CYWHS Nursing & Midwifery Clinical Standards

Endotracheal Tube - intubation/ fixation/extubation - NICU

The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy is the current endorsed version. Document Number Publication Date Functional Group - Sub Group Summary cs2007_452 23 August 2007 Individual Health Care Care Planning and Delivery Some neonates require intubation to maintain a patent airway, adequate ventilation and oxygenation 9.3.11Endotracheal tube intubation of the neonate 9.3.17 Oral endotracheal intubation neonate 9.3.7 Endotracheal tube taping 9.3.19 Endotracheal tube - extubation MUH NICU C Saunders (nicucm@cywhs.sa.gov.au) T Cord-udy RM NICU, C Lyon CN PICU, C Markwart CN NICU, L Mills CLC NICU, C Woodward CN NICU, P Lowe CM NICU, S CTaylor CN NICU Leadership and Management / Research Regional Director - Nursing and Midwifery NICU 8 May 2007 RN/RM

Replaces

Lead Writer Lead Writer Contact Others Involved In Writing

Accreditation Action Group Responsible Executive Director Responsible Applies to Review Date Minimum Competency Level Key Words Status Endorsed by Endorsement Date

For Endorsement CSRG 8 August 2007

Board of Directors Compliance with this clinical standard is mandatory

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CYWHS Nursing & Midwifery Clinical Standard

Endotracheal Tube - intubation/ fixation/extubation - NICU
The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy is the current endorsed version. This Clinical Standard was printed on 23-Aug-07

Introduction
Some neonates require intubation to maintain a patent airway, provide adequate ventilation and oxygenation. The nurses role is to prepare the patient, equipment and medications and to assist the Medical Officer (MO) / Neonatal Nurse Practitioner (NNP) with the procedure Intubation is recognised as a painful procedure with adverse physiological responses and the risk of trauma to the airways. Premedication is given for any non-urgent intubation1, 2,3,4,5,6 Oro-tracheal intubation is the route of preference in an emergency and for inexperienced operators 3,5,7,8 Fixation (taping) of an endotracheal tube is performed to ensure the intended position of the tube is maintained and the risk of accidental extubation is minimised. Many fixation devices and techniques are described in the literature 3, 8 Extubation is performed when the endotracheal tube is no longer required or a replacement tube is necessary

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Definition(s)
Endotracheal tube (ETT): oral/nasal, siliconised, latex free tube with a radiopaque blue line. (Non-Murphy eye) 9 Murphy Eye: is a side vent near the distal end of an ETT to prevent complete respiratory obstruction in the event that the open end of the ETT were to become sealed by contact with the tracheal wall or occluded by a mass or mucous plug25 Intubation: insertion of an ETT into the trachea via the nose (naso-tracheal route) or mouth (oro-tracheal route) using a laryngoscope1 Premedication: the use of sedatives, analgesics, neuromuscular blockers and anticholinergics in isolation or combination to facilitate tracheal intubation. Optimises intubation conditions and helps to minimise the adverse physiologic effects of intubation 1, 6 Extubation: removal of the ETT Cricoid cartilage: is the lowermost of the laryngeal cartilages12 Cricoid pressure: is the downward pressure applied to the cricoid cartilage using the fore or middle finger to compress the oesophagus between the cricoid cartilage and the anterior surface of the vertebral body3,12

Indications
INTUBATION1, 3,8,10 Any condition that requires a patent airway and/or artificial ventilation or oxygenation EXTUBATION Blocked ETT Elective change of ETT Resolution of indication for intubation

Contraindications
The presence of cervical injuries is a contraindication to intubation with a laryngoscope in older patients not a frequent problem in neonates 8 Muscle relaxation is contraindicated in situations known to be associated with difficult intubation e.g. Pierre Robin sequence or when the operator is inexperienced with these medications1,5

