Both endotracheal intubation and gastric tube placement will be discussed here together, as intubation always requires gastric tube placement to enable gastric decompression (after bag-and-mask ventilation) and drainage of air and fluid. Gastric air removal consequently improves the excursion of the diaphragm. Moreover, esophageal atresia may be diagnosed clinically by this procedure, when the tube cannot be placed into the stomach, and instead rolls up in the oropharynx (if in doubt, inject 10 ml of air into the gastric tube and auscultate simultaneously over the gastric area).

Indication

See p. 158.

Urgency for intubation – decision making based on the clinical presentation of the neonate

• Elective intubation

• Semi-elective (“semi-urgent to urgent”) intubation

• Emergency intubation

Elective and semi-elective intubation

Elective intubation

• Clinical presentation: stable, spontaneously breathing neonate with adequate SpO2 and blood gas

• For premedication see p. 83

• Nasotracheal intubation is preferred by many centers because of the more secure ET fixation (lower accidental extubation rates); alternative: oral intubation

• Indication: e.g., a spontaneously breathing neonate, receiving continuous prostaglandin E1 (PGE1) intravenous (IV) infusion prior to a long distant transport (e.g., TGA, HLH)

Semi-elective intubation

• Clinical presentation: neonate with acceptable SpO2 and heart rate under bag-and-mask ventilation or NP-CPAP

• For premedication see p. 83

• Nasotracheal intubation or oral intubation

• Indication: e.g., a neonate with poor lung expansion/respiratory distress syndrome with CO2 retention prior to respiratory failure