying to
visualize the cords.
 Intubation Procedure
 Take a step back
 Lower your head to
the level of the label
 Slowly advance
laryngoscope until
you visualize the
epiglottis
 Use straight or curved
blade appropriately
 Intubation Procedure
 Visualize the vocal
cords
 Meconium below
cords?
 Both moving if not
paralyzed?
 Structurally normal?
 Pick up endotracheal
tube and pass
between vocal cords
Assessing Endotracheal Tube
Placement
 Direct visualization
 End tidal CO2 monitoring
 Chest rise
 Auscultation
 ETT vapor
 Less reliable
 Chest X-ray
 Intubation Procedure
 Secure endotracheal tube to lip with tape
 Do not let go of tube until secure
 Reassess that endotracheal tube is still in
place.
 Assess the neonate –
 Improving? More pink? Heart rate
increasing?
 Continue resuscitation – proceed to B and
C….
 Common Problems
 Esophageal Intubation
 Blade placed too deep, cords not visualized
 Tongue obscures visualization
 Sweep tongue to one side with blade
 More anterior lift
 Tape on blade
 Cannot see cords
 Head is hyper-extended - reposition
 Common Problems
 Cannot intubate
 Most neonates can be bag valve mask
ventilated easily
 Call early for anesthesiology assistance
• “Bag ventilating with oxygen can prolong life for a
long time, repeatedly attempting and failing
intubation will not.”
 Surgical airway
 Difficult Neonatal Airways
 Must always be prepared for something
abnormal
 Increasing awareness of problems
beforehand because of neonatal
ultrasound
 “Things you can see” versus “Things you
may find”
 Difficult Neonatal Airways
 Congenital malformations
 “Things you can see”
 Predictable from looking at the patient
• Cleft lip and palate
• Pierre Robin syndrome
• Treacher Collins syndrome
• Goldenhar syndrome
• Apert and Crouzon Syndrome
 Congenital Malformations
 Cleft Lip and Palate
 Most common
congenital face
malformation

 Pierre Robin
Sequence
 Obstruction is usually
at the nasopharyngeal
level
 Congenital Malformations
 Apert and Crouzon
 Maxillary hypoplasia
 Nasopharyngeal
airway compromise

 Goldenhar syndrome
 Unilateral anomalies
 Higher incidence of
airway anomalies
 Congenital Malformations
 Treacher Collins
 Choanal
atresia/stenosis more
common

 Down’s Syndrome
 Subglottic stenosis
more common
 Remember
atlantoaxial instability
 Difficult Neonatal Airways
 Congenital Malformations
 “Things you may find”
• Laryngomalacia
• Hemangioma or
Lymphangioma
• Tracheal web
• Laryngeal atresia
• Subglotic stenosis
 Congenital Malformations
 Laryngomalacia
 A sequence between
fully formed to atresia
 Congenital Malformations
 Laryngeal Web

 Tracheal Atresia
 Survive only if
tracheoesophageal
fistula or emergent
trach
 Congenital Malformations
 Hemangioma or
Lymphangioma
 Only about 30%
present at birth
 Congenital Malformations
 Subglottic Stenosis
 In Review
 Proper positioning is critical for successful
neonatal intubation
 Call for help early if unable to intubate or for any
congenital anomalies
 Continue to provide oxygen with bag valve mask
ventilation
 Practice makes perfect
 It is estimated that you need to perform at least 90
intubations to be able to intubate successfully on the
first or second attempt at least 80% of the time
 QUESTIONS?