DECIDING WHEN TO INTUBATE MAY BE

CHALLENGING!!!
INTUBATION AND POSITIVE PRESSURE
VENTILATION SHOULD BE STRONGLY CONSIDERED
WHEN THE FOLLOWING RESPIRATORY FAILURE
WARNING SIGNS ARE PRESENT:
1) Labored respiratory effort, mod. to sev.
retractions, grunting, nasal flaring.
2) Not able to maintain acceptable O2 sat for
suspected disease process.
NOTE: some forms of cyanotic congenital heart
dse, O2 sat may remain <90%, however
respiratory distress may be mild.
3) Rapidly increasing O2 concentration to
maintain O2 sat >90%
4) PCO2 >55mmHg and pH < 7.25
5) Unable to ventilate and/or oxygenate
adequately with bag/mask ventilation & infant
not candidate for nasal continous positive
airway pressure (CPAP).
6) Infant has diaphragmatic hernia (CDH).
NOTE: bag/mask ventilation fills up stomach
and intestine located in the chest. This
worsens distress. Intubate infant if CDH
suspected and infant in distress.
7) Severe apnea and bradycardia.
8) Gasping: signifies extremely critical
state and should be treated with
bag/mask ventilation, then endotracheal
intubation with assisted ventilation
PRE-TRANSPORT/ TRANSFER MONITORING
EVALUATE Oxygen saturation (pulse
oximetry)
Oxygen concentration (percent)
being delivered
Skin perfusion
Strength of the pulses in the arms
and legs
VITAL
SIGNS
Temperature
Respiratory rate and effort
Heart rate and rhythm
Blood pressure
TESTS Chest x-ray (abdominal x-ray
if problem is GI)
Blood sugar
Blood gas (ABG)
Blood culture
Complete blood count (CBC)
BLOOD GAS EVALUATION- NORMAL VALUES
ARTERIAL CAPILLARY
pH 7.30-7.45 7.30-7.45
pCO2 35-45 mmHg 35-50 mmHg
pO2 (on room air) 50-80 mmHg 35-45 mmHg (not
useful for assesing
oxygenation)
Bicarbonate (HCO3) 19-26 mEq/L 19-26 mEq/L
Base Excess -4 to +4 -4 to +4
Oxyhemoglobin
Saturation (pulse
oximeter) on room air
90-95 %
NOTE: The p02 and saturation will vary with altitude. Warm heel
for 3-5 min before CBG obtained.
ENDOTRACHEAL TUBE (ET TUBE) SIZE AND
INSERTION DEPTH
Tube size (ID
mm)
Weight (gms) Gestational
Age (weeks)
Insertion
Depth (cm)*
2.5 Below 1000 Below 28 6.5-7 (at the
lip)
3.0 1000-2000 28-34 7-8
3.5 2000-3000 34-38 8-9
3.5-4.0 Above 3000 Above 38 >9
*(centimeter marking on the tube when the inserted tube is
measured at the LIP)
INSERTION DEPTH USING LIP TO TIP
MEASUREMENT: WEIGHT IN KILOGRAMS PLUS 6
1. For extremely low-birth weight infants, (less
than 1000 grms), the ET tube insertion depth at
the lip is usually between 5.5 & 7 cm. Confirm
location by exam & chest X-ray. Tip location will
vary with head position, therefore, take each x-
ray with the head in the same position.
2. A size 2 ET tube is too small that ventilation is
impaired & insertion of this size tube should be
avoided. Consult with the tertiary center
neonatologist prior to inserting 2.0 mm ET tube.
(THORACOCENTESIS)
NEEDLE ASPIRATION
PROCEDURE
THORACOCENTESIS
is an invasive procedure to
remove fluid or air from the pleural space for
diagnostic or therapeutic purposes.
A cannula, or hollow needle, is carefully
introduced into the thorax, generally after
administration of local anesthesia. The
procedure was first described in 1852.
Pneumothorax is one of the disease
condition that this procedure is used.
PNEUMOTHORAX
is an abnormal collection of air or gas in
the pleural space that separates
the lung from the chest wall and which may
interfere with normal breathing.
Sudden respiratory deterioration may be
signs of pneumothorax.
Signs include:
Bradycardia
Hypotension
Desaturation
Shift in PMI
USE COLD LIGHT TRANSILLUMINATOR
FOR
RAPID DETECTION. IF TIME ALLOWS,
EVALUATE CHEST X-RAY
NEEDLE ASPIRATION KIT
Angiocath gauge
18, 20,22
3 way stopcock
T-connector
30ml syringe
Antiseptic solution
NEEDLE ASPIRATION PROCEDURE
Connect the T-connect to the male end of the
stopcock and connect the 30 ml syringe to
the female of the stopcock.
After the catheter is inserted into the pleural
space and the stylette is withdrawn, connect
the T-connector to the hub of the catheter.
Open stopcock to patient.
Aspirate air in the chest.
When resistance is felt or plunger is pulled back to the
30 ml mark, turn the stopcock off to the patient.
Push the air out of the syringe.
Open the stopcock to the patient again and repeat the
procedure.
If air is continuously aspirated from the chest, a chest
tube may need to be placed.
Consult the tertiary center as needed for guidance.
CHEST TUBE SIZES: Small or premature infant Fr 8/
Large or term infant Fr 10