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For many neonatal intubation is the Holy grail of pediatric procedures. I can still remember my first neonatal intubation. There were many senior staff watching me. The baby was extremely premature and worst of all, I knew that a successful neonatal intubation was required to progress in my training. Thankfully, my more recent intubations don't have that associated pressure, but it takes ongoing experience to maintain the skill. And if you've been out of pediatric practice for some time, you can lose your confidence in this procedure. I'm Doctor Matthew Sayers, a consultant, pediatrician with over 10 years experience in pediatrics and I have performed a number of successful and unsuccessful neonatal intubations. In this video, I will share my experience and tips on how to safely and successfully perform a neonatal intubation. We will focus on nasal intubation in this video as this is the preferred method in my area of practice. Thanks to all guidelines and documents in this video are available in the video description and also on the OA medical app. In this video, we will consider the case of a baby born at 35 weeks gestation by emergency cesarean section for maternal preeclampsia baby required inflation and ventilation, breast and delivery suite and has been brought to NICU on CPAP. They have severe subcostal recession and F IO two of 60% and are having frequent pauses in their breathing. A capillary blood class shows a ph of 7.05 A P CO2 of 12 A bicarb of 20 base excess minus two and lactate of four. Their chest X ray is as shown, their birth weight is 2.2 kg in a baby with respiratory difficulties, there are a number of different modes of respiratory support. You can use to assist them low flow oxygen via incubator oxygen or nasal cannula provides additional F IO two but doesn't provide any pressure support high flow oxygen or CPAP, provide continuous expiratory pressure support to keep the alveoli from collapsing but do not assist with inspiration. Noninvasive ventilation or intubation and ventilation provides pressure support to both inspiration and expiration which can assist or take over from the baby's breathing. Which of these to use depends on the clinical status of the baby. The cause of respiratory difficulties where the baby will be cared for and blood gas results. We normally intubate babies for respiratory failure that is severe and not responding to other therapies. This is diagnosed by severe work of breathing high F IO two and respiratory acidemia on blood gasses do remember that a very preterm baby is allowed permissive hypercapnia with a target PH of 7.25 to 7.35. If the baby continues to deteriorate, decide these procedures and other therapies to improve their ventilation, then intubation and ventilation will be required. Babies will also need intubated for certain surgical procedures were transferred to another hospital. If the respiratory system is too unstable to travel in a significant congenital diaphragmatic hernia, immediate intubation after delivery is required to stop the bile filling with air and compressing the lungs. In this example, intubation and ventilation is the most appropriate management. This is because the baby has severe respiratory distress with associated respiratory failure. They are having apneas which indicate respiratory failure and their blood gas demonstrates a severe respiratory acidemia without compensation. A lisa procedure may improve their respiratory distress but they are too unwell for this to be sufficient and may not tolerate the procedure. Well, given their level of respiratory distress, cpap high flow or nasal oxygen will not provide enough respiratory support to address the respiratory failure. Noninvasive ventilation is mainly used more in the context of weaning from mechanical ventilation and is not suitable as an acute alternative to intubation. In this case, in an intubation, we pass an endotracheal tube through the baby's vocal cords. This provides a very secure airway and then we attach a ventilator which uses pressure changes to move air into and out of the lungs. We do not currently use cuffed tubes in neonates in which a small balloon is inflated on the tube. Below the cords to create a tight seal due to concerns that this may damage the area below the larynx and cause subglottic stenosis surfactant can also be passed down the endotracheal tube. And we will see how to do this later in the video. Do not forget that intubation is not the only way to maintain an airway. And if you're waiting for a senior staff member to assist you in an intubation, the following techniques should be employed. Always remember to focus on airway position, hand and mask position and decompressing the stomach via a no G tube. If the baby is difficult to ventilate with a Neop, an I GL airway can also be used to support the airway until senior help arrives as this is much easier to insert than an ET tube. Whilst there are no contraindications to intubation, always make sure a senior staff member is present, particularly if the baby has a history of difficult intubation, they are very unstable or there is a congenital head or neck abnormality. An elective or semielective intubation should always have premedication administered as this is a painful procedure that will be extremely poorly tolerated in a conscious baby who has not received premedication in a cardiac arrest or severe desaturation that does not respond to airway maneuvers. And neop puff and oral intubation should be performed without any premedication. Premedication consists of fentaNYL which is an analgesic and sedative suxamethonium which causes neuromuscular paralysis and atropine which reduces the incidence of vagal induced bradycardia. Make sure you give and flush fentaNYL slowly over at least five minutes as this can cause chest wall rigidity. It can be helpful to use a timer and give 1/5 of the volume every minute and the same with the flush. If there is very severe chest wall rigidity, give naloxone suxamethonium should not be given if there is a history of severe hyperkalaemia, severe sepsis for more than one week suspected neuromuscular disorder, severe hepatic disease or a family history of malignant hyperthermia, atropine can rarely cause arrhythmias. Consult a senior neonatologist about alternative premedication. If any of these contraindications are present in my area of practice. The following premedications are preferred. These are either available in prefilled syringes or need to be reconstituted as per this table. Reconstitution can take some time to ensure there are sufficient medical and nursing staff available to help in making up these medications if required, work out the drug doses manually as well as checking with the medication app. A link to a useful drug calculator is available in the video description for this baby. The doses would be as follows. Prepare your team. You will need the intubator who maintains the airway at all times and performs the intubation. The medication team who make up and administer the premedications and any additional emergency medications required during the intubation. The assistant who assists withholding and passing items to the intubator. The team leader who directs all members of the team and closely monitors