NextGen Learning To Elevate Your Airway Practice
Breaking News
In 2024, a randomized trial published in The New England Journal of Medicine demonstrated that video laryngoscopy resulted in a higher first-attempt success rate (74%) compared to direct laryngoscopy (45%) among neonates undergoing urgent intubation. The New England Journal of Medicine. 2024;390(20):1885-1894. doi:10.1056/NEJMoa2402785.
Setting Up Your Equipment
Tools of the Trade
Spend some time getting to know the essential details of all the necessary equipment (coming soon).
Clinical Pearl
The Neonatal Intubation
Learn the essential steps of neonatal intubation.
Troubleshooting tips
Get a few troubleshooting pearls from Jennifer Lin, MD. Our neonatology expert
The 7 Laws of Neonatal Intubation
We’ve compiled the laws of neonatal intubation for you. These laws are immutable. Take them to heart, and your intubations will be safer, or ignore them at your peril.
1. Prioritize Oxygenation
- Oxygenation over intubation is the first law and most important law.
- Optimize oxygenation and ventilation with a bag valve mask or CPAP before attempting intubation.
- Halt at any point during an intubation attempt if hypoxia starts to occur.
- Use a colorimetric or capnography device to confirm tube placement.
- Check bilateral chest rise and auscultate breath sounds.
2. Choose the Right Equipment
- Appropriate Endotracheal Tube (ETT):
- Size based on weight or gestational age (e.g., 2.5 mm ID for ≤1 kg, 3.0 mm ID for 1–2 kg, 3.5 mm ID for >2 kg).
- Uncuffed tubes for neonates, though cuffed tubes may be used in specific cases.
- Laryngoscope:
- Use a straight blade (e.g., Miller size 0 or 00) to better visualize the anteriorly placed neonatal larynx.
- Suction Equipment:
- Suction catheter size appropriate for neonatal airways to clear secretions.
- Use a colorimetric or capnography device to confirm tube placement.
3. Position Position Position
One of the most important things you can do to give yourself a chance at a successful intubation happens before you pick up the laryngoscope. Correct positioning is the key.
- Start With a Neutral “Sniffing” Position:
- Use a small shoulder roll to align the oral, pharyngeal, and tracheal axes.
- Avoid hyperextension or over-flexion, which can obstruct the airway.
4. Don’t Plunge and Pray
Your stress response during intubation and shorter distances mean it’s easy to override critical anatomic landmarks, leading to delays in tracheal access and increased risk of esophageal intubation. The answer is to slow down and take an incremental approach:
- Slow Gentle Insertion:
- Minimize trauma by advancing the laryngoscope gently while lifting the tongue and epiglottis.
- Visualization:
- Identify key landmarks: vocal cords, arytenoids, and glottis.
- Tube Placement:
- Insert the ETT to the appropriate depth based on weight or formula (e.g., [(Weight in kg × 3) + 6] cm).
5. Have a Toolbox of Skills
It’s unrealistic to think you will get every intubation immediately, but it is expected that when your first look is sub-optimal, you will have a toolbox of problem-solving skills. Develop this toolbox for the most common difficulties.
- Difficulty Identifying Key Anatomic Landmarks:
- Slowly back up until the landmarks you need come into view.
- Adjust the head position.
- Clear secretions.
6. Never Let Go
- Secure the Tube:
- Once the intubation is complete, guard that tube with your life until properly secured to prevent dislodgement.
7. Maintain Your Skill
- Neonatal intubation is a high-skill procedure requiring frequent practice through simulation and hands-on training to maintain proficiency.
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