(2) Schedule prophylactic suctioning for tube patency

only as often as needed to maintain it.

(3) Consider increase in monitored airway resistance as indication for suctioning.

f. Readjust humidification as indicated by catheter

and volume of secretions.

g. Avoid inadvertent suction during insertion of catheter.

Use lowest vacuum pressure effective in clearing

secretions within a few seconds.

h. Do not insert catheter as far as it will go or until

reflex cough occurs. Use prescribed length. Do not

suction if catheter is inserted too far; just touching

the catheter to the tracheal wall may cause trauma.

i. Limit time of insertion and suctioning to least time

required to remove secretions.

5. Technique for intubated patients

a. For artificial airways, use sterile technique with one

sterile gloved hand and one free hand.

b. Monitor oxygen saturation continuously during suctioning.

c. Monitor heart rate continuously.

d. It is usually best to remove infant from ventilator

and have second person perform assisted ventilation

manually, using the following guidelines adjusted to

individual needs.

(1) FiO2 set at or up to 10% higher than baseline

(a) Monitor oxygenation. Adjust FiO2 to prevent swings in oxygenation.

(b) Evaluate effect of procedure.

(2) Peak inspiratory pressure as on ventilator or up

to 10 cm H2O higher

(3) Continuous distending airway pressures same as

on ventilator

(4) Respiratory rate 40 to 60 breaths/min, applying

an inspiratory hold intermittently

When there is a high risk of pulmonary air

leak as in the presence of significant interstitial

emphysema, it may be safer to use a technique of

Chapter 36 ■ Endotracheal Intubation 245

rapid manual ventilation at lower peak pressure

instead of sighing with a prolonged inspiratory

pressure. In other cases in which loss of lung volume with suctioning is of greater concern, use

sigh with a hold on inflation at a rate similar to

ventilator. With suctioning, there is a loss of lung

volume with a decrease in compliance. The

adverse effect persists for a significant time when

mechanical ventilation at the same setting is

used during and after the suction procedure.

e. Determine length of endotracheal tube plus adapter

and note on suction catheter as limit of depth of

insertion.

f. Set vacuum at lowest level to achieve removal of

secretions. The level of vacuum required depends

on a number of variables, including

(1) Air tightness of system and fluctuations in generated vacuum pressure

(2) Accuracy of manometer

(3) Diameter of catheter (smaller catheter, higher

pressure)

(4) Thickness and tenacity of secretions

g. Holding catheter in one hand, moisten tip with

water or saline. Note appropriateness of suction

level by rate of liquid uptake. Adjust pressure with

free hand.

h. Open artificial airway with free hand.

(1) Detach from bag; hold oxygen near end of tube,

or

(2) Open suction port of specialized endotracheal

tube adapter.

i. With free hand, stabilize airway. Pass catheter down

airway to depth limit noted for the patient’s endotracheal tube. Do not apply vacuum during insertion

(i.e., keep suction control port open).

j. Close proximal suction control port and withdraw

catheter.

k. Limit time for insertion and removal to 15 to 20 seconds.

l. Reattach endotracheal tube to bag and ventilate for

10 to 15 breaths or until patient is stable.

(1) Note oxygenation.

(2) Note heart rate.

(3) Note chest excursions.

m. If secretions are thick or tenacious, instill 0.25 mL

of saline into endotracheal tube and continue ventilation.

n. Clear catheter with sterile water.

o. Repeat process until airway is clear.

G. Fixation Techniques

Many fixation devices and techniques have been described

in the literature. None of them can prevent all accidental

extubations or malpositions (11,14,19). Here, we describe a

simple and effective method.

1. Prepare two 8- to 10-cm lengths of adhesive tape split

half of the length and one 10- to 15-cm length without

a split.

2. Paint skin adjacent to the sides of the mouth and above

the lips with tincture of benzoin or Hollister medical

adhesive spray. Avoid use of tincture of benzoin in lowbirthweight infants; it increases epidermal stripping.

(Fig. 36.11).

3. Allow to dry while holding the tube in place.

4. Tape the unsplit end of the adhesive to the cheek on

one side of the mouth, and wrap the bottom half of the

split end clockwise around the endotracheal tube at the

lip. Fold the last 2-mm end of tape on itself to leave a

tab for easier removal (Fig. 36.12). Secure the other

half of the split end above the upper lip.

5. Repeat the procedure from the other side, reversing the

direction of the taping and securing half on that side of

the upper lip (Fig. 36.12).

6. Secure one end of the long tape to one cheek at the

zygoma. Loop the tape around the tube, and secure the

other end to a similar point on the opposite cheek.

7. Note the markings on the endotracheal tube at the

level of the lips and the tape.

8. Whenever the tape appears loosened by secretions,

remove tape and repeat application of benzoin while

holding tube at appropriate lip-to-tip depth.

H. Planned Extubation

Various vasoconstrictors and anti-inflammatory medications

have been recommended to reduce postextubation stridor

and to improve the success of extubation. Systemically

administered dexamethasone appears to have very little, if

any, effect in reducing acute postextubation stridor in neonates and children (20). Local application of steroids

directly to the vocal cords has not been well studied.

1. Perform chest physiotherapy and suction prior to extubation.

2. Release all fixation devices while holding tube in place.

3. Using manual ventilation, provide the infant a sigh

breath, and then withdraw tube during exhalation.

4. Avoid suctioning during tube withdrawal, unless specifically utilizing the tube to remove thick foreign material from trachea.

5. Allow recovery time before suctioning oropharynx.

6. Keep the inspired gases well humidified.

I. Complications

1. Acute trauma (21–23)

a. Tracheal or hypopharyngeal perforation

b. Pseudodiverticulum

c. Hemorrhage

d. Laryngeal edema