Chapter 37 ■ Tracheotomy 253

21. Secure the tracheostomy tube with twill tape tied firmly

around the neck. Once tied, only one finger should fit

between the tape and the neck when the baby’s neck is

in neutral position.

22. Secure the stay sutures to the chest with tape labeled as

to correct side (Fig. 37.4).

23. Transport the patient back to the intensive care unit

with a backup endotracheal tube and laryngoscope.

24. Obtain chest radiograph on arrival in unit, to check

tube position and lung status.

F. Postoperative Management

1. Provide intensive nursing (see C).

2. Keep spare tracheostomy tubes at bedside (same size

and one smaller).

3. Replace nasogastric tube for nutrition and to avoid

aerophagia.

4. Suction secretions as needed to avoid plugging. For first

24 hours, be liberal with saline irrigation.

5. Make sure the ventilator tubing is not pulling on the

tracheostomy tube.

6. Be aggressive with wound care so that stoma heals

quickly and, thereby, limits granulation. Clean once a

shift with half-strength peroxide and cotton swabs, then

apply antibiotic ointment.

The first tracheostomy change is performed by surgical team in 4 to 7 days. Thereafter, weekly changes are

sufficient.

G. Early Complications (0 to 7 days)

1. Bleeding: Thyroid, venous, arterial

2. Accidental decannulation or displacement in neck—

stay sutures are the child’s lifeline back to the trachea to

allow replacement of the tube.

3. Plugging of tube with secretions (Fig. 37.5)

Fig. 37.4. Fixation of stay sutures. As soon as the position of the

tracheostomy tube is confirmed and stomal ventilation is started, the

tube may be fixed. Equal tension is kept on the stay sutures during

taping. Right suture is marked to avoid confusion in future placement.

A B

Fig. 37.5. Total obstructions of tracheostomy tubes. A: Mucus plug incompletely suctioned. B: Dry

mucus plug pushed deeper by a suction catheter.

254 Section VII ■ Tube Replacement

a. Avoid by increasing humidity, saline irrigation, and

suctioning.

4. Infection of wound or pneumonia—avoid by local care

and by taking care of secretions.

5. Air leaks

a. Pneumothorax—may need chest tube

b. Pneumomediastinum—serial films

c. Subcutaneous emphysema—usually limited (avoid

occlusive dressing)

6. Tracheoesophageal fistula—iatrogenic

H. Late Complications (after 1 week)

1. Obstruction and decannulation remain ongoing risks

that require vigilant care.

2. Stomal infection and granulation—avoided by careful

wound care

3. Proximal tracheal granuloma—commonly occurs at the

point where the tube rubs against the superior aspect of

the tracheal opening, creating an obstruction between

the vocal cords and the tube that can impede routine tracheostomy tube changes. This requires operative removal.

4. Distal tracheal granulation—from overly aggressive

suctioning or tube angulation causing rubbing of the

tip against the tracheal wall. Hallmark sign is bloody

secretions.

5. Stenosis—preventing decannulation later on

a. Part of original pathology for which tracheotomy

was performed

b. Ongoing obliteration from active inflammatory

factors

c. Consequence of procedure itself; from stomal

collapse or distal cicatrix

6. Tracheocutaneous fistula after tube removal—normal

physiologic sequela, but needs secondary procedure for

closure

References

1. Sisk EA, Kim TB, Schumacher R, et al. Tracheotomy in very low

birth weight neonates: indications and outcomes. Laryngoscope.

2006;116:928.

2. Wooten CT, French LC, Thomas RG, et al. Tracheotomy in the

first year of life: outcomes in term infants, the Vanderbilt experience. Otolaryngol Head Neck Surg. 2004;134:365.

3. Kremer B, Botos-Kremer AI, Eckel HE, et al. Indications, complications and surgical techniques for pediatric tracheostomies—an

update. J Pediatr Surg. 2002;37:1556.

4. Crysdale WS, Feldman RI, Naito K. Tracheostomies: a

10 year experience in 319 children. Ann Oto Laryngol. 1988;97:

439.

5. Sidman JD, Jaquan A, Couser RJ. Tracheostomy and decannulation rates in a level 3 neonatal intensive care unit: a 12 year study.

Laryngoscope. 2006;116:136.