Equipment
Resuscitation trolley Oxygen/air blender and/or oxygen flow meter connected to gas source Infant resuscitation bag or Neopuff22 and appropriate size mask , connected to blender/flow meter and function checked Suction catheter size 8Fg connected (set to 15kpa)and function checked Follow Link to Suction Neonate -NICU
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Suction catheter graduated wye size 5FG and 6FG available Cardio respiratory monitor Oximeter and or transcutaneous monitor Stethoscope Radiant warmer Follow Link to Overhead Radiant Heater Sterile prem towel Sterile scissors Maternity sterile water swabs Syringes/needles to draw up prescribed pre-medication Appropriate medication label/s

Add for intubation Laryngoscope handle and appropriate size straight blade for neonate, function checked and ready for use

Google Images

Miller blades Size 00 or 0 blade for premature neonate Size 1 blade for term5,11,12 Magill forceps

Fibre-optic blades

Google Images

CO2 (Carbon Dioxide) detector (Pedi-Cap) 3,10,12,16,21 ETT tube introducer (stylette) sterile (only open if requested). Used for oral intubation. If used it should not protrude from the end of the ETT and should be secured so that it cannot advance further into the ETT11,12

ETT9 Portex with a blue line

Weight/tube size guidelines9 WEIGHT < 500g < 1000g 1000-2000g 2000-3000g > 3000g ORAL/NASAL 11,12 2.00mm 2.5mm 3.0mm 3.5mm 3.5-4.0mm ORAL (Cole tube) 2.0mm 2.5mm 3.0mm

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ETT tube length guide chart (on resuscitation trolley) This chart indicates the position for a nasal tube at the nare based on the crown to heel length of the neonate and is most useful when the weight is not known. The depth of insertion for an oral tube at the centre of the upper lip is 1cm less than for a nasal tube

ENDO-TRACHEAL TUBE LENGTH CHART Method of estimation of ideal Naso-Tracheal Tube Length (Pediatrics Vol 41 p 823, June 1968) (In emergency use 20% of crown-heel length) This measurement is only a guideline from external nares to tracheal position
14

13

12

11

TUBE LENGTH - CMS

10

30

32

34

36

38

40

42

44

46

48

50

52

54

56

58

60

CROWN HEEL - CMS

Alternatively when the weight is known the following formula can be used 6cm + weight in kg for oral tube11,12 6cm + weight in kg plus 1cm for nasal tube

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Ventilator function checked and ready for use Securing Tapes (e.g. SLEEK, BDF, Elastoplast) NeoBar endotracheal tube holder23 No sting barrier film wipe (e.g. Cavilon) optional Silk 4/0 888 (oral taping only) Naso-gastric tube for decompression of stomach post procedure Follow Link to Naso/Oro gastric tube

Process

INTUBATION Medical Officer (MO)/Neonatal Nurse Practitioner (NNP) Perform hand hygiene and observe standard precautions14,15 Inform parents of need for procedure at an appropriate time Collect equipment Ensure patent IV access Discuss the provision of pre-medication with the MO/NNP and obtain written order Prepare medication20 (ready to be administered) Ensure the neonate is maintained in a thermo-neutral environment. Use radiant warmer if indicated Follow Link to Overhead Radiant Heater Place prem towel on trolley and assemble equipment maintaining sterility of the ETT For nasal intubation For oral intubation o o o Do not cut Oral tubes (can be trimmed after fixation to the NeoBar) Cole tubes are not cut Select appropriate size NeoBar fixation device Cut the ETT to measured length plus 4cm3,8 Cut appropriate tapes for securing ETT

