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The rapid provision of effective ventilation is the single best predictor of successful neonatal resuscitation (1). Ineffective ventilatory support leads to hypoxia and increased morbidity and mortality (2). Endotracheal intubation is a highly-skilled procedure providing a secure airway for effective positive pressure ventilation. There are situations where intubation can be difficult either at, or after, delivery. Before undertaking any intubation attempt it is important to consider the experience of the person intubating, if the appropriate help and equipment is available, if there are any indicators that might make intubation more difficult and what steps you will take in the event that intubation is not possible.
This guideline provides an approach to difficult neonatal intubation. It must be remembered that the primary goal is to adequately oxygenate the baby until a definitive airway can be established. Intubation is not always required in order to achieve this. Multiple unsuccessful intubation attempts can further compromise a difficult airway.
In situations where an airway is deemed as ‘difficult’, this should clearly be stated at the front of the patient notes.
Users of this guideline should be aware of the West of Scotland MCN guideline: “Intubation & Premedication of neonates” which outlines the pathway for uneventful intubation.
In most babies, laryngoscopy results in a clear view of the larynx. However, this is not always the case. The view of the larynx is classified as follows (3):
Figure 1: Laryngoscopy views
* By ‘cricoid’ we actually mean ‘BURP’ which stands for applying Backwards, Upwards, Right Pressure to the larynx. Cricoid in the truest sense of the word means compression of the oesophagus to prevent aspiration.
Figure 2: ‘BURP’
1 - ‘Backward’ pressure towards cervical spine 2 - ‘Upward’ pressure towards jaw 3 - ‘Right pressure’ – push larynx towards baby’s right. |
Whilst the majority of neonatal intubations are straightforward there are some situations where intubation can be very difficult. In the majority of cases, these situations can be predicted beforehand however there are occasions when difficulties with intubation occur unexpectedly (2).
ANTICIPATED
UNANTICIPATED
All equipment must be checked regularly and after usage by a named member of nursing staff. The difficult airway packs must be kept fully stocked at all times with all equipment in date. Any problems should be reported during the morning safety brief.
THE ‘DIFFICULT AIRWAY PACK’
The following equipment can be found in the Difficult Airway Pack:
Attached to the pack there should also be the following laminated charts:
LMA use is widespread amongst anaesthetists and it can be a life-saving device in situations where maintaining an airway or intubation is proving difficult. Once the skill is developed, insertion of an LMA takes around 5 seconds (4) and studies indicate it can allow pressures of up to 40cmH2O to be delivered (4). It takes practice and instruction and can make things worse if done incorrectly. Although recommended for babies >2kg in weight, there is evidence of successful use of LMAs in babies as small as 1kg (5).
LEARNING POINT: In the West of Scotland, we use the i-Gel™ supraglottic airway (Intersurgical, Liverpool, NY, USA). The i-Gel uses a non-inflating, soft gel cuff which may reduce trauma to soft tissue.
Insertion of a supraglottic airway
Figure 2: The final position of the iGel in the airway
Figure 3: Fixation of the iGel
VIDEOLARYNGOSCOPY
The use of videolaryngoscopy for intubation is a new development in neonatology. It is a useful tool in the teaching of intubation to junior trainees and reduces the stress of the intubator (6). It’s use in the difficult airway allows viewing of a larger image onto a screen enabling potentially improved view of the larynx.
FLEXIBLE BRONCHOSCOPY
Flexible Bronchoscopy can be used in cases of difficult intubation. For cases in the RHC NICU where elective intubation is predicted to be difficult, a bronchoscopist skilled in intubation (Dr Coutts or Dr Peters) should be on standby wherever possible.
NEEDLE CRICOTHYRODOTOMY
This involves the insertion of a pink or green cannula through the cricothyroid membrane. This is a ‘last resort’ scenario and should only be used when the baby cannot be adequately enough oxygenated to maintain heart rate.
