A B

Fig. 36.1. A: Vallecula cyst, causing stridor and proximal airway

obstruction. B: Endotracheal tube passes beneath cyst. C: Same

patient after laser surgical treatment.

Table 36.1

Endotracheal Tube Diameter

for Patient Weight and

Gestational Age

Tube Size (ID mm) Weight (g) Gestational Age (wk)

2.5 <1,000 <28

3.0 1,000–2,000 28–34

3.5 2,000–3,000 34–38

4.0 >3,000 >38

238 Section VI ■ Respiratory Care

b. Secure tube carefully in position to avoid dislodgement, kinking, or movement.

(1) Vary contact point from side to side to prevent

damage to developing palate and palatal ridges

(7,8).

(2) Note relationship of head position to intratracheal depth of tube on radiograph (9).

9. Do not leave endotracheal tube unattached from continuous positive airway pressure; the natural expiratory

resistance is lost by bypassing the upper airway.

10. Recognize that in neonates, endotracheal tubes are

often pushed in too far because of the short distance

from the glottis to the carina. Use a standardized graph

or location device (2,5).

11. Recognize the association of a short trachea (fewer than

15 tracheal cartilage rings) with certain syndromes:

DiGeorge syndrome, skeletal dysplasias, brevicollis,

congenital rubella syndrome, interrupted aortic arch,

and other congenital syndromes involving the tracheal

area (10).

Fig. 36.2. Anatomic view of neonatal upper airway. The glottis

sits very close to the base of the tongue, so visualization is easiest

without hyperextending the neck.

Table 36.2 Trouble-Shooting Problems with Endotracheal Intubation

Problem Suggested Approach for Solution

Infant’s tongue gets in way. Push tongue aside with finger before inserting blade.

Secretions prevent visualization. Suction prior to intubation attempt.

Tube seems too big to fit through vocal cords. Verify correct tube size for patient weight and gestational

age.

Vocal cords are closed. Decrease angle of neck extension.

Apply traction to blade.

Apply a short puff of air through the tube onto the vocal

cords.

Select smaller tube size.

Evaluate for airway stenosis.

Unsure of appropriate tube length. Await spontaneous breath.

Apply gentle suprasternal pressure.

Difficult to ventilate after intubation. Insert tube just past vocal cord.

Predetermine tube length.

Obtain chest radiograph with head in neutral position to

confirm tube position relative to carina.

Swelling of neck and anterior chest. Verify that tube is in trachea.

Verify that tube is not in bronchus.

Consider tube and/or airway obstruction.

Consider pulmonary air leak into mediastinum/pericardium (Fig. 38.8A, B)

Blood return from endotracheal tube. Evaluate for tracheal perforation.

Tube slips into main bronchus. Avoid neck hyperextension.

Secure tape fixation.

Maintain correct lip-to-tip distance.

Unplanned extubation. Regularly verify correct tube distance.

Secure tape and replace as necessary.

Support neck when moving infant.

Avoid neck hyperextension or traction on tube.

Secure infant’s hands.

Chapter 36 ■ Endotracheal Intubation 239

12. Identify and prevent the factors that are most likely to

contribute to spontaneous extubation (11).