Intubation and Ventilation of the Newborn

Indications for elective intubation

What you'll need for elective intubations

Ventilator instructions

In labour ward, consider emergency intubation during: resuscitation requiring cardiac compressions, if you are unable to improve the saturations by mask ventilation only or if the baby has no/poor respiratory effort after 10 minutes of mask ventilation. (The baby will soon let you know if you intubated him/her unnecessarily in which case it is easy to remove the tube and apologise for the inconvenience.) 

Indications for elective intubation (despite adequate CPAP): 

• Respiratory failure: PaCO2 > 7.5kPa and pH < 7.25 (baby not crying) 
• Pa02 < 6.5 kPa or saturations <90% on >60% oxygen 
• Increasingly severe work of breathing 
• Severe or recurrent apnoeas 
• Definite NEC with peritonitis/severe metabolic acidosis (CPAP not indicated) 

For elective intubations, prepare yourself thoroughly. You’ll need: 

• Senior back-up if possible. Plus a senior nurse familiar with resuscitations and paediatrics 
• Fully stocked resuscitation trolley 
• Equipment for manual ventilation including correct fitting face mask 
• Suctioning tube and connection to vacuum apparatus 
• Folded nappy for under the shoulders of baby 
• Reliable intravenous access 
• Drugs (Atropine 0.02mg/kg, ketamine 2mg/kg and Scoline 2mg/kg). Only give Scoline if you can successfully ventilate baby with mask face neopuff, since baby will stop breathing for a few minutes. Take note of how to dilute these drugs as calculation/preparation mistake can cause permanent cardiac arrest! 

For intubation technique, watch “neonatal intubation” demonstration under Video Tuts on the paarlpaeds website (www.paarlpaeds.org). There is no need to cut the ETT first. Nasal intubation is preferred pre-transfer if you are familiar with this procedure. 

Ventilator instructions: 

1. Switch on ventilator and connect air and O2 tubes. 
2. Choose new patient. Enter patient weight and ETT size. 
3. Choose TCVL/SIMV ventilation mode. 
4. Initial settings FiO2 1.0 (100% O2). PEEP 5 (positive end expiratory pressure) and PIP 26 (peak inspiratory pressure). 
5. Start with rate at 40/min and inspiratory time of 0.35s. (Aim for a tidal volume 4-6ml/kg). 
6. Oxygen can be weaned by 10% every 3 min if saturations on baby >95%. 
7. Do ABG 30 min after baby was put onto ventilator and adjust settings accordingly. 
8. Request a CXR to confirm correct ETT placement (level T2) and exclude pneumothorax etc. If at any stage the pulse oximetry stays below 86% despite 100% oxygen (or the “sats probe does not pick up”), assess the ABC’s plus capillary refill time, DOPES and discuss with consultant urgently. 
9. Aim for a pH 7.25-7.4, PaO2 7-10 kPa, pCO2 5 - 7.5 kPa unless a different range is preferred for conditions such as PPHN, CLD or congenital heart disease. 
10. To improve Sats (ie increase oxygenation), increase FiO2, PIP, PEEP (max 10) and inspiratory time. 
11. To lower CO2 (ie improve ventilation), adjust ventilator rate (↑ to max 60), PIP(↑) and PEEP(↓). 
12. If ventilated baby starts desaturating check DOPES (Dislodged ETT, Obstruction, Pressure/PIP, Equipment failure, Sedation). 
13.