Techniques for Endotracheal Intubation Specific to Unique Patient Needs

416 Appendix D

c. Dislodgement from left mainstem bronchus

d. Ventilatory insufficiency due to significant disease in

the only lung being ventilated

Nonvisualized Oral Intubation

This technique has a higher risk of complications and is less

often successful than when direct visualization is used.

Reserve the blind oral intubation for true emergencies in

small infants when there is equipment failure (e.g., laryngoscope light) and when ventilation by mask is contraindicated (e.g., thick meconium).

1. Stand at infant’s feet.

2. Carefully slide first two fingers of gloved, left hand into

back of oropharynx at the base of tongue, until reaching

vallecula and epiglottis. Keep fingers in the center of

the tongue.

3. Using index finger, pull epiglottis forward.

4. Keep infant’s head in midline.

5. With right hand, guide ET tube, without stylet, along

left middle finger, which is held just above index finger.

6. Advance tube carefully just beyond fingertips.

7. Avoid pushing against any obstruction.

8. If available, have assistant press gently on trachea in suprasternal notch and report when tube passes under finger.

9. Verify position, and fix tube as previously described.

Blind Nasotracheal Intubation (5)

Blind nasotracheal intubation is often used in adults.

Because a stiff tube is needed, the chance of perforation in

infants is greater if a stylet is used. Although an intubation

under direct visualization is preferred, the presence of

severe micrognathia or oral masses makes this approach

valuable. It is critical not to push against any resistance.

1. Keep infant supine with neck flexed and shoulders supported by a small roll.

2. Shape a stylet so the tip of the endotracheal tube will

curve anteriorly at 90░degrees. Be certain the tip of the

stylet stays above the end of the ET tube. Alternately,

freeze an ET tube in this configuration and remove stylet just prior to insertion.

3. Maintaining the curve in the tube anterior, insert the

tube carefully through the nostril until its tip is in the

oropharynx.

4. Pull the jaw forward into a sniff position with the head

midline and put slight external pressure over the cricoid cartilage.

5. Advance the tube to a suitable depth unless there is any

resistance.

6. Remove stylet and verify presence of exhaled humidity

and equal breath sounds.

Intubation in Severe Cleft Defects

There are several possible modifications for ET tubes that

are useful for fixation or elective intubation when there is a

large cleft palate. For emergency intubations, the following

modification using a standard tongue blade is usually

immediately available (6). For techniques or difficult intubation alternatives, see above (7).

1. Open infant’s mouth and lay sterile tongue blade flat

across maxilla, with ends extending from corners

mouth. Have assistant hold in place.

2. Follow steps for routine intubation, using tongue blade

for support of laryngoscope as necessary.

3. After intubation, fix tube to padded tongue blade.

4. Recognize that tongue thrust on tube in absence of a

normal palate may lead to extubation even without visible external lengthening of tube.

Emergency Retrograde Intubation (8)

When facial anomalies preclude other routes, retrograde

intubation using a modified Seldinger technique is possible. Because the cartilaginous support of the trachea is so

poor, needle puncture is far more difficult in neonates.

Equipment

1. Venous cannula with stylet, 14 or 16 gauge

2. Feeding catheter. Verify that the catheter will pass

through the lumen of the angiocath.

a. A 14-gauge cannula will admit a 5-French (Fr) feeding tube.

b. A 16-gauge cannula will admit a 3.5-Fr feeding tube.

3. Hemostat

4. Endotracheal tube

Technique

1. Sedate infant if possible.

2. Clean skin over cricothyroid area.

3. At the level of the cricothyroid, puncture skin with cannula and stylet. Angle cannula at 45 degrees from the

skin and directed toward the head.

4. Insert into lumen or trachea only until there is a give in

resistance or air returns.

5. Remove the stylet.

6. Thread feeding tube through the lumen of the

cannula until it can be retrieved from the nose or oropharynx.