Ensure the infant resuscitation bag is connected to oxygen/air blender and flow meter at 8 L/min. Ensure NEOPUFF is connected to oxygen/air blender and flow meter at 8L/min with PEEP and PIP pressures set and function checked Follow Link to Hand Ventilation-Neopuff -Womens and Babies Division NB Blended oxygen is given to maintain oxygen saturation within prescribed limits12 Ensure 8FG suction catheter is attached to wall suction set at a pressure of 15-20 kPa Follow Link Suction Neonate and function checked Increase sound volume of QRS complex on cardiac monitor to an acceptable level for staff involved in procedure Perform baseline observations Aspirate the stomach and remove gastric tube if in situ
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Position the neonate supine with arms gently restrained, chest exposed and head towards the operator in a slightly extended sniffing position5,3,12 Place the laryngoscope, Magill forceps (if requested), ETT and suction catheter within easy reach of operator and assistant (ready to hand to MO/NNP on request) If medication for intubation is ordered ensure MO/NNP is present and has instructed medication to be given. NB Administer medications as per Pharmacy guidelines Intubation attempts should be limited to 20-30secs3,5 Hold the laryngoscope between the thumb and first finger of the left hand, using other fingers to support the chin Pass the laryngoscope blade into the right side of the mouth and position it midline and to the left, deflecting the tongue

Google Images

Raise the laryngoscope blade gently to lift the epiglottis and reveal the visible vocal cords, ensuring that excessive pressure is not placed on the neonates upper gums

Google Images

Gently suction any secretions from the larynx prior to inserting the ETT Should the neonates condition deteriorate during the procedure the neonate should be allowed to recover with hand ventilation as necessary3,5,12 Hold the prepared ETT in right hand and insert into The ( L ) or ( R ) nare or orally and insert the ETT along the side of the laryngoscope blade through the vocal cords and up to The determined length for a Portex tube To the shoulder for a Cole tube Apply light pressure to the cricoid cartilage if requested3,12

Google Images

Remove the laryngoscope blade carefully Once intubated attach and gently ventilate with the infant resuscitation bag/Neopuff22 to achieve adequate chest expansion and optimal oxygenation Check correct tube position by

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Attachment of a CO2 detector3,10,12,16,21 Auscultation of the chest for equal air entry Observation of symmetric chest-wall movement and Clinical improvement of colour and heart rate3,5 Maintain the position of the tube in the trachea and secure in place (Blue line of ETT should be positioned towards the left ear)

NASAL TUBE FIXATION TAPING - RM/RN Cut two lengths of SLEEK/BDF that are double the distance from the middle of the upper lip to 1cm in front of the ear and double the width of the upper lip

Cut a split halfway along the length of each strip (trouser legs)

Cut one short, narrow piece of sleek that will fit across the nose Clean face with maternity sterile water swabs ( to remove e.g. vernix) and allow to dry Apply no sting barrier film to the cheeks, upper lip and nose bridge and allow to dry, becomes sticky to touch The first trouser leg tape approaches from the side of the nose in which the ETT is placed The unsplit section is applied to the cheek The upper leg is taped over the nose and across the opposite cheek The lower leg is wrapped around the ETT, thereby effectively anchoring the tube in the correct position

Assess air entry after first tape is applied The second trouser leg tape approaches from the other side of the face The lower leg is taped under the nose and across to the opposite cheek The upper leg is taped over the nose and then wrapped around the ETT to further anchor the tube

To facilitate subsequent removal of tape from around the ETT fold over ends of tape approximately 2mm8 A third trouser leg tape may be required in the case of a larger, more active neonate. If so, this is applied in the same way as the first tape The short, narrow piece of tape is positioned across the bridge of the nose to further secure the applied tapes
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Care is taken to avoid creases in the skin or undue pressure on the skin, (e.g. preventing eyes from closing), nares and septum Assess air entry Attach the ETT to the ventilator circuit ensuring the ventilator settings are as prescribed by the MO/NNP Insert nasogastric tube if required to aspirate air from the stomach Follow Link to Naso/Oro gastric tube insertion Settle neonate in a position which promotes optimal neurodevelopment Record on the Neonatal Problem Sheet and Nursing Care Plan ETT size Length at which cut and taped Date Time

Document procedure on the Vital signs and respiratory flow chart Progress notes

Chest x-ray is required to confirm correct position of ETT Clean and restock resuscitation trolley