 

252 Section VII ■ Tube Replacement

2. Apply monitors, check IV line, and confirm satisfactory

ventilation through endotracheal tube.

3. Have anesthesia team proceed with inhalation agents,

oxygen supplementation, and IV agents, as needed for

satisfactory level of general anesthesia.

4. Position patient with neck extended, using shoulder roll.

5. Remove nasogastric tube to avoid confusion when palpating trachea. Do not place esophageal stethoscope.

6. Inject skin incision and the deeper tissues with local

anesthetic (0.5 to 1 mL of 50% lidocaine with 1:200,000

epinephrine).

7. Prep the surgical site from above the chin to below the

clavicles. Give IV antibiotic to cover skin flora.

8. Drape the patient with surgical towels, allowing the

anesthesiologist access to the endotracheal tube and

the securing tape.

9. Identify the following landmarks: Suprasternal notch,

chin, midline, trachea, and cricoid. In small neonates,

the cricoid may be difficult to palpate.

10. Make the skin incision approximately midway between

the sternal notch and the cricoid, either vertically or horizontally. Incisions in either plane tend to heal as a circular stoma; however, the horizontal has a slightly better

cosmetic effect, whereas the vertical allows more exposure in the midline.

11. Excise excess subcutaneous fat with cautery.

12. Identify the strap muscles and repeatedly palpate the

trachea to confirm the midline. Split the raphe to separate the muscles.

13. Grab the fascia of the strap muscles with hemostats to

retract them outward and laterally, thereby exposing

the thyroid gland, cricoid, and trachea.

14. Place Senn retractors on either side of the trachea for

optimal visibility.

15. Displace the thyroid gland, using blunt dissection to

expose the tracheal rings. If this is not possible, divide

the thyroid isthmus, suture, and ligate.

16. Place vertical stay sutures in paramedian position at the

level where tracheal entry is planned—usually the third

and fourth ring (Fig. 37.2).

17. Incise trachea vertically for two or three rings, depending on the size needed for the tube employed.

18. Have the anesthesiologist loosen the tape and withdraw

the endotracheal tube until the tip is just visible

(Fig. 37.3).

19. Place the appropriate tracheostomy tube with the

flange parallel to the trachea so that the tube more easily enters the trachea and passes posteriorly, then rotate

the flange 90 degrees.

20. Have the anesthesiologist confirm placement by checking end-tidal carbon dioxide and oxygen saturation, as

well as auscultation of both sides of the chest.

Fig. 37.1. Sagittal section. Larynx lies more cephalad than in

adult. Note the proximity of the thyroid isthmus to the tracheal

rings. (Drawing contributed by John Bosma, MD)

Fig. 37.2. Placement of stay sutures through the tracheal wall.

Fig. 37.3. Artistic conception of view through tracheal incision

with the tip of the endotracheal tube visible. Stay sutures hold cartilages open.

 

accidental extubation, and tracheal avulsion: three airway catastrophes associated with significant decrease in peak pressure. Crit

Care Med. 1989;17:701.

36. Naumovski L, Schaffer K, Fleisher B. Ingestion of a laryngoscope

light bulb during delivery room resuscitation. Pediatrics.

1991;87:581.

37. Oca MJ, Becker MA, Dechert RE, et al. Relationship of neonatal

endotracheal tube size and airway resistance. Respir Care.

2002;47:994.

250

37 Tracheotomy

38 Thoracostomy

39 Pericardiocentesis

40 Gastric and Transpyloric Tubes

41 Gastrostomy

42 Neonatal Ostomy and Gastrostomy Care

VII Tube Replacement

251

Hosai Hesham

Gregory J. Milmoe

37 Tracheotomy

A. Indications (1–5)

1. Prolonged need for ventilator support—most common

2. Acquired subglottic stenosis after prolonged intubation

3. Craniofacial abnormalities with severe airway obstruction (e.g., Pierre-Robin sequence, Pfeiffer syndrome,

Treacher Collins syndrome)

