Neonatal airway and anesthesia

1. The Neonatal AirwayThe Neonatal Airway
HOSSAM M ATEF;MDHOSSAM M ATEF;MD
SUEZ CANAL UNIVERSITYSUEZ CANAL UNIVERSITY
ANESTHESIA DEPARTANESTHESIA DEPART

2. Goals of PresentationGoals of Presentation
 Differences between neonatal and adultDifferences between neonatal and adult
airwayairway
 Neonatal intubation technique andNeonatal intubation technique and
equipmentequipment
 Common mistakes and complications ofCommon mistakes and complications of
intubationintubation
 Syndromes commonly associated withSyndromes commonly associated with
difficult neonatal airwaysdifficult neonatal airways

3. Why do we care?Why do we care?
 Prompt intubation of a distressed neonatePrompt intubation of a distressed neonate
can be life-savingcan be life-saving
 Residents are getting less trainingResidents are getting less training

4. The Neonatal AirwayThe Neonatal Airway
 Compared to adults,Compared to adults,
structures are…structures are…

SmallerSmaller

More anteriorMore anterior

Epiglottis is floppierEpiglottis is floppier

Larger tongueLarger tongue

Larger occiputLarger occiput

Narrowest portion ofNarrowest portion of
airway is the cricoidairway is the cricoid

5. Indications for IntubationIndications for Intubation
 In delivery roomIn delivery room

Cardiorespiratory instabilityCardiorespiratory instability

Meconium during birth, with a depressedMeconium during birth, with a depressed
infantinfant

Prematurity requiring need for surfactantPrematurity requiring need for surfactant
therapytherapy

Congenital malformationsCongenital malformations

6. Indications for IntubationIndications for Intubation
 In NICUIn NICU

Unable to protect airwayUnable to protect airway

Hypercarbic respiratory failureHypercarbic respiratory failure

Hypoxic respiratory failureHypoxic respiratory failure

Therapeutic indicationTherapeutic indication

7. What do you need?What do you need?
MMonitors - Cardiac and pulse oximetryonitors - Cardiac and pulse oximetry
SSuction - catheteruction - catheter
MMachine - Laryngoscope, ventilator orachine - Laryngoscope, ventilator or
bag/maskbag/mask
AAirway - Endotracheal tubeirway - Endotracheal tube
IIntravenous - Peripheral or central linentravenous - Peripheral or central line
DDrugs --rugs --
Sedation/analgesia/paralysis/atropineSedation/analgesia/paralysis/atropine

8. Laryngoscope BladesLaryngoscope Blades
 Straight blades areStraight blades are
placedplaced under theunder the
epiglottisepiglottis and used toand used to
lift anteriorly tolift anteriorly to
expose the cords.expose the cords.
 Curved blades areCurved blades are
placed in theplaced in the valeculavalecula
and lifted anteriorly toand lifted anteriorly to
expose the cords.expose the cords.
Macintosh
Miller
Wisconsin

9. Endotracheal TubesEndotracheal Tubes
 Endotracheal tubes are divided by the sizeEndotracheal tubes are divided by the size
of their internal diameterof their internal diameter
 For neonates endotracheal tube sizeFor neonates endotracheal tube size
roughly corresponds to 1/10roughly corresponds to 1/10thth
ofof
gestational age rounded down to thegestational age rounded down to the
nearest size.nearest size.

For exampleFor example
• A 36 week premie would get a 3.5 ETTA 36 week premie would get a 3.5 ETT
• A 28 week premie would get a 2.5 ETTA 28 week premie would get a 2.5 ETT

10. Intubation ProcedureIntubation Procedure
 Proper positioningProper positioning

EquipmentEquipment
• Bed and patient at comfortable heightBed and patient at comfortable height
• Suction and meconium aspirator readily availableSuction and meconium aspirator readily available
• Endotracheal tubes not under warmerEndotracheal tubes not under warmer
• All equipment tested and working just prior to useAll equipment tested and working just prior to use

PatientPatient
• Shoulder rollShoulder roll
• Head in sniffing positionHead in sniffing position

Too much hyperextension can make visualization difficultToo much hyperextension can make visualization difficult

11. Intubation ProcedureIntubation Procedure
 Pre-oxygenate with 100% bag valve maskPre-oxygenate with 100% bag valve mask
ventilationventilation

Contraindicated in known congenitalContraindicated in known congenital
diaphragmatic herniadiaphragmatic hernia
 Apply monitorsApply monitors
 Give drugsGive drugs

Remember minimum atropine doseRemember minimum atropine dose

Ensure ability to bag/mask ventilate beforeEnsure ability to bag/mask ventilate before
paralysisparalysis

12. Intubation ProcedureIntubation Procedure
 Inserting theInserting the
laryngoscope bladelaryngoscope blade

Hold laryngoscope inHold laryngoscope in
left handleft hand

While standing aboveWhile standing above
the patient, insert thethe patient, insert the
blade in the right sideblade in the right side
of the mouthof the mouth
WITHOUT trying toWITHOUT trying to
visualize the cords.visualize the cords.

13. Intubation ProcedureIntubation Procedure
 Take a step backTake a step back
 Lower your head toLower your head to
the level of the labelthe level of the label
 Slowly advanceSlowly advance
laryngoscope untillaryngoscope until
you visualize theyou visualize the
epiglottisepiglottis
 Use straight or curvedUse straight or curved
blade appropriatelyblade appropriately

14. Intubation ProcedureIntubation Procedure
 Visualize the vocalVisualize the vocal
cordscords

Meconium belowMeconium below
cords?cords?

Both moving if notBoth moving if not
paralyzed?paralyzed?

