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  Intubation of Neonates  
  Cannulation of Veins  
Intubation of trachea is used to provide ventilatory support to a critically ill infant and to support neonates with respiratory insufficiency (1). The method was initially used in neonates in the USA (2,3) and is practiced in paediatric intensive and neonatal care. The method is very simple but at times we fail to intubate - not because we do not know how to intubate but because we have failed to understand the reasons for failure.
If this is a procedure practiced in the hospital for a long time, "Why on earth has this person published this in a web site ?
The answers are simple but the situations is more complex " You must be a parent or a relative of child on ventilator to answer this question. As a doctor you should know the reason"
Learning this technique is difficult, using a manikin to practice will not give you the confidence to intubate. When there was an opportunity to intubate gab it but learn the technique by observing before hand. Using a manikin alone to learn intubation does not not necessarily guarantees success. I feel it is easier to intubate a normal baby than a manikin, and once you successful intubate an infant you will definitely gain confidence.
My main ambition is to teach this technique to as many doctors as possible. After fifteen years of experience in intubating, resuscitating and teaching this technique to doctors - I feel my method of teaching should be available to who ever is keen on learning and understanding this simple life saving technique.
 
Learning intubation is not by knowing how to intubate but knowing what not to do. I adopted simple four steps to help the doctor remember and perform the procedure - quickly and confidently. The procedure learnt methodically is less likely to fail than one learnt very haphazard fashion under stress. I have explained this procedure to help you learn later teach other doctors and nurses.
 
I have found it repulsive to see some doctors working in intensive care - with less experience but abundant confidence. They are not good to themselves nor good to the profession. Please remember performing this procedure efficiently is the first step in resuscitation but knowing how to intubate does not mean to say you know how to resuscitate "Intubation is Not Resuscitation"
 

WHAT ARE THE PROBLEMS ?
  • Text book explains the procedure but it is not as simple as explained.
  • Learning and teaching this technique is difficult as the procedure is an emergency procedure.
  • Procedure must be performed as quickly as possible to successfully resuscitate.
  • Repeated failure makes procedure more difficult for others to intubate as the cords starts swelling and bleeding obstructing the view.
  • Person who teaches this technique must be very competent and sure of success if the student fails to intubate
  • Teachers will be under enormous pressure to take over the procedure - lost opportunity to junior doctor.
  • Junior doctors are not frank to confess that they have not intubated before.
  • Teachers must learn to identify juniors who have and who have not intubated.
  • The longer you take to intubate - more traumatic it is to the baby and difficult for others to intubate.
 
Cockburn (1971) & Gregory (1975) reviewed patho-physiology of neo-natal asphyxia and its management. It is not possible to determine how long the apnoea infant was hypoxic prior to delivery. The longer the apnoea exists the greater the risk of brain damage. It is very important to reduce the duration of hypoxia after the birth of the child to minimise damage to the brain.
 
The equipment in the resuscitation should be checked regularly, and prior to delivery of the baby. If the medical staff are not available or experienced, the baby can be given oxygen via mask (Mushin & Hiflard l%7). This is the only method required for the majority of depressed babies. It is safe and suitable for use by doctors and midwives. Initially, clear the airway using gentle suction, then apply the appropriate oral airway. Using the correct size facemask and keep the head slightly extended. The facemask should cover the nose and make adequate contact with the face. The bag is inflated 40 to 50 times a minute. Watch the movements of the infants chest and abdomen to ensure adequate lung expansion and ventilation (Forfar & Arnold; et al: Text Book of Paediatrics).
 
Blowing oxygen directly on the face from direct source should be discouraged. This cold oxygen will produce vaso-constriction of vessels in the face, resulting in pallor or cyanosis. Babies who are not breathing need chest inflation and oxygenation to prevent further hypoxia. Excessive oxygenation by over enthusiastic bagging should be discouraged as this results in lowering carbon di-oxide (babies need some carbon dioxide to stimulate spontaneous respiration)
   
 
Indications Infant requiring mechanical ventilation
  Immaturity / Preterm infant
  Progressive respiratory distress
  Apnoea
  Rising arterial carbon dioxide
  Intractable hypoxia unresponsive to CPAP (continuos positive airway pressure)
  Coma
  Cerebral oedema
  Status epilepticus
 
 
Intubation is NOT Resuscitation
Remember intubating baby is the easy part of resuscitation as most problems start after intubating and establishing airway. The major problem I encountered was when to stop resuscitation and extubate to declare that the baby is dead. My teacher told me a long time ago "We are not God, our job is to postpone death". This helped me to ease my pain and prevented me from moping in depression for not being successful at saving one life.
 
Deciding when to intubate is not easy either. It may be easy to intubate but the problems usually start after intubating. The infants I found difficult in deciding to intubate and ventilate are babies who are making some effort to breathe, meconium aspiration babies, known asthmatics and babies with severe bronchiolitis. These infants are not easy to intubate and are very difficult to ventilate.
 
I feel it would make life easier for various medical practitioners, nurses, and para-medics to know how to intubate. The procedure is not difficult, and you do not require special skills to just push a small tube into the airway (provided you have a laryngoscope)
 
This procedure is not to be attempted by non-medical personnel. I did mention in the beginning that "Intubation is not Resuscitation". The problems usually start after you secure an airway. If you do not have a tube or laryngoscope, you will be able to sustain life if you can administer oxygen using a bag and facemask
 
Please note that attempting to intubate is a must, but persevering to intubate can be dangerous. Please call for help if you cannot intubate after two attempts "Remember giving oxygen via mask can sustain life for a long time, but continuously trying and failing to intubate cannot"
 
We have tried to explain various steps to practice and learn how to intubate. The emphasis is not mainly on various anatomical positions of the oropharynx but on positioning the baby and yourself. You can look at the way a doctor positions himself/herself while intubating and confidently say whether he/she has intubated before. I have taught this procedure to various doctors and nurses who have benefited and helped others to learn. I felt that I should share my observations to a wider community.
 
 

10 GOLDEN RULES

You Must

  1. Check the resuscitation equipment, oxygen and the laryngoscope
  2. Have the suction catheter (size 10) connected and checked
  3. Try to intubate when the opportunity arises
  4. Be confident and be calm
  5. Call for help as soon as you start the procedure
  6. Stop if not successful after 2nd attempt and continue to give oxygen via bag and mask
  7. Extubate and continue with bag and mask oxygen if the baby's heart rate does not comeup in 2 minutes, or the baby not pink in 1-2 min.
  8. Pause for two minutes and give oxygen via bag and mask between attempts
  9. Teach others to intubate
  10. Encourage and support doctors and nurses to be confiedent.
   

You Will Not

  1. Miss an opportunity - this will help patient if you are successful
  2. Continue the procedure after 2 attempts
  3. Blame yourself if not successful
  4. Criticise others and undermine their confidence because they failed to intubate
  5. Take over the procedure from others unless you are requested by the other doctor.
  6. Continue to give oxygen via endotracheal tube if the child does not improve after intubation (tube may be dislodged, kinked or too far in the right broncus
  7. Become over confident and think you know how to resuscitate
  8. Pull out the endotracheal tube and undermine others confidence (tube might be too far down the right bronchus - repositioning you will help others to gain confidence at intubating).
  9. Discourage others
  10. Blame others for afiling to intubate
  Dr Kadiyali M Srivatsa.
Copyright © 1995 [Kingsmead Technology]. All rights reserved.
Revised: January 07, 2000.