4. Congenital bilateral vocal cord paralysis

5. Laryngeal web, subglottic hemangioma

6. Congenital tracheal stenosis, severe tracheomalacia

7. Congenital neuromuscular disease with insufficient

respiratory effort

8. Neurologic disease with aspiration risk, central apnea,

or intractable seizures

B. Contraindications

1. Unstable physiology—wait until stabilized

a. Sepsis

b. Pneumonia not yet controlled

c. Pulmonary instability requiring high inspiratory

pressures (peak inspiratory pressure >35 to 40 cms

H2O) or need for high-frequency ventilation

d. Cardiovascular instability (e.g., shunting, arrhythmia, or hypotension)

e. Evolving renal or neurologic injuries

2. Distal obstruction not relievable by tracheostomy

a. Congenital stenosis at the carina

b. External compression from mediastinal mass

3. Congenital anomalies that make the trachea relatively

inaccessible

a. Massive cervical hemangioma—bleeding issues

b. Massive cervical lymphangioma—severe distortion

of neck anatomy

c. Massive goiter—might be manageable medically

d. Chest syndromes with severe kyphoscoliosis or tracheal distortion

C. Precautions

1. Patient should be stable (see B); anticipate need for

increased pulmonary support temporarily to counter

atelectasis and reactive secretions from surgical stimulation.

2. Tracheotomy tubes allow for air leak through the stoma

and larynx. In contrast, an endotracheal tube fits more

snugly at the cricoid, creating a more closed system for

ventilation.

3. Neonates are less able to tolerate bacteremia; use perioperative antibiotic to cover skin flora.

4. If the patient is not currently intubated, have endoscopy equipment available and discuss intubation

options with the anesthesiologist.

5. The infant larynx differs from that of the adult and

older child (Fig. 37.1).

a. More pliable and mobile

b. Relatively higher in neck

c. Thymus and innominate artery can override trachea

in surgical field

6. This procedure should be done only in a facility where

there is appropriate support for postoperative management.

D. Equipment

All Sterile

1. Prep tray with brushes, towels, and Betadine

2. Tracheotomy tray

a. Scalpel with no. 15 blade

b. Hemostats

c. Small scissors (iris, tenotomy, small Mayo)

d. Retractors—Senn or Ragnell

e. Suction—no. 7 Frazier

f. Forceps—Adson

3. Sutures: 3-0 and 4-0 nonabsorbable on small, curved

needles

4. Neonatal tracheotomy tubes

a. Have several calibers available

b. Standard tubes are noncuffed, but in special circumstances, a cuff may be needed.

E. Technique

1. Check instruments, sutures, and available tracheotomy

tubes.

 

12. Jain A, Finer NN, Hilton S, et al. A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates. Resuscitation. 2004;60:297.

13. Sutherland PD, Quinn M. Nellcor Stat Cap differentiates esophageal from tracheal intubation. Arch Dis Child Fetal Neonat Ed.

1995;73:184F.

14. Loughead JL, Brennan RA, DeJuilio P, et al. Reducing accidental

extubation in neonates. Jt Comm J Qual Patient Saf. 2008;34:

164.

15. Spence K, Barr P. Nasal versus oral intubation for mechanical ventilation of newborn infants. Cochrane Database Syst Rev.

2000;CD000948.

16. Oei J, Hari R, Butha T, et al. Facilitation of neonatal nasotracheal

intubation with premedication: a randomized controlled trial.

J Paediatr Child Health. 2002;38:146.

17. El Masry A, Williams PF, Chipman DW, et al. The impact of

closed endotracheal suctioning systems on mechanical ventilator

performance. Respir Care. 2005;50:345.

18. Tingay DG, Copnell B, Mills JF, et al. Effects of open endotracheal suction on lung volume in infants receiving HFOV.

Intensive Care Med. 2007;33:689.

19. Richards S. A method for securing pediatric endotracheal tubes.

Anesth Analg. 1981;60:224.

20. Khemani RG, Randolph A, Markovitz B. Corticosteroids for the

prevention and treatment of post-extubation stridor in neonates,

children and adults. Cochrane Database Syst Rev. 2009;

CD001000.

21. Doherty KM, Tabaee A, Castillo M, et al. Neonatal tracheal rupture complicating endotracheal intubation: a case report and

indications for conservative management. Int J Pediatr

Otorhinolaryngol. 2005;69:111.

