Airway management in neonates and infants: Recommendations

Abstract

Tracheal intubation is one of the most frequently performed medical procedures in neonatal intensive care units. Younger children, pre-term and full-term infants are at the highest risk of respiratory and traumatic complications when securing the airway. A difficult airway implies a clinical situation in which difficult airway management occurs by an experienced specialist. It is recommended to apply an adequate depth of sedation or general anesthesia with muscle relaxation in neonates and infants during the airway management in order to ensure the comfort and safety of the patients. The use of a videolaryngoscope with standard blades (Macintosh and Miller) is recommended for securing the airway, especially in neonates and infants. Use of passive oxygenation during tracheal intubation prolongs the safe duration of apnea, increases functional residual capacity and reduces the incidence of hypoxemia. The use of supraglottic airway device for rescue ventilation and oxygenation is advised if tracheal intubation has failed and ventilation with a face mask is inadequate. Limiting the number of tracheal intubation attempts is recommended. If two or fewer laryngoscopies are unsuccessful, operator should switch to indirect methods for intubation. After four attempts, intubators should stop and wake the child. It is advised to immediately check the position of the tube simultaneously with clinical signs and the appearance of sustainable carbon dioxide curve. Assessment of clinical indicators is necessary to predict successful awake extubation. A tidal volume greater than 5 ml/kg may indicate readiness for extubation.