Structurally normal?Structurally normal?
 Pick up endotrachealPick up endotracheal
tube and passtube and pass
between vocal cordsbetween vocal cords

15. Assessing Endotracheal TubeAssessing Endotracheal Tube
PlacementPlacement
 Direct visualizationDirect visualization
 End tidal COEnd tidal CO22 monitoringmonitoring
 Chest riseChest rise
 AuscultationAuscultation
 ETT vaporETT vapor

Less reliableLess reliable
 Chest X-rayChest X-ray

16. Intubation ProcedureIntubation Procedure
 Secure endotracheal tube to lip with tapeSecure endotracheal tube to lip with tape

Do not let go of tube until secureDo not let go of tube until secure
 Reassess that endotracheal tube is still inReassess that endotracheal tube is still in
place.place.
 Assess the neonate –Assess the neonate –

Improving? More pink? Heart rateImproving? More pink? Heart rate
increasing?increasing?
 Continue resuscitation – proceed to B andContinue resuscitation – proceed to B and
C….C….

17. Common ProblemsCommon Problems
 Esophageal IntubationEsophageal Intubation

Blade placed too deep, cords not visualizedBlade placed too deep, cords not visualized
 Tongue obscures visualizationTongue obscures visualization

Sweep tongue to one side with bladeSweep tongue to one side with blade

More anterior liftMore anterior lift
 Cannot see cordsCannot see cords

Head is hyper-extended - repositionHead is hyper-extended - reposition

18. Common ProblemsCommon Problems
 Cannot intubateCannot intubate

Most neonates can be bag valve maskMost neonates can be bag valve mask
ventilated easilyventilated easily

Call early for anesthesiology assistanceCall early for anesthesiology assistance
• ““Bag ventilating with oxygen can prolong life for aBag ventilating with oxygen can prolong life for a
long time, repeatedly attempting and failinglong time, repeatedly attempting and failing
intubation will not.”intubation will not.”

Surgical airwaySurgical airway

19. Difficult Neonatal AirwaysDifficult Neonatal Airways
 Abnormal airwayAbnormal airway
 Increasing awareness of problemsIncreasing awareness of problems
beforehand because of neonatalbeforehand because of neonatal
ultrasoundultrasound
 ““Things you can see” versus “Things youThings you can see” versus “Things you
may find”may find”

20. Difficult Neonatal AirwaysDifficult Neonatal Airways
 Congenital malformationsCongenital malformations

““Things you can see”Things you can see”

Predictable from looking at the patientPredictable from looking at the patient
• Cleft lip and palateCleft lip and palate
• Pierre Robin syndromePierre Robin syndrome
• Treacher Collins syndromeTreacher Collins syndrome
• Goldenhar syndromeGoldenhar syndrome
• Apert and Crouzon SyndromeApert and Crouzon Syndrome

21. Congenital MalformationsCongenital Malformations
 Cleft Lip and PalateCleft Lip and Palate

Most commonMost common
congenital facecongenital face
malformationmalformation
 Pierre RobinPierre Robin
SequenceSequence

Obstruction is usuallyObstruction is usually
at the nasopharyngealat the nasopharyngeal
levellevel

22. Congenital MalformationsCongenital Malformations
 Apert and CrouzonApert and Crouzon

Maxillary hypoplasiaMaxillary hypoplasia

NasopharyngealNasopharyngeal
airway compromiseairway compromise
 Goldenhar syndromeGoldenhar syndrome

Unilateral anomaliesUnilateral anomalies

Higher incidence ofHigher incidence of
airway anomaliesairway anomalies

23. Congenital MalformationsCongenital Malformations
 Treacher CollinsTreacher Collins

ChoanalChoanal
atresia/stenosis moreatresia/stenosis more
commoncommon
 Down’s SyndromeDown’s Syndrome

Subglottic stenosisSubglottic stenosis
more commonmore common

RememberRemember
atlantoaxial instabilityatlantoaxial instability

24. Difficult Neonatal AirwaysDifficult Neonatal Airways
 Congenital MalformationsCongenital Malformations

““Things you may find”Things you may find”
• LaryngomalaciaLaryngomalacia
• Hemangioma orHemangioma or
LymphangiomaLymphangioma
• Tracheal webTracheal web
• Laryngeal atresiaLaryngeal atresia
• Subglotic stenosisSubglotic stenosis

25. Congenital MalformationsCongenital Malformations
 LaryngomalaciaLaryngomalacia

A sequence betweenA sequence between
fully formed to atresiafully formed to atresia

26. Congenital MalformationsCongenital Malformations
 Laryngeal WebLaryngeal Web
 Tracheal AtresiaTracheal Atresia

Survive only ifSurvive only if
tracheoesophagealtracheoesophageal
fistula or emergentfistula or emergent
trachtrach

27. Congenital MalformationsCongenital Malformations
 Hemangioma orHemangioma or
LymphangiomaLymphangioma

Only about 30%Only about 30%
present at birthpresent at birth

28. Congenital MalformationsCongenital Malformations
 Subglottic StenosisSubglottic Stenosis

29. In ReviewIn Review
 Proper positioning is critical for successfulProper positioning is critical for successful
neonatal intubationneonatal intubation
 Call for help early if unable to intubate or for anyCall for help early if unable to intubate or for any
congenital anomaliescongenital anomalies

Continue to provide oxygen with bag valve maskContinue to provide oxygen with bag valve mask
ventilationventilation
 Practice makes perfectPractice makes perfect

It is estimated that you need to perform at least 90It is estimated that you need to perform at least 90
intubations to be able to intubate successfully on theintubations to be able to intubate successfully on the
first or second attempt at least 80% of the timefirst or second attempt at least 80% of the time

30.  QUESTIONS?QUESTIONS?