1. The Neonatal Airway and Neonatal Intubation Matthew L. Paden, MD Pediatric Critical Care Fellow Emory University Children’s Healthcare of Atlanta

2. Goals of Presentation  Recognize differences between neonatal and adult airway  Review neonatal intubation technique and equipment  Review common mistakes and complications of intubation  Examine syndromes commonly associated with difficult neonatal airways

3. Why do we care?  Prompt intubation of a distressed neonate can be life-saving Increasingly premature population Increasingly premature population  Residents are getting less training at this RRC limitation of intensive care training (1994) RRC limitation of intensive care training (1994) Revision of NRP protocols (2000) Revision of NRP protocols (2000)

4. Why do we care?  Database of all neonatal intubations at UCSD from 1992-2002 9190 attempts recorded 9190 attempts recorded  What did they find? Successful intubation on each attempt Successful intubation on each attempt PGY1 33%, PGY2 40%, PGY3 40%PGY1 33%, PGY2 40%, PGY3 40% Total intubations attempted during residency Total intubations attempted during residency 1994 – 38(+/- 19), 2002 – 12(+/- 6)1994 – 38(+/- 19), 2002 – 12(+/- 6) Total intubations successful during residency Total intubations successful during residency 1994 – 24(+/- 14), 2002 – 4(+/-2)1994 – 24(+/- 14), 2002 – 4(+/-2)  Conclusion “Pediatric trainees are currently provided inadequate experience to allow development of proficiency at neonatal intubation.” “Pediatric trainees are currently provided inadequate experience to allow development of proficiency at neonatal intubation.” NN Finer, et al. Neonatal Intubation: Success of Pediatric Trainees. J Peds 2005;146:638-41.

5. The Neonatal Airway  Compared to adults, structures are… Smaller Smaller More anterior More anterior Epiglottis is floppier Epiglottis is floppier Larger tongue Larger tongue Larger occiput Larger occiput Narrowest portion of airway is the cricoid Narrowest portion of airway is the cricoid

6. Airway Anatomy  Embryology Larynx from 4 th and 5 th arches Larynx from 4 th and 5 th arches Primitive larynx altered by hypobranchial eminence, epiglottis, arytenoids Primitive larynx altered by hypobranchial eminence, epiglottis, arytenoids Laryngeal lumen obliterated and recanalized Laryngeal lumen obliterated and recanalized

7. Indications for Intubation  In delivery room Cardiorespiratory instability Cardiorespiratory instability Meconium during birth, with a depressed infant Meconium during birth, with a depressed infant Prematurity requiring need for surfactant therapy Prematurity requiring need for surfactant therapy Congenital malformations Congenital malformations

8. Indications for Intubation  In NICU Unable to protect airway Unable to protect airway Hypercarbic respiratory failure Hypercarbic respiratory failure Hypoxic respiratory failure Hypoxic respiratory failure Therapeutic indication Therapeutic indication

9. What do you need? Monitors - Cardiac and pulse oximetry Suction - Yankauer or catheter Machine - Laryngoscope, ventilator or bag/mask Airway - Endotracheal tube Intravenous - Peripheral or central line Drugs -- Sedation/analgesia/paralysis/atropine

10. Laryngoscope Blades  Straight blades are placed under the epiglottis and used to lift anteriorly to expose the cords.  Curved blades are placed in the valecula and lifted anteriorly to expose the cords. Macintosh Miller Wisconsin

11. Endotracheal Tubes  Endotracheal tubes are divided by the size of their internal diameter  For neonates endotracheal tube size roughly corresponds to 1/10 th of gestational age rounded down to the nearest size. For example For example A 36 week premie would get a 3.5 ETTA 36 week premie would get a 3.5 ETT A 28 week premie would get a 2.5 ETTA 28 week premie would get a 2.5 ETT

12. Intubation Procedure  Proper positioning Equipment Equipment Bed and patient at comfortable heightBed and patient at comfortable height Suction and meconium aspirator readily availableSuction and meconium aspirator readily available Endotracheal tubes not under warmerEndotracheal tubes not under warmer All equipment tested and working just prior to useAll equipment tested and working just prior to use Patient Patient Shoulder rollShoulder roll Head in sniffing positionHead in sniffing position Too much hyperextension can make visualization difficult Too much hyperextension can make visualization difficult

13. Intubation Procedure  Pre-oxygenate with 100% bag valve mask ventilation Contraindicated in known congenital diaphragmatic hernia Contraindicated in known congenital diaphragmatic hernia  Apply monitors  Give drugs Remember minimum atropine dose Remember minimum atropine dose Ensure ability to bag/mask ventilate before paralysis Ensure ability to bag/mask ventilate before paralysis

14. Intubation Procedure  Inserting the laryngoscope blade Hold laryngoscope in left hand Hold laryngoscope in left hand While standing above the patient, insert the blade in the right side of the mouth WITHOUT trying to visualize the cords. While standing above the patient, insert the blade in the right side of the mouth WITHOUT trying to visualize the cords.

