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RSPT 2353 – Neonatal/Pediatric Respiratory Care
Airway Maintenance
Lecture notes
I.
The Neonatal and Pediatric Airway
a. The narrowest point of the neonates’ airway is at the cricoid cartilage.
b. Use uncuffed tubes under 6.5 because of increased problems with
subglottic stenosis
c. The preemie’s airway can be occluded with the chin on the chest even
when the endotracheal tube is in place
d. Tape the tube with the patient in the sniffing position over extending
will pull tube up & chin down will push tube down
e. Retape the endotracheal tube as often as needed or the tube will come
out.
f. The neonatal endotracheal tube come out much more often than adult
ones do because they are so short and flexible and because they are
not cuffed.
g. The tubes used for neonates can easily become soft, making it difficult
to intubate. To prevent this, keep the ETT outside of the warmer.
h. Both Pediatric and Neonatal ETTs are cut to decrease deadspace.
II.
Bagging the neonate or infant
a. select the correct mask: covers the bridge of the nose to the chin but
not the eyes
b. select the correct bag
i. self inflating: neo-sized 250
ii. non-self inflating bag: neo-sized 500 ml
c. Place a manometer in line-- to keep PIP the same bagging as you will
do on the ventilator (30-35 pressure limit)
d. Infant’s head should be in the sniffing position
e. Bag with finger tips and at a rate of 40-60 bpm
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f. Observe chest rise and watch pulse ox for saturation as well as HR,
both should rise to normal limits
g. Listen to Bilateral Breath sounds and readjust head to get better seal
III.
Selection of tube size and related equipment
a. Neonatal Population
Infant’s
wt
ETT
Blade
Suction
Catheter
Less than
1000
grams
< 1 kg
2.5 ID
0 sized Straight
Miller blade
5-6 French
10002000
grams
1 kg – 2
kg
3.0 ID
0 Straight Miller
blade
6 French
20003000
grams
2 kg – 3 kg
3.5 ID
0 or 1 Straight
Miller blade
8 French
> 3000
grams
> 3 kg
4.0 ID
1 Straight Miller
blade
8 French
b. Pediatric Population or the larger infant – For this population an ETT
can be selected by utilizing the following formula:
ID = (Age in years ÷ 4) + 4
To estimate the length for this population use the following formula:
Length = 12 + (age in years ÷ 2)
For Nasotracheal intubation length use:
Length = 15 + (age in years ÷ 3)
c. Oral vs. Nasotracheal intubation
i. The main argument in this issue is patient comfort.
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ii. Most thought that the nasotracheal tube is more comfortable,
but recent evidence has shown that there may be no difference
between the two
iii. Nasal intubation should be avoided in closed head injuries
because the nasal passage might open into CSF area
ORAL
NASO
Stimulates salivation, ETT can slip out of
position
Does not stimulate salivation
Can maintain position
Can bite down on ETT
Can not interfere with ETT
Can cause palatal groove
Can cause sinusitis, pressure necrosis
Sinus drainage can collect in oral cavity
Can prevent sinus drainage
ETT suctioning is not difficult
ETT suctioning may be difficult
Oral hygiene may be difficult
Access for NG or NJ tube is limited
d. During the intubation procedures always have 2 extra ETTs: one ½
size larger and one ½ size smaller
e. Other equipment you may need include:
 CO2 detector, also called EZ cap
 Stylet
 Syringe for cuffed ETT
IV.
Taping the ETT
a. Immediately after intubation, the patient should be bagged, the chest
auscultated at the basal axillary of both lung fields. The patient’s head
should be in the sniffing position not hyper extended nor flex onto the
chin.
b. If the tube is not in correct position the SpO2 will continue to drop,
chest will not rise and there will not be BBS
c. Once the tube is in the correction position note the number, tape the
tube and obtain a chest film.
d. If the tube is 1-2 cm above the carina, chart the correct position.
e. If not advance or pull back the tube and note the new number.
f. Every institution will vary as to how the pt should be taped. Refer to
the hospital or unit policies.
g. Generic taping: refer to pp.212, fig 15-5
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h. The use of benzoin and adhesive remover has been stopped in the
neonatal population due to the fact that chemicals in these products
can be absorbed into the preemie’s skin.
V.
i.
The use of duoderm or stoma dressing is utilized for the protection of
the patient’s skin.
j.
For removal of tape the use of gauze and either NS or sterile water can
be used. There is also a new product called Sali-Wipes which are
individual wipes with NS in a package.
Suctioning
a. Suction catheter should be half the size of the endotracheal tube
b. Suction vacuum should be set at 60-80 for infants, 80 – 100 for
pediatrics
c. Limited to less than 5 - 10 seconds of suction
d. Saline irrigation needs to be limited to .33 mL of normal saline
e. Pre-oxygenate at 10-15% higher FiO2 unless patient has problems,
then increase as needed for pediatrics
f. Do not pre-oxygenate in neonates. Disconnect for suctioning or bag
with same FiO2 via blender.