22. Mahieu HF, de Bree R, Ekkelkamp S, et al. Tracheal and laryngeal rupture in neonates: complication of delivery or of intubation?. Ann Otol Rhinol Laryngol. 2004;113:786.

23. Gomes Cordeiro AM, Fernandes JC, Troster EJ. Possible risk factors associated with moderate or severe airway injuries in children

who underwent endotracheal intubation. Pediatr Crit Care Med.

2004;5:364.

24. Dankle SK, Schuller DE, McClead RE. Risk factors for neonatal

acquired subglottic stenosis. Ann Otol Rhinol Laryngol. 1986;95:626.

25. Johnson LB, Rutter MJ, Shott SR, et al. Acquired subglottic cysts

in preterm infants. J Otolaryngol. 2005;34:75.

26. Angelos GM, Smith DR, Jorgenson R, et al. Oral complications

associated with neonatal oral tracheal intubation: a critical review.

Pediatr Dent. 1989;11:133.

27. Kahn DJ, Spinazzola R. Acquired oral commissure defect: a complication of prolonged endotracheal intubation. J Perinatol.

2005;25:612.

28. Gowdar K, Bull M, Schreiner R, et al. Nasal deformities in neonates. Their occurrence in those treated with nasal continuous

positive airway pressure and nasal endotracheal tubes. Am J Dis

Child. 1980;134:954.

29. Rotschild A, Dison PJ, Chitayat D, et al. Midfacial hypoplasia

associated with long-term intubation for bronchopulmonary dysplasia. Am J Dis Child. 1990;144:1302.

30. Halac E, Indiveri DR, Obergaon RJ, et al. Complication of nasal

endotracheal intubation. J Pediatr. 1983;103:166.

31. De Dooy J, Leven M, Stevens W, et al. Endotracheal colonization

at birth is associated with a pathogen-dependent pro- and antiinflammatory cytokine response in ventilated preterm infants: a prospective cohort study. Pediatr Res. 2004;56:547.

32. Marshall TA, Deeder R, Pai S, et al. Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care

Med. 1984;12:501.

33. Bagshaw O, Gillis J, Schell D. Delayed recognition of esophageal

intubation in a neonate: role of radiologic diagnosis. Crit Care

Med. 1994;22:2020.

34. Rivera R, Tibballs J. Complications of endotracheal intubation

and mechanical ventilation in infants and children. Crit Care

Med. 1992;20:193.

35. Spear RM, Sauder RA, Nichols DG. Endotracheal tube rupture,

 

Chapter 36 ■ Endotracheal Intubation 249

References

1. Yates AP, Harries AJ, Hatch DJ. Estimation of nasotracheal tube

length in infants and children. Br J Anaesth. 1987;59:524.

2. De la Sierra Antona M, Lopez-Herce J, Ruperez M, et al.

Estimation of the length of nasotracheal tube to be introduced in

children. J Pediatr. 2002;140:772.

3. Freeman JA, Fredricks BJ, Best CJ. Evaluation of a new method

for determining tracheal tube length in children. Anaesthesia.

1995;50:1050.

4. Shukla HK, Hendricks-Munoz KD, Atakent Y, et al. Rapid estimation of insertional length of endotracheal intubation in newborn infants. J Pediatr. 1997;131:561.

5. Kim KO, Um WS, Kim CS. Comparative evaluation of methods

for ensuring the correct position of the tracheal tube in children

undergoing open heart surgery. Anaesthesia. 2003;58:889.

6. Leung YY, Hung CT, Tan ST. Evaluation of the new Viewmax

laryngoscope in a simulated difficult airway. Acta Anaesthesiol

Scand. 2006;50:562.

7. Erenberg A, Nowak AJ. Palatal groove formation in neonates and

infants with orotracheal tubes. Am J Dis Child. 1984;138:974.

8. Macey-Dare LV, Moles DR, Evans RD. Long-term effect of neonatal endotracheal intubation on palatal form and symmetry in

8–11 year-old children. Eur J Orthodont. 1999;21:703.

9. Lang M, Jonat S, Nikischin W. Detection and correction of endotracheal-tube position in premature neonates. Pediatr Pulmonol.

2002;34:455.

10. Wells TR, Wells AL, Galvis DA, et al. Diagnostic aspects and syndromal associations of short trachea with bronchial intubation.

