Page 580 - Clinical Application of Mechanical Ventilation

546 Chapter 17

INTUBATION

In most instances, intubation of the trachea is a necessary part of mechanical ven-
tilation of the neonate. Although this chapter will discuss basics of intubation, it is
beyond the scope of this chapter to cover the procedure in detail. Those interested
in studying the procedure are referred to any of the several excellent neonatal/
pediatric respiratory texts for that information. Here, the indications, equipment,
and general considerations of neonatal intubation are covered.

Indications

Endotracheal intubation of a neonate is indicated when (1) prolonged or inadequate
Intubation is indicated in bag-mask ventilation is present; (2) chest compressions are needed and heart rate
(1) inadequate or prolonged
bag-mask ventilation; (2) low remains low; (3) endotracheal administration of epinephrine or surfactant is indi-
heart rate during chest com- cated; (4) meconium is present at delivery and the neonate is nonvigorous, meaning
pressions; (3) endotracheal
administration of epinephrine the neonate has a slow heart rate (,100/min), inadequate respirations, and/or poor
or surfactant; (4) the presence muscle tone. Intubation needs to be done as quickly as possible to remove meco-
of meconium at delivery in a
nonvigorous neonate (slow nium from the airway before manual ventilation; and (5) the neonate is extremely
heart rate (,100/min), premature and mechanical ventilation is inevitable.
inadequate respirations, and/
or poor muscle tone); and Other less common indications may include presence of obstructive lesions such
(5) extreme prematurity.
as trachealmalacia, tracheal web, tracheal stenosis, laryngeal paralysis, and extrinsic
masses. Diaphragmatic hernia, removal of pulmonary secretions, maintaining the
airway during surgery, and obtaining tracheal aspirates also require intubation.
Table 17-1 shows the method of assessing a neonate using the Apgar score.
Parameters listed are assigned points based on findings shown in the table.
Resuscitation of a neonate should continue while scoring the Apgar. The scores range
from 0 to 10 and they are given at 1 and 5 min. Scoring stops if the score is 7 or
higher at 5 min. However, scoring should continue every 5 min up to 20 min if the
score is less than 7.

TABLE 17-1 Apgar Score

0 1 2

Heart rate None Slow (,100) Irregular Over 100

Respiratory effort Apnea Irregular, shallow, gasping Good, crying

Muscle tone Flaccid Some flexion of extremities Well flexed
Reflex No response to stimulus Grimace Cough or sneeze

Color Pale blue Blue extremities, pink body Pink all over
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