the baby's observations during the procedure. And the scribe who records all events and times. You need to prepare your equipment. Ensure you have appropriately sized laryngoscope and blades, et tubes, face mask, suction, lubricant and an NG tube. As well as a capnogram, TBC and brown tape for securing the tube size your et tube and laryngoscope based on the weight of the baby. Also remember the predicted insertion distance based on weight, always make sure you have a working cannula before starting the intubation. As it is extremely frustrating to have your whole team and equipment set up and ready to go. Only to have to recannulate the baby for premedication, preoxygenate the baby with a face mask, appropriate pressures and an F IO two of 100% support breathing with ventilation breaths if required if medication is being used, give this now take care to give and flush fentaNYL slowly to avoid chest wall rigidity. You will need to support ventilation as medications are given, insert the ET tube into the nose, using the NG tube as an introducer slide, the et tube posteriorly into the pharynx and remove the NG tube. Carefully, insert the laryngoscope blade into the mouth, taking care not to hip, the lips or palate, adjust it in an upwards and outwards motion, not by rocking it up and down, which can damage the palate. Identify the epiglottis and place the laryngoscope blade into the vacua anterior to this by lifting the laryngoscope blade upward and outward. The cords should come into view. Suction may be required to help with this carefully insert the closed forceps and gently grip the tip of the ET tube and pull it slowly forwards through the cords. A helper can apply gentle pressure at the other end of the tube to assist with this aim for the black line to be just through the cords in an oral intubation. Rather than passing the ET tube into the nose and advancing it with forceps, you will pass the ET tube through the cords under direct vision by hand. This can be easier in an emergency or in a difficult intubation check how far you have inserted the tube by looking at the closest number marking at the nostril and compare it with the predicted distance for weight. If there is a large discrepancy, adjust the tube in or out to the predicted distance during the intubation. If there is an episode of bradycardia, that does not resolve within 20 seconds, you must either complete the intubation in the next few seconds. If you're nearly finished or else withdraw the ET tube and bag the baby using the Neop Puff prolonged bradycardia indicates decompensation from desaturation and must be addressed urgently quickly attach a capnograph to the ET tube and attach the Neop Puff to the capnograph. The capnograph should change color with every inflation breath from a purple to yellow color indicating that gas exchange is taking place. If there is no color change, the et tube will need to be removed. You should also see an increase in oxygen saturations and heart rate and you should hear clear air entry at both lung bases on auscultation. Now that we have confirmed the tube has passed through the cords. It is important to secure it in place. Adhesive brown tape cut into trouser legs is secured to the filtrum and the nose and then wrapped around the tube. As shown, take care not to occlude the other nostril or eyes in premature babies, duoderm should be applied to the skin first to protect it from the brown tape T BCA dark brown liquid can be applied to increase adhesiveness. After you have confirmed successful intubation, you can attach the ET tube to the ventilator. Some default settings for a preterm and term baby are on screen. We will not go into detail of ventilator testings or adjustment in this video. Always perform a chest X ray to confirm tube position. After intubation, the et tube should sit at the T two position roughly at the level of the clavicles. If the X ray is not rotated, it must be above the carina. If the baby has signs of R DS is premature and hasn't had lia just before the intubation, you should give surfactant after intubation. The dose is 200 mg per kilogram. But select the closest full vial, draw up the surfactant into a syringe and attach an OG tube or lease a catheter to it, measure the OG tube alongside the ET tube and cut the end so that they are the same length. If the ot tube is longer than the ET tube, the surfactant will be instilled into the right main bronchus. After successful intubation pass the OG tube down the ET tube and fairly quickly instill the surfactant. Remove the OG tube and attach the ventilator or neop puff to the ET tube. I will now demonstrate a real time nasal intubation to put all these steps together. Intubation and ventilation has a number of complications in babies, particularly extremely preterm babies. And the purpose of LISA procedure is to limit unnecessary intubations. Intubations can cause trauma to the lips, palate and cords to take great care not to damage these during the procedure. Prolonged intubation can cause scar tissue to develop beyond the vocal cords called subglottic stenosis which can cause stridor, airway issues and difficulties in extubation. Some babies can also develop severe stridor after extubation and steroids are sometimes given for subsequent extubations to limit this occurring longer term complications of ventilation include bronchopulmonary dysplasia, which is believed to be strongly associated with viral trauma from mechanical ventilation. If an intubated baby deteriorates, assess them using the dope pneumonic check if the tube is displaced by checking the tapes are in the correct position. Apply a capnograph and check a chest X ray check if the tube is obstructed by suctioning the tube. A few drops of saline can help to loosen any obstruction to help with this check. If there is a pneumothorax, using a cold light source point of care. Ultrasound or a chest X ray, check the equipment, take the baby off the ventilator and use the Neop puff to attempt to bag them using 100% F IO two. If after all these steps, the baby is still not improving, the ET tube will have to be removed. What do you do if there is an unexpected difficult airway during the intubation or you can't intubate and can't ventilate. Senior help is required urgently call a consultant, neonatologist, anesthetist and ent consultant again, ensure you're following your standard airway maneuvers which can be lost in the stress of an emergency. Use a two person jaw thrust with a sheet below the baby's shoulder blades, ensure a neutral airway position and decompress the stomach with a no G tube. An eye gel can also be attempted. There is an algorithm on screen on how to address laryngospasm. Video, laryngoscopy is growing in popularity in a number of units in this technique. The laryngoscope shows the chords on a video screen rather than the intubator, viewing them under direct vision. This is the advantage of allowing the leader or experienced staff member to provide advice and feedback to the intubator. Thanks so much for watching, please like this video, comment with any clinical questions or feedback you have and subscribe to the channel and our other social media accounts including Instagram, Twitter, Med All and Ola to stay up to date with future videos. I look forward to seeing you again soon.