Am J Dis Child. 1990;144:1369.

11. Lucas da Silva PS, de Carvalho WB. Unplanned extubation in

pediatric critically ill patients: a systematic review and best

practice recommendations. Pediatr Crit Care Med. 2010;11:

287.

 

Chapter 36 ■ Endotracheal Intubation 247

Fig. 36.21. Radiograph demonstrating an endotracheal tube

malpositioned in the bronchus intermedius, with resulting atelectasis of the right upper lobe and of the left lung. There is marked

overaeration of the right middle and lower lobes but no pneumothorax shown.

Fig. 36.18. Palatal groove after prolonged oral intubation.

Such grooves may be seen after prolonged use of endotracheal or

oral gastric tubes when the normal forces of the tongue are prevented from assisting palatal development.

Fig. 36.19. Acquired oral commissure defect: a complication

of prolonged endotracheal intubation. (Reprinted by permission

from Macmillan Publishers Ltd. J Perinatol. 2005;25:612.)

Fig. 36.20. Nasal stenosis due to nasal cartilage necrosis following an indwelling nasotracheal tube.

248 Section VI ■ Respiratory Care

Fig. 36.22. Relatively uncommon malposition of an endotracheal tube in the left bronchus with atelectasis of much of the

right lung.

c. Increased intracranial pressure

d. Hypoxemia

e. Hypertension

f. Apnea

g. Bradycardia and cardiac arrest

6. Misplacements into esophagus or bronchus (32,33)

(Figs. 36.21 through 36.23)

a. Atelectasis

b. Pulmonary air leak

c. Loss of tube into esophagus

d. Tube crosses tracheoesophageal fistula

7. Displacement; accidental extubation (11,14)

8. Obstruction (34)

9. Kinking, proximally or distally

10. Unrecognized disconnection from adapter or pressure

source

11. Rupture of endotracheal tube (35)

12. Foreign body from stylet left unrecognized in airway

13. Swallowed laryngoscope light (36)

14. Postextubation atelectasis (35)

15. Increased airway resistance increasing work of breathing (37)

A B

Fig. 36.23. A: Radiograph suggesting that the endotracheal tube is in the right mainstem bronchus.

Note the gaseous distension of the stomach. The wavy tube on the right is external. B: In the lateral view,

the same endotracheal tube is easily seen to be in the esophagus (arrowheads) posterior to the trachea

(arrows).

 

246 Section VI ■ Respiratory Care

e. Mucosal necrosis (Fig. 36.15)

f. Vocal cord injuries

g. Dislocation of arytenoid

2. Chronic trauma (23–25)

a. Cricoid ulceration and fibrosis

b. Glottic and/or subglottic stenosis (Fig. 36.15)

c. Subglottic granuloma (Figs. 36.16 and 36.17)

d. Hoarseness, stridor, wheezing

e. Subglottic cyst

f. Tracheomegaly

g. Protrusion of laryngeal ventricle

3. Interference by oral tube with oral development

(7,8,26,27)

a. Alveolar grooving

b. Palatal grooves (Fig. 36.18)

c. Acquired oral commissure defect (Fig. 36.19)

d. Posterior cross-bite

e. Defective dentition

(1) Enamel hypoplasia

(2) Incisor hypoplasia

f. Poor speech intelligibility

4. Local effects from nasal tube (28–30)

a. Erosion of nasal septum

b. Stenosis of nasal vestibule (Fig. 36.20)

Fig. 36.17. Glottic granuloma after intubation. Epiglottis is

manually retracted to reveal granuloma below cords. Esophageal

opening is clearly visible beneath airway.

Fig. 36.16. Radiographic magnification high-kilovoltage film

(×2) demonstrating an abrupt cutoff of the right bronchus intermedius (arrow) due to an endobronchial granuloma, with secondary volume loss at the right lung base. Although these granulomas

may be due to endotracheal tube trauma, in this area they are

more likely related to suction tube injury. The endotracheal tube

is just entering the right bronchus.

c. Nasal congestion

d. Midfacial hypoplasia

e. Otitis media

5. Systemic side effects (31,32)

a. Infection

b. Aspiration

Fig. 36.15. Subglottic erosion and stenosis after intubation.

 

(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