MANUAL. Category: Nursery Ref Policy #: Topic: ENDOTRACHEAL INTUBATION: ASSISTING

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1 Cvenant Health Rural Pediatrics POLICY PROCEDURE Initiated by: MANUAL Apprved by: Site Administratr Nursery Date First Issued: August 2015 Categry: Nursery Ref Plicy #: Tpic: ENDOTRACHEAL INTUBATION: ASSISTING 1.0 PURPOSE T prvide guidelines fr assisting with endtracheal intubatin. 2.0 APPLICABILITY All Cvenant Health Emplyees 3.0 POLICY STATEMENT 3.1 Indicatins fr endtracheal intubatin include: T prvide elective r emergency airway maintenance in cnditins prducing r resulting frm respiratry insufficiency including the fllwing: Prlnged r severe apnea PaCO 2 greater than 60 in the presence f acidsis FiCO 2 requirements greater than 0.80 Delivery rm resuscitatin Tracheal suctining fr mecnium in a depressed infant A cmbinatin f clinical cnditins such a tachypnea, grunting, and indrawing nt respnsive t CPAP T deliver psitive airway pressure Fr lavage r tracheal tilet T prevent r t relieve critical airway bstructin 3.2 The endtracheal intubatin must be rdered when the baby is a patient in the Nenatal Nursery. In the delivery rm, the individual assuming the lead fr the resuscitatin makes the decisin. 3.3 Each qualified individual is limited t a maximum f tw attempts at endtracheal intubatin unless there is n ther individual available and the patient requires mechanical ventilatin urgently. 3.4 All intubatins require the presence f a respiratry therapist, the bedside nurse and a certified intubatr. 3.5 Pre-intubatin medicatins are given t all babies unless it is an emergency. 3.6 The nurse in charge will be ntified. 3.7 T minimize the prblem f pr xygenatin, the patient is pre-xygenated with a T- piece resuscitatr, free flw xygen is given during the prcedure, the infant is hand ventilated with a T-piece device between attempts, and attempts are limited t 20 secnds in length.

2 4.0 EQUIPMENT Endtracheal Tube f Apprpriate Size: Weight ETT Size Less than 1000 grams 2.5 mm grams 3.0 mm grams mm Greater than 3000 grams mm Page 2 f 5 Water Sluble Lubricant Stethscpe Laryngscpe McGill frceps fr nasal intubatin Stylet fr ral intubatin Suctin Catheter #8 & #10 French Wall suctin set at mmhg ½ - ¾ adhesive tape, depending n infant size f fixatin device Thin hydrcllid such as Duderm T-piece resuscitatr r bagger & apprpriate mask with blended xygen surce Medicatins: Atrpine, Fentanyl and Succinylchline Heat surce: Radiant warmer r warming lights Persnnel: Persn certified t intubate, respiratry therapist, and registered nurse. The assisting rles can be carried ut by any f the persnnel with the exceptin that all ventilatr set-up and adjustments are dne by the RRT. End tidal CO2 mnitr

3 5.0 PROCEDURE ACTION 1. Health care prvider assists the infant s breathing as necessary until intubatin is accmplished. 2. Respiratry Therapist, beside nurse and charge nurse are infrmed f prcedure. 3. Perfrm hand hygiene. Ensure intravenus access. Obtain pre-medicatins fr administratin. 4. Assemble equipment and prepare fr use. A stylet is ften needed fr ral intubatin and McGill frceps are used fr nasal intubatin. Test bag r T-piece resuscitatr. Test suctin. 5. Prepare adhesive tape and Duderm fr use r btain fixatin device. 6. Ensure infant has adequate head surce, cardiac, xygen saturatin and end tidal CO2 mnitring. 7. Determine if the infant has been fed in the previus 4 hurs. If s, suctin the stmach befre prceeding with the prcedure. 8. Administer pre-medicatins. Supprt the infant s breathing. 9. Assist the persn intubating as necessary e.g. tracheal pressure, psitining, tube advancement, suctining etc. 10. Mnitr infant s tlerance f prcedure. 11. Use end tidal CO2 mnitr t verify successful endtracheal intubatin. 12. Discuss ventilatin parameters and bld gas mnitring. Obtain rder fr chest x- ray and surfactant as required. RATIONALE Page 3 f 5 The infant s breathing is assisted if he/she is unable t ventilate/xygenate well independently. Necessary persnnel are infrmed s that resuscitative equipment & ventilatrs are readied. Oral intubatin is preferred during emergency resuscitatin and fr shrt-term intubatin. Nasal intubatin is preferred fr lng-term ventilatin. Duderm is applied next t skin under adhesive t reduce skin trauma. Taping methds may vary between ral r nasal rute and persnnel intubating the baby. Heat is used t prevent cld stress and mnitring allws fr recgnitin f patient deteriratin. T prevent aspiratin f stmach cntents. Intubatin causes an increased intracranial pressure and decreased xygenatin. Premedicatins can amelirate the pressure rise, xygenatin fall, and trauma assciated with intubatin. The infant requires respiratry supprt because the pre-medicatins stp spntaneus breathing. T ensure the prcedure ges smthly, thus minimizing trauma t the infant and decreasing the duratin f the prcedure. Each intubatin attempt shuld be n greater than 20 secnds in length. An attempt shuld be abandned and the infant ventilated with a mask if nt tlerated. 13. Chart ETT size inserted and length f tube T assist with determinatin f suctin depth and

4 at the lip r naris. 14. Order when t restart feeds if applicable. 15. Dcument the prcedure n the patient s chart. The name f the individual wh cmpleted the prcedure, the number f attempts at the prcedure, the infant s respnse, the size f tube inserted, the rute the tube was inserted and the depth the tube was inserted shuld be included. size f suctin catheter t use. Page 4 f DOCUMENTATION The prcedure shuld be dcumented n the patient s chart. The name f the individual wh cmpleted the prcedure, the number f attempts at the prcedure, the infant s respnse, the size f tube inserted, the rute the tube was inserted and the depth the tube was inserted shuld be included. 7.0 RELATED DOCUMENTS Adapted with permissin frm Stllery Children s Plicy and Prcedure Manual: m Endtracheal Intubatin - Assisting, Prcedure, March RELATED POLICIES AND PROCEDURES T-Piece Ventilatin Basic Assessment Endtracheal Extubatin IV Push Medicatin Pain Assessment Skin Care Ventilated Infant (Care f) Plicy Nenatal Resuscitatin Manual

5 Page 5 f REFERENCES Barringtn, K., Finer, N.N., & Etches, P. (1989). Succinylchline and atrpine fr premedicatin f the newbrn infant befre nastracheal intubatin. A randmized, cntrlled study. Critical Care Medicine, 12(12), Kattwinkel, J. (Ed.) (2006). Nenatal Resuscitatin Textbk (5 th ed). American Academy f Pediatrics & American Heart Assciatin. Rais-Gahrami, K. (2007). Endtracheal intubatin. In: M.G. MacDnald & J. Ramasethu (Ed.) Atlas f Prcedures in Nenatlgy (4 th ed., pp ). Philadelphia: Wlters Kluwer / Lippinctt Williams & Wilkins.