Chapter 36 ■ Endotracheal Intubation 243

Use of the Magill forceps is often more cumbersome than helpful in smaller infants. A Magill forceps

should always be available, but in a properly positioned

infant, a curved tube usually passes directly into the trachea without forceps unless the neck is excessively

extended, flexed, or rotated. Secure tube and verify

position. The length of a nasotracheal tube for correct

positioning of the tip in the trachea is approximately

2 cm longer than the equivalent length of an orotracheal tube.

A B

A B

Fig. 36.13. Although the carina is usually at the level of T4 on the anteroposterior supine chest radiograph, this relationship may be significantly disturbed by a number of factors, including radiographic technique (x-ray tube position, angulation). For this reason, and because the carina is usually easily visualized,

as in these cases, one should directly relate the tip of the endotracheal tube to the carina radiographically,

knowing the position of the head at the time of film exposure. In both cases, films were taken to verify

endotracheal tube position but demonstrated problems with other procedures. A: Appropriate radiographic

angle. (Note the oral gastric tube in the esophagus and not reaching the stomach.) B: Slightly lordotic

radiographic angle. (Note the central venous line coiled in the heart.)

Fig. 36.14. Sequential radiographs demonstrate the effect of head rotation on bevel direction. A: With

the head rotated to the right, the bevel appears to be directed against the tracheal wall. B: The head is

rotated to the left, and the bevel is now positioned properly. If the bevel is directed against the posterior

tracheal wall in a spontaneously breathing infant, there may be symptoms of tracheal obstruction on expiration. Rather than turning the head to achieve satisfactory position, rotate the endotracheal tube and

retape in position.

244 Section VI ■ Respiratory Care

F. Tracheal Suctioning

Suctioning of the nose, mouth, and pharynx is potentially

quite traumatic in neonates. The same equipment, precaution, and complications apply as for tracheal suctioning.

Always suction an endotracheal tube before suctioning the

mouth; suction the mouth before the nose.

1. Indications

a. To clear tracheobronchial airway of secretions

b. To keep artificial airway patent

c. To obtain material for analysis or culture

2. Relative contraindications

a. Recent surgery in the area

b. Extreme reactive bradycardia

c. Pulmonary hemorrhage

d. Oscillatory ventilation

3. Equipment

Sterile

a. Saline for instillation into airway

b. Saline or water for irrigation of catheter

c. Gloves

d. Suction catheters

(1) Available safety features

(a) Markings at measured intervals

(b) Microscopically smooth surface

(c) Multiple side holes in different planes

(d) Large-bore hole for occlusion to initiate vacuum

(e) No more than half the inside diameter of

artificial airway

 (i) Use 8 Fr for endotracheal tube >3.5 mm.

(ii) Use 5 Fr for endotracheal tube <3.5 mm.

e. Modified endotracheal tube adapter that allows passage of suction catheter without disconnecting tube

from ventilator (Novometrix C/S Suction Adapter;

Novometrix Medical Systems, Wallingford,

Connecticut) (17)

Nonsterile

a. Adjustable vacuum source and attachments

(1) Pressure set just high enough to move secretions

into suction catheter

(2) Mechanically controlled pressure source

Pressure generated by oral suction on mucus

extractors can be extremely variable and dangerously high (18).

(3) Specimen trap, tubing, and pressure gauge

b. Ventilatory device as indicated

(1) Manometer

(2) Warmed, humidified oxygen at controlled

level

(3) Bag with positive end-expiratory pressure device

4. Precautions

a. When feasible, use two people when suctioning the

airway to minimize the risk of patient compromise

and complications and to shorten the procedure time.

b. Determine for each patient if it is better to continue

mechanical ventilation during suctioning or to use a

sigh with inflation hold after suctioning. Consider

the effect of interruption of ventilator therapy and

loss of lung volume with each catheter passage.

c. Allow patient to recover between passages of catheter.

d. Stabilize head and airway to prevent tube dislodgement.

e. Assess secretions by auscultation and palpation to

determine frequency for suctioning.

(1) Avoid unnecessary suctioning just to follow a

schedule.