Page 581 - Clinical Application of Mechanical Ventilation

Neonatal Mechanical Ventilation 547

Equipment

The basic equipment and supplies for intubation include a laryngoscope, an ap-
Use laryngoscope propriately sized laryngoscope blade with light, and an endotracheal tube (ETT).
blade size 1 for most term
newborns, size 0 for preemies Miller blade sizes of 1, 0, and 00 are used to intubate most term newborns, preemies
and size 00 for micropreemies.
and micropreemies, respectively. Selection of an ETT is based on the birth weight
or gestational age of the neonate. Table 17-2 shows the guidelines for selecting an
ETT for neonates as published in the Neonatal Resuscitation Program (NRP) by
the American Academy of Pediatrics and American Heart Association (2006). These
guidelines are commonly used by hospitals with labor and delivery rooms.
Other essential equipment may include airway suctioning devices, adhesive tape
or other ETT stabilizers, flow inflating bag with 200 to 450 mL capacity and a flow
restricting valve, airway manometer, and masks of different sizes (i.e., preemie, neo-
nate, and infant) to fit over the tip of chin, mouth, and nose. The use of a T-piece
resuscitator is a reliable option, in lieu of a bag and mask resuscitator, to provide
ventilation to a neonate. An oxygen blender should be able to deliver a wide range
of F O (up to 100% oxygen), so weaning from oxygen may be guided by SpO
I
2
2
readings and clinical signs. The SpO for premature infants less than 32 weeks ges-
2
tation should be maintained between 85% and 92% to minimize the incidence of
retinopathy of prematurity (ROP).
Intubation. Intubation should be done by two persons. The person performing the
Each intubation attempt
should be limited to 20 sec. intubation should be responsible for bag-mask ventilation, intubation, and stabili-
Bag-mask ventilation with zation of the ETT. Another person may help by passing the intubation equipment,
oxygen must be done between
attempts. monitoring the patient and vital signs, and timing of the procedure. Each intuba-
tion attempt should be limited to 20 sec, and bag-mask ventilation with oxygen
between attempts must be done to maintain acceptable SpO and vital signs.
2
The infant should be put in a sniffing position and delivered free-flow oxygen dur-
ing the procedure. The blade should sweep the tongue from right to left as the blade
is placed into the infant’s mouth. Gently advance the blade until the tip lies just
beyond the base of the tongue. Lift the blade slightly by raising the entire blade, not
just the tip. Look for landmarks. The vocal cords should appear as vertical stripes
on each side of the glottis. Suction if necessary. Apply cricoid pressure as needed

TABLE 17-2 Selection of Neonatal Endotracheal Tubes

Tube Size (Id mm) Weight Gestational Age
2.5 Below 1,000 g Below 28 weeks

3.0 1,000 to 2,000 g 28 to 34 weeks

3.5 2,000 to 3,000 g 34 to 38 weeks
3.5–4.0 Above 3,000 g Above 38 weeks
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