When the assessment of risk factors indicates the likelihood of extensive resuscitation who should be present at the time of birth?

The size of the tube and depth of intubation are selected according to the infant's weight and gestational age.

For endotracheal tube diameter:

• 2.5 mm for infants < 1000 g or < 28 weeks gestation

• 3 mm for infants 1000 to 2000 g or 28 to 34 weeks gestation

• 3.5 mm for infants > 2000 g or > 34 weeks gestation

For insertion depth, the marker at the lip should typically be at

• 5.5 to 6.5 cm for infants who weigh < 1 kg

• 7 cm for infants who weigh 1 kg

• 8 cm for infants who weigh 2 kg

• 9 cm for infants who weigh 3 kg

Many endotracheal tubes have insertion markings to be positioned at the level of the vocal cords to guide the initial placement.

Immediately after intubation, clinicians should listen for bilaterally equal breath sounds. Selective intubation of the right mainstem bronchus with decreased breath sounds on the left is common if the tube is inserted too deeply.

Tracheal intubation should be confirmed by testing for exhaled CO2 using a colorimetric detector. A positive test, in which the colorimetric indicator turns from purple/blue to yellow, confirms tracheal intubation. A negative test is most commonly due to esophageal intubation but may occur when ventilation is insufficient or there is very poor cardiac output. A fixed yellow color can be due to direct contamination by epinephrine or may indicate the device is defective.

Proper endotracheal tube depth should result in the tip of the tube being about halfway between the clavicles and the carina on chest x-ray, coinciding roughly with vertebral level T1-T2.

For infants ≥ 34 weeks (or ≥ 2000 g), a laryngeal mask airway may be used if there is difficulty intubating the infant. Infants of any gestational age can be sustained with appropriate bag-and-mask PPV if team members are unable to place an endotracheal tube. In these infants, a nasogastric tube should be placed to allow for decompression of the stomach.

After intubation, if the heart rate does not improve and there is insufficient chest rise with adequate peak inspiratory pressure, the airway may be obstructed and suctioning should be done. Thinner-diameter catheters (5 to 8 F) may clear an endotracheal tube of thin secretions but are ineffective for thick secretions, blood, or meconium. In such cases, the endotracheal tube can be removed while applying continuous suction with a meconium aspirator and sometimes the trachea can be directly suctioned with a larger (10 to 12 F) catheter. After suctioning the trachea, the infant is reintubated.

If the infant is adequately ventilated and the heart rate remains < 60 beats/minute, chest compressions should be given using the 2-thumb/chest encircling technique in a coordinated ratio of 3 compressions to 1 ventilation with 90 compressions and 30 ventilations per minute. The 2-finger technique of chest compression is no longer recommended. Intubation is always indicated before initiating chest compression, and the oxygen concentration should be increased to 100%. The heart rate should be reassessed after 60 seconds of chest compressions.

If severe bradycardia persists while the infant is adequately ventilated and chest compressions have been given for 1 minute, catheterize the umbilical vein or place an intraosseous needle to give intravascular epinephrine as soon as possible. While access is being established, a dose of epinephrine may be given via the endotracheal tube, but the efficacy of this route is unknown. The dose of epinephrine is 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of the 0.1 mg/mL solution, previously known as 1:10,000 solution), repeated as needed every 3 to 5 minutes. Higher doses of epinephrine have been considered in the past but are no longer recommended.

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Page 2

1. aCould not be calculated for 25 infants (20 with no extensive resuscitation, 5 with extensive resuscitation) due to gestational age being out of range for the growth chart used
2. bNot collected for 804 infants (770 with no extensive resuscitation, 34 with extensive resuscitation)