Intubation

• Difficult airway? 

  1. History of difficult intubation, micrognathia, craniofacial abnormalities, large tongue, signs of respiratory obstruction.

  2. If yes, avoid paralytics and be prepared to call anesthesia ASAP.

• Wt. in kg + 6 (not very precise), preferably refer to table below:

  1. Preferably, identify the double black lines at the distal tip of the endotracheal tube; once the vocal folds are aligned in between the black lines, your tube is likely in the correct position (advanced, other methods until comfortable with direct laryngoscopy).

• Pre-medication order (avoiding morphine due to long onset of action ~15 minutes):

  1. Fentanyl slow push over 3 minutes (monitor for rigid chest; shallow breathing/apnea, unable to bag).

  2. Midazolam if applicable (do not use routinely, avoid in preterm infants).

  3. Atropine if applicable to minimize bradycardia and/or decrease secretions.

  4. Vecuronium 1 minute prior to intubation if applicable (avoid if infant is depressed or difficult airway).

Pre-intubation:

☐ Verify consent (if non-emergent)

☐ IV access

☐ Endotracheal tubes x2 (including one size down)

☐ Laryngoscope (1, 0, 00, 000) based on infant size and preference

☐ Set and verify pressures on T-piece

☐ ET CO2 detector

☐ Suction catheter 

☐ Stethoscope

☐ Manual cuff to cycle q1minute if arterial line not available

☐ Drugs drawn up to pre-medicate if applicable

☐ Designate roles (leader/monitor, intubator(s), RT to hold tube, RT to ventilate, auscultator, RN)

Post-intubation:

☐ Ventilator settings

☐ Chest x-ray ordered (X-ray: 1 cm above the carina or around T2-T3)

☐ Blood gas timing post-intubation

☐ Update family

General Criteria (though clinical judgement overrides any individual criteria below)

• FiO2 <40%

• pCO2 < 55

• TV < 6 mL/kg

• CMV MAP < 10

• HFV MAP < 12

Other Considerations:

• Recommend weaning off sedative medications prior to extubation

• Patient must have sufficient respiratory effort

• Consider pretreating with caffeine 

• Frequent desaturations on MV should not be a contraindication to extubation, as many times hypoxemia results from loss of FRC associated with abdominal contractions and not related to lung disease