Iowa Neonatology Handbook: Procedures

Technique for Insertion of an Endotracheal (ET) Tube

Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed

I. Indications.

A. Provide airway for mechanical ventilatory support.

B. Relieve critical upper airway obstruction.

C. Provide route for selective bronchial ventilation.

D. Assist in pulmonary hygiene when secretions cannot be otherwise cleared.

E. Obtain direct tracheal cultures.

II. The correct endotracheal tube (ETT) size and length of insertion (tip to lip distance) can be estimated from the infant's weight.

The tube should not fit tightly between the vocal cords in order to minimize upper airway trauma.

III. In most cases an infant can be adequately ventilated by bag and mask so that endotracheal intubation can be done as a controlled procedure. The ONE IMPORTANT EXCEPTION is in cases of known or suspected congenital diaphragmatic hernia.

Preparation is important to performing successfully. Check availability of following equipment prior to procedure - suction, laryngoscope with functioning light source, appropriate laryngoscope blade size (Miller 0 or Miller 1), supply of ETTs, stethoscope, tape and adhesive. Use of oxyscope blade (laryngoscope blade with port built-in for blow-by oxygen) may allow patient to tolerate procedure better.

IV. Technique.

A. Prior to attempting insertion of ETT and as indicated by clinical condition, ventilate the infant with bag and mask using 80-100% oxygen. If unable to insert the ETT within 30 seconds, ventilate the infant again for 30-60 seconds before reattempting intubation.

B. Infant's head should be slightly extended (in the sniffing position) with the body aligned straight.

C. The laryngoscope is held with the thumb and first 1-2 fingers of the left hand. Pushing down gently on the larynx with the fifth finger (or leaving an assistant do it) may help to visualize the vocal cords. Avoid extreme tension or tilt of the laryngoscope.

D. The ETT is held in the right hand and inserted between the vocal cords so that the tip is 1-2 cm below the vocal cords.

E. Check tube position by auscultation of the chest (and abdomen) to ensure equal aeration of both lungs and observation of chest movement with positive pressure inflation.

F. Secure ETT by applying adhesive (Hollister spray) to upper lip followed by two pieces of 1/4 inch adhesive tape placed on lip and securely around ETT.

G. Verify ETT position by chest x-ray.

V. Intubation should be attempted without the use of a stylet. If a stylet is necessary, be sure the stylet tip does not extend beyond the end of the ETT.

VI. If the infant will require intubation for greater than 7 days, consider use of palate plate to prevent formation of a palatal groove. Palate plates can be obtained by requesting a consultation from Pediatric Dentistry.

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