15. Intubation Procedure  Take a step back  Lower your head to the level of the label  Slowly advance laryngoscope until you visualize the epiglottis  Use straight or curved blade appropriately

16. Intubation Procedure  Visualize the vocal cords Meconium below cords? Meconium below cords? Both moving if not paralyzed? Both moving if not paralyzed? Structurally normal? Structurally normal?  Pick up endotracheal tube and pass between vocal cords

17. Assessing Endotracheal Tube Placement  Direct visualization  End tidal CO 2 monitoring  Chest rise  Auscultation  ETT vapor Less reliable Less reliable  Chest X-ray

18. Intubation Procedure  Secure endotracheal tube to lip with tape Do not let go of tube until secure Do not let go of tube until secure  Reassess that endotracheal tube is still in place.  Assess the neonate – Improving? More pink? Heart rate increasing? Improving? More pink? Heart rate increasing?  Continue resuscitation – proceed to B and C….

19. Common Problems  Esophageal Intubation Blade placed too deep, cords not visualized Blade placed too deep, cords not visualized  Tongue obscures visualization Sweep tongue to one side with blade Sweep tongue to one side with blade More anterior lift More anterior lift Tape on blade Tape on blade  Cannot see cords Head is hyper-extended - reposition Head is hyper-extended - reposition

20. Common Problems  Cannot intubate Most neonates can be bag valve mask ventilated easily Most neonates can be bag valve mask ventilated easily Call early for anesthesiology assistance Call early for anesthesiology assistance “Bag ventilating with oxygen can prolong life for a long time, repeatedly attempting and failing intubation will not.”“Bag ventilating with oxygen can prolong life for a long time, repeatedly attempting and failing intubation will not.” Surgical airway Surgical airway

21. Difficult Neonatal Airways  Must always be prepared for something abnormal  Increasing awareness of problems beforehand because of neonatal ultrasound  “Things you can see” versus “Things you may find”

22. Difficult Neonatal Airways  Congenital malformations “Things you can see” “Things you can see” Predictable from looking at the patient Predictable from looking at the patient Cleft lip and palateCleft lip and palate Pierre Robin syndromePierre Robin syndrome Treacher Collins syndromeTreacher Collins syndrome Goldenhar syndromeGoldenhar syndrome Apert and Crouzon SyndromeApert and Crouzon Syndrome

23. Congenital Malformations  Cleft Lip and Palate Most common congenital face malformation Most common congenital face malformation  Pierre Robin Sequence Obstruction is usually at the nasopharyngeal level Obstruction is usually at the nasopharyngeal level

24. Congenital Malformations  Apert and Crouzon Maxillary hypoplasia Maxillary hypoplasia Nasopharyngeal airway compromise Nasopharyngeal airway compromise  Goldenhar syndrome Unilateral anomalies Unilateral anomalies Higher incidence of airway anomalies Higher incidence of airway anomalies

25. Congenital Malformations  Treacher Collins Choanal atresia/stenosis more common Choanal atresia/stenosis more common  Down’s Syndrome Subglottic stenosis more common Subglottic stenosis more common Remember atlantoaxial instability Remember atlantoaxial instability

26. Difficult Neonatal Airways  Congenital Malformations “Things you may find” “Things you may find” LaryngomalaciaLaryngomalacia Hemangioma or LymphangiomaHemangioma or Lymphangioma Tracheal webTracheal web Laryngeal atresiaLaryngeal atresia Subglotic stenosisSubglotic stenosis

27. Congenital Malformations  Laryngomalacia A sequence between fully formed to atresia A sequence between fully formed to atresia

28. Congenital Malformations  Laryngeal Web  Tracheal Atresia Survive only if tracheoesophageal fistula or emergent trach Survive only if tracheoesophageal fistula or emergent trach

29. Congenital Malformations  Hemangioma or Lymphangioma Only about 30% present at birth Only about 30% present at birth

30. Congenital Malformations  Subglottic Stenosis

31. In Review  Proper positioning is critical for successful neonatal intubation  Call for help early if unable to intubate or for any congenital anomalies Continue to provide oxygen with bag valve mask ventilation Continue to provide oxygen with bag valve mask ventilation  Practice makes perfect It is estimated that you need to perform at least 90 intubations to be able to intubate successfully on the first or second attempt at least 80% of the time It is estimated that you need to perform at least 90 intubations to be able to intubate successfully on the first or second attempt at least 80% of the time

32.  QUESTIONS?