NASAL TUBE RE-TAPING RM/RN This is a two person procedure (one of whom must be a NICC trained nurse) Check resuscitation equipment is available and function checked- Follow Link to Hand Ventilation-Neopuff-Womens and Babies Division Check the position documented in the case notes at which the ETT is to be taped Cut appropriate tapes AS ABOVE - Follow Link to NASAL TUBE FIXATION TAPING Ensure MO/NNP available if needed Aspirate the stomach prior to the procedure. If a nasogastric tube is in situ, aspirate and remove. If a transpyloric tube is in situ retain Position the neonate supine and flat with arms gently restrained and chest exposed Increase ventilation and oxygen to settings utilised during endotracheal suction to compensate for a probable increase in requirements during this procedure Follow Link to Suction Neonate -NICU Check air entry with the stethoscope for comparison with post procedure auscultation Consider giving Sucrose prior to procedure Hold neonates head in the midline position whilst the position of the tube is maintained securely by the assistant Unwind the trouser legs from the ETT Remove existing tapes with adhesive remover/water Clean skin with sterile water swabs then dry Observe the condition of the nares and skin Ensure blue line of ETT is positioned towards the left ear Apply tapes AS ABOVE - Follow Link to NASAL TUBE FIXATION TAPING Assess air entry

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Insert nasogastric tube if required and tape into position or retape transpyloric tube - Follow link to Naso gastric Tube Follow link to Transpyloric Tube Gradually reduce ventilation settings to pre-procedure levels in accordance with the neonates tolerance of the procedure Settle neonate into a position that promotes optimal neurodevelopment

Document procedure on the Vital signs and respiratory flow chart Progress notes Nursing care plan

If the ETT position has been altered this is recorded on the Neonatal problem sheet Nursing care plan

Chest x-ray may be required to confirm position of ETT Clean and restock resuscitation trolley

ORAL TUBE FIXATION RM/RN Appropriate size NeoBar fixation device

Neotech Products

Using the disposable tape measure supplied with the NeoBar, measure from the mid line of the septum of the upper lip to the tragus of the ear The colour on the tape in front of the ear corresponds to the colour NeoBar size required If the tape borders between two colours, always use the larger NeoBar Ensure skin is clean and dry Apply no sting barrier film to area in front of ear and allow to dry, becomes sticky to touch Position NeoBar across centre of mouth NB NeoBar and ETT should not contact lips and ensure the ETT is under the NeoBar Remove clear liners from tabs and apply tabs in front of ear on bone NB warm tabs with hands prior to applying for better initial adhesion Hold in place for 60 seconds Use 1cm BDF tape and with ETT under the bar

Wrap tape completely around ETT first

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Then Continue taping around both ETT and the platform

For emergency removal, carefully cut thin portion of the NeoBar with blunt scissors, at junction of bar and tab

ORAL TUBE NEOBAR REPLACEMENT RM/RN This is a two person procedure, (one of whom must be a NICC trained nurse) Check resuscitation equipment is function checked Check the position documented in the case notes at which the ETT is to be taped Ensure MO/NNP available if needed Aspirate the stomach prior to the procedure. If a nasogastric tube is in situ, aspirate and remove. If a transpyloric tube is in situ retain Position the neonate supine and flat with arms gently restrained and chest exposed Increase ventilation and oxygen to settings utilised during endotracheal suction to compensate for a probable increase in requirements during this procedure Follow Link to Suction Neonate -NICU Check air entry with the stethoscope for comparison with post procedure auscultation Hold neonates head in the midline position whilst the position of the tube is maintained securely by the assistant Unwrap the tape from the ETT and platform Slowly peel back the tabs as you swab with adhesive remover/water Clean skin with maternity sterile water swabs then dry Observe the condition of the skin Ensure blue line of ETT is positioned towards the left ear Apply NeoBar AS ABOVE Follow Link to ORAL TUBE FIXATION Assess air entry Insert nasogastric tube if required and tape into position or retape transpyloric tube - Follow link to Naso gastric Tube o Follow link to Transpyloric Tube Gradually reduce ventilation settings to pre-procedure levels in accordance with the neonates tolerance of the procedure Settle neonate into a position that promotes optimal neurodevelopment