Remember: this procedure allows oxygen delivery to the lungs. It is not an effective means of ventilating and is used as a means of oxygenating until a surgical airway can be established.
See Appendix 6: Set-up for needle cricothyroidotomy
SURGICAL TRACHEOSTOMY
Although intubation allows a definitive airway, it is not necessary for adequate ventilation provided the baby receives good bag-mask ventilation. Effective bag-mask ventilation is indicated by chest wall expansion with a rising heart rate remaining greater than 100.
LEARNING POINT: effective bag-mask ventilation can be as effective as ventilation through an endotracheal tube
If, however, the baby continues to require respiratory support with bag-mask ventilation, it is reasonable to attempt intubation as long as clinician with adequate experience is available.
If intubation is successful, confirm position by:
Fix ETT in place using nasal-tragal length as a guide for depth of insertion.
Ensure ETT remains above the carina on chest X-ray
Figure 4: Correct positioning of the neonatal airway
In this situation, effective bag-mask ventilation is absolutely necessary. We would advise a maximum of 2 attempts at intubation in total by the Registrar. Each attempt should last no more than 30 seconds. In between attempts, the resuscitator should return to bag-mask ventilation via the T-piece.
LEARNING POINT: repeated attempts at intubation can cause damage to the airway and should be avoided.
Where intubation is proving difficult, the resuscitator should:
Where ventilation is adequate through bag-mask ventilation however intubation is proving difficult, it is important to remember that repeated intubation attempts can damage the airway and make bag-mask ventilation more difficult. The resuscitator should await senior support.
In situations where intubation is proving difficult for the consultant, consider the following:
If intubation continues to prove difficult:
See Appendix 2 – ‘The Can’t Intubate, Can Ventilate’ Flowchart
LEARNING POINT: Call for help early!
This is the situation where intubation has proven unsuccessful and bag-mask ventilation is proving inadequate as shown by low saturations and a falling heart rate.
However, in most situations the situation can be improved by simple ‘trouble-shooting’ techniques:
If these have been worked through and the situation remains critical, this is a medical emergency.
LEARNING POINT: Needle cricothyroidotomy only helps with oxygenation. It cannot provide ventilation.
See Appendix 3 – ‘The Can’t Intubate, Can’t Ventilate’ Flowchart
See Appendix 4 – ‘The Critical Situation’
See Appendix 5 – ‘Checklist for the Problematic Intubation’
West of Scotland Managed Clinical Network
The Expected Difficult Airway Checklist
Prior to commencing intubation, the WoS Intubation & Premedication Guideline should be read and understood.
Does this baby have a condition making intubation likely to be problematic? |
Yes / No |
Is there an appropriate team available?
|
Yes / No |
Is the ‘difficult airway pack’ fully stocked? |
Yes / No |
Is the ‘difficult airway pack’ readily available |
Yes / No |
Are anaesthetics/ ENT aware of the situation prior to starting? |
Yes / No |
Does each team member have an allocated role? |
Yes / No |
Is there a clear plan for escalation based on the WoS difficult airway flowchart? |
Yes / No |
Is the WoS difficult airway flowchart clearly accessible? |
Yes / No |
Is an LMA readily available? |
Yes / No |
Required Kit:
Procedure:
Open (inspiration) |
Closed (expiration) |
Last reviewed: 11 December 2020
Next review: 01 November 2023
Author(s): Dr Andrew MacLaren – Neonatal Grid Trainee – GG&C
Co-Author(s): Other Professionals consulted: Dr Kathleen O’Reilly – Neonatal Consultant – RHC; Dr Colin Peters – Neonatal Consultant - RHC; Dr Jonathan Coutts – Neonatal Consultant – RHC; Dr Joyce O’Shea – Neonatal Consultant – RHC; Dr Rob Ghent – Consultant Anaesthetist - RHC
Approved By: West of Scotland MCN for Neonatology