Chapter 36 ■ Endotracheal Intubation 241

2 cm into trachea or until the tip is felt passing the

suprasternal notch by the assistant (Fig. 36.9).

14. If the tube appears too large or does not pass easily,

decrease angle of neck extension.

15. Confirm endotracheal tube position within the trachea

(13).

a. We currently use Pedi-Cap (Nellcore, Waukesha,

Wisconsin) end-tidal CO2 detector to verify the

position of the endotracheal tube within the trachea. This technique responds quickly to exhaled

CO2 with a simple color change from purple to yellow. It also features an easy-to-see display window

that provides constant visual feedback with breathto-breath response (Fig. 36.10).

b. While gently ventilating with an Ambu bag, auscultate to make sure the breath sounds and chest movement are equal in both sides of the chest.

c. Observe respiratory wave pattern on oscilloscope to

determine that artificial breath is at least as effective

as spontaneous breath.

d. Verify lip-to-tip distance.

16. If the endotracheal tube is correctly placed in the

midtracheal region, there should be

a. Pedi-Cap response to exhaled CO2 by a reversible

color change, purple to yellow

b. Equal bilateral breath sounds

c. Slight rise of the chest with each ventilation

d. No air heard entering stomach

e. No gastric distention

17. Suction endotracheal tube with sterile catheter, following technique described under F, below.

18. Attach appropriate mechanical ventilatory device.

19. Adjust required FiO2.

20. Secure the tube to the infant’s face (Figs. 36.11 and

36.12).

When using adhesive tape, make sure that the face

is dried thoroughly to ensure adherence of the tape and

to protect the skin. A more permanent fastening can be

done later when a radiograph confirms correct placement of the endotracheal tube (14).

21. Obtain chest radiograph with head in neutral position,

and note the lip-to-tip distance and direction of bevel

(Figs. 36.13 and 36.14).

Fig. 36.10. Pedi-Cap CO2 detector. Pedi-Cap is a trademark of

Tyco Healthcare Group LP. (Reprinted by permission from

Nellcor Puritan Bennett, Inc).

A

B

Fig. 36.9. A: Pass the endotracheal tube through the glottis to the appropriately predetermined length

and remove laryngoscope. B: An assistant applies gentle pressure in the suprasternal notch to open the

larynx, and to detect when the tube passes into the trachea.

242 Section VI ■ Respiratory Care

When a correct tube length has been determined

for the infant, note the tube marking at the level of the

infant’s lips.

22. Cut off excess tube length, to leave 4 cm from the

infant’s lips, and reattach adapter firmly.

If a longer external length is required, before

replacing the adapter, slip a short length of a larger

endotracheal tube around the narrower tube to prevent

kinking, for example, a 6-cm length of 3.5-mm tube

over a 2.5-mm tube.

23. Reconfirm tube marking at lip regularly, to avoid unnoticed advancement of the tube into the airway.

24. Retape tube as necessary to maintain stability.

Nasotracheal Intubation

In neonates, orotracheal intubation is preferred because it is

easier and faster to perform and there are few proven advantages to nasal intubations in small infants (15). Nasotracheal

tubes are preferred in very active infants with copious oral

secretions, making it difficult to keep the tube taped in position. When anatomy precludes oral intubation or for oral

surgery, nasotracheal intubation may become necessary.

There is strong evidence that premedication (sedation and

analgesia) allows for a shorter time for intubation and

improves physiologic stability (16).

1. Use sterile endotracheal tube. If stylet is used to curve

tube, remove it prior to nasal insertion.

2. If desired, premedicate with atropine (20 mcg/kg) and

succinylcholine (2 mg/kg) just before inserting tube. Be

prepared to provide assisted bag-and-mask ventilation.

3. If orotracheal tube is already in place, release fixation

and position at far left of the mouth, to allow continued

ventilation during nasotracheal intubation.

4. Directly visualize oropharynx with laryngoscope as

described previously, taking particular care not to

hyperextend neck.

5. Suction oropharynx while keeping laryngoscope in

place.

6. Insert tube through nostril following natural curve of

nasopharynx.

7. As tube passes into the pharynx, align the tip with the

center of the tracheal orifice, moving infant’s head as

needed.

8. When the tip of the nasotracheal tube appears to be in

direct line with the glottis, have an assistant carefully

withdraw the orotracheal tube.

9. Apply gentle pressure over the suprasternal notch and

advance tube through cords.

Fig. 36.11. After initially determining that the endotracheal

tube is in the correct position, connect the tube to an artificial

ventilation source. In the term neonate, begin fixation of the tube

by painting the philtrum with tincture of benzoin or Hollister

medical adhesive spray and allowing it to dry. Avoid use of tincture

of benzoin in low-birthweight infants, as it increases epidermal

stripping.

A B

Fig. 36.12. Fixation of tube with half split tape. A: Lower half of one split tape (1) encircles the tube,

and the upper half (2) attaches to the upper lip. B: Second split tape (3) upper half attaches to the upper

lip, while the lower half (4) encircles the tube.