Document procedure on the Vital signs and respiratory flow chart Progress notes Nursing care plan

If the ETT position has been altered this is recorded on the Neonatal problem sheet Nursing care plan

Chest x-ray may be required to confirm position of ETT Clean and restock resuscitation trolley

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ORAL TUBE TAPING NB When a NeoBar is unable to be used e.g. hare lip/cleft palate 4/0 silk 888 suture material Elastoplast Cut a piece of Elastoplast to fit across the upper lip Cut BDF tapes - trouser leg NB SLEEK should not be used for this method as the SLEEK can tear at the central connection point resulting in an unsecured tube Apply no sting barrier film to the cheeks, upper lip and allow to dry, becomes sticky to touch Place a piece of Elastoplast across the upper lip The MO/NNP anchors the ETT by placing a suture through the ETT and then through the lower edge of the Elastoplast The first trouser leg is secured to one cheek and the top leg is taped across the Elastoplast and opposite cheek The bottom leg is wrapped around the ETT anchoring it in the correct position Assess air entry after the first tape is applied The second trouser leg is secured to the opposite cheek and the top leg is taped across the upper lip The bottom leg is wrapped around the ETT An additional short, narrow piece of tape may be positioned across the upper lip for reinforcement

EXTUBATION NNP/RM/RN Nasal CPAP13, Oxygen therapy via Isolette, nasal cannula or head box is function checked and ready for use (as ordered) Follow Link to Oxygen Therapy This is a two person procedure, (one of whom must be a NICC trained nurse) Resuscitation trolley Resuscitation bag/NEOPUFF function checked and ready for use Perform chest physiotherapy only if ordered19 Follow Link to Chest Physiotherapy Suction ETT Follow Link to Suction Neonate - NICU Reventilate for 5 minutes or until neonates vital signs are stable Ensure MO/NNP is available Cease feeds and commence IV fluids as prescribed Follow Link to Assembly, Priming and Connection of Lines Administer Respiratory stimulant17,20 or steroid18,20 if prescribed Aspirate stomach and remove gastric tube if in situ. Retain transpyloric tube if in situ Gently remove tape/tabs from neonates face as described above Remove the ETT and suction (using a size 8FG suction catheter) the Nose Nasopharynx Mouth (avoid deep suctioning) Follow Link to Suction Neonate - NICU

Apply Neopuff with appropriate size mask and predetermined PEEP pressure over the neonates nose and mouth - Follow Link to Hand Ventilation-Neopuff Womens and Babies Division Give enough oxygen (if required) to maintain the neonate within prescribed oxygen saturation limits
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Clean the face using sterile water swabs and dry Commence alternative respiratory support as prescribed or assist with reintubation Monitor neonates respiratory effort and oxygenation Position neonate prone if possible Follow Link to Positioning & Wrapping of Neonates/Infants. Position to promote optimal neurodevelopment Organise post extubation blood gas +/- chest x-ray as ordered Feeds are not recommenced for at least four hours and until neonates condition is reassessed by MO/NNP Document procedure, date and time on the Neonatal problem sheet (include the number of ventilated hours) Vital signs and respiratory flow chart Progress notes Clean and restock resuscitation trolley

Associated Links
Overhead Radiant Heater Hand Ventilation-Neopuff-Womens and Babies Division Chest Physiotherapy Naso/Oro gastric tube insertion Neonate -NICU Neonate NICU Transpyloric Tube Oxygen Therapy Assembly, Priming and Connection of Lines Positioning & Wrapping of Neonates/Infants

