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Endotracheal tube management in NICU

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This guideline covers the following topics:

  • Assisting with intubation 
  • Securing an endotracheal tube 
  • Endotracheal tube suctioning 
  • Extubation

Indications for Intubation

  • To assist ventilation in respiratory insufficiency
  • To aid airway management
  • Pre or post-operative respiratory support
Emergency Elective
Failure of mask airway control Extreme prematurity
Congenital or structural airway abnormalities Prolonged ventilation
Diaphragmatic hernia Endotracheal tube change
Prolonged resuscitation Unstable airway
Administration of surfactant Respiratory support in neonatal sepsis / necrotising enterocolitis
Severe meconium aspiration syndrome  
Apnoea of prematurity  


  • Pharyngeal, oesophageal and tracheal trauma or perforation
  • Cardiorespiratory instability during intubation attempts
  • Intubation of right mainstem bronchus
  • Accidental extubation
  • Blockage of endotracheal tube with secretions
  • Nosocomial respiratory infection
  • Erosion of nares or septum (nasal intubation)
  • Palatal groove formation, acquired cleft palate, and defective primary dentition (oral intubation)
  • Acