NICU intubation tips

[mobrol]

Well I'm doing my NICU this month and everything is going well, except for the 3 or 4 intubation attempts that were unsuccesful. Everyone says it comes with time, and experience but I'm really nervous about not being able to do it when its needed (ie during a code, or a kid that needs to go back on a vent).
So my fellow residents I would greately appreciate any advice/tips regarding this matter
Thanks

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[bks524]

Thats the first thing. Very rarely is there a kid that needs to be intubated in 5 secs on the first attempt. So relax!

Next, don't over extend the neck-this is a common mistake. Put the role under there shoulders in a correct position.

Next, relax again.

the other thing that I would suggest is never blindly intubate. Not just for the obvious reason, but also it ruins your confidence. If you don't see the cords, pull out and bag. If you see the cords and can't get it to go in, pull out and bag. Odds of hitting blindly are zero. So it is better to pull out and reorganize than to ruin any confidence you may have had.

Finally it does come with time. People should understand that intubating often takes a few attempts. I only knew one attending at my program that never took a second look-so relax.

Someone gave me the same advice and it helped tremendously. Now I never miss-haha

 

[meconiumdelee]

Remember that the cords are going to be more anterior in the kids than adults.

That means you'll really have to pull the laryngoscope UP (not cranking back)

As the previous poster said, don't hyperextend the neck.


Suction when you need it--if there is crap in the way, you won't see the cords.

Practice, practice, practice. Also make sure you can bag effectively.

Always ask the RT's for help. They're a great source (if you have access to them).

 

[edmadison]

I agree with the previous posters -- I would also defer to the Oldbear as he has likely taught hundreds of residents how to do this. I will add two tips which helped me tremendously.

First, you usually have much more time than you think you do, so don't rush. get your view. Wait until you can see the cords and then don't take your eyes off of them!

Second, get down low and look straight rather than looking down. You need to get your eyes looking as close to parallel to the baby's body as you can. Once I started doing this, I was much more successful on my intubation attempts.

Also, its good to keep in mind Cornfeld's Law of Neonatal Resuscitation: During delivery room resuscitation, the heart rate of the baby and the resident will always add up to 200.

Ed

 

[oldbearprofessor]

Second, get down low and look straight rather than looking down. You need to get your eyes looking as close to parallel to the baby's body as you can. Once I started doing this, I was much more successful on my intubation attempts.

Ed

This is an EXCELLENT tip. I can't believe how often I see folks standing up looking down trying to intubate a baby. Won't happen. Bend your back and get to the baby's level.

In general, the tips here are good. One thing I do when teaching is to take the laryngoscope for a resident that is having trouble and show them the cords opening and closing. It's not possible to learn to intubate if you don't know what you're looking at. Teaching intubation is hands-on. I take the largyngoscope the first time, find the cords, get them opening and closing and have the resident pass the tube. Next time, the resident does it all and I check quickly before they pass the tube to make sure it's going in.

For really little babies < 700 g or so, the laryngoscope gets used almost like a tongue depressor - just barely put it in and go to it.

Also, it's very common for newbies to successfully intubate a baby and then pull the tube out accidentally seconds later. Have someone show you how to use your finger to hold the tube up against the roof of the baby's mouth while the first piece of tape is put around to hold it.

Finally, remember the basic rule of 7-8-9. If you put that 3.0 tube in and you have it at the 11 at the mouth, you're waaaay down the right mainstem. I call this "screwing the tube in" (hmm, hope that doesn't set off the dirty word filter. 😛) and is a sign of pride in one's success at intubation. However, for the baby's sake, don't put that 3.0 tube in beyond the 8 to 9 mark at the lip.

 

[group_theory]

is it advisable to have the tip of the Miller blade go in too deep (into the esophagus) and pull back until the vocal cords pop into view? (or would it cause too much trauma/edema)

 

[oldbearprofessor]

is it advisable to have the tip of the Miller blade go in too deep (into the esophagus) and pull back until the vocal cords pop into view? (or would it cause too much trauma/edema)

Be very cautious. Easy to lacerate the tongue that way. I've done it once and it wasn't pretty and I didn't feel warm and fuzzy when they were putting in a stitch to stop the bleeding.

Sometimes you have to go forward and pull the blade out to find the cords, but make sure the baby is still and watch the blade very carefully.

 

[dr.b.natural]

Here's a few other tips that work for intubating anyone, but are especially helpful in the NICU where everything is smaller.

In general the depth is 6+the weight in kilos, but I always find it hard to pay attention to those numbers as I'm trying to pass the tube through the cords. The bottom of the ET tube has 3 sets of lines - a single, double and triple line. If you stop when the double line passes through the cords, the tip of the tube ends up in the right spot - usually right between the 2nd rib and the carina.

Also, don't use the groove in the scope to pass the tube. That's the groove you look down to visualize. Pass the tube just next to that groove.

And as others have alread mentioned, the importance of lifting, and not cranking cannot be overemphasized.

 

[kickazzz2000]

Get your azz as low as it will go and the cords will magically appear.