References
1. Lodha A, Ohlsson A, Shah V. Premedication for endotracheal intubation in neonates. (Protocol) Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD004499. DOI: 10.1002/14651858.CD004499. Level 1 2. Shah V, Ohlsson A. The effectiveness of premedication for endotracheal intubation in mechanically ventilated neonates: a systematic review. Clinics in Perinatology. 2002; 29(3):535-554 Level 11 3. Merenstein GB, Gardner SL; Handbook of neonatal intensive care. 6th edition. 2006; 67-69,610-612 Level 111-2 4. Dempsey EM, Al Hazzani F, Faucher D and Barrington KJ; Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit; Arch. Dis. Child. Fetal Neonatal Ed. 2006; 91; F279-F282; originally published online 7 Feb 2006; DOI:10.1136/adc.2005.087213 Level IV 5. Neonatal Handbook, NETS Victoria, Neonatal Handbook Editorial Board, Enquiries: Ellen Bowman & Simon Fraser. 6. DeBoer SL, Peterson LV; Sedation for Nonemergent Neonatal Intubation, Neonatal Network, October 2001; 20(7): p.19-23 7. Spence K, Barr P. Nasal versus oral intubation for mechanical ventilation of newborn infants. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD000948. DOI: 10.1002/14651858.CD000948. Level 1 8. MacDonald MG, Ramasethu J; Atlas of procedures in neonatology 3rd edition 2002; Lippincott Williams and Wilkins; 253-269
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9. Smiths Medical Australasia Pty. Ltd. Brisbane, QLD, Australia. [monograph on the internet] [cited on line 3/7/2007] http://www.smiths-medical.com 10. DeBoer S, Seaver M; End-tidal CO2 verification of endotracheal tube placement in neonates, Neonatal Network, May/June 2004; 23(3): p. 29-38 Level IV 11. The Australian Resuscitation Council Online; Section 13, Neonatal Guidelines. February 2006. [monograph on internet] [cited on line 3/07/2007]http://www.resus.org.au 12. Kattwinkel J, editor. Lesson 5 Endotracheal intubation. In: Textbook of Neonatal Resuscitation. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2006. p. 5-1 to 5-42 13. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD000143. DOI: 10.1002/14651858.CD000143. Level 1 14. Child, Youth, Womens Health Service. Standard and Additional Precautions. Procedure PR2006_055; Adelaide (Australia): 2007 15. Child, Youth, Womens Health Service. Hand Hygiene and Hand Care for Staff who have hands on Patient Care. Procedure PR2006_056; Adelaide (Australia): 2007 16. O'Donnell CPF, Kamlin COF, Davis PG and Morley CJ; Endotracheal Intubation Attempts During Neonatal Resuscitation: Success Rates, Duration, and Adverse Effects Pediatrics, 2006; 117(1); 16-21 [monograph on internet] [cited on line 3/07/2007]http://www.pediatrics.org 17. Henderson-Smart DJ, Davis PG. Prophylactic methylxanthines for extubation in preterm infants. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD000139.DOI: 10.1002/14651858.CD000139. Level 1 18. Davis PG, Henderson-Smart DJ. Intravenous dexamethasone for extubation of newborn infants. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD000308. DOI: 10.1002/14651858.CD000308. Level 1 19. Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation. Cochrane Database of Systematic Reviews 2202, Issue2. Art. No.: CD000283. DOI:10.1002/14651858.CD000283. Level 1 20. Neonatal Medication Manual. Womens and Childrens Hospital 2006 21. Pedi-Cap Tyco Healthcare Group LP. Nellcor Puritan Bennett Division. USA 22. Fisher and Paykel Healthcare. [monograph on interent] [cited on line 28/06/2007]http://www.fphcare.com 23. NeoBar Endotracheal Tube Holder [monograph on internet] [cited on line 28/06/2007 http://www.neotechproducts.com 24. Anaesthesia & Analgesia. 2005; 100:1854-1855 2005 International Anaesthetic Research Society. doi: 10.12/01.ANE.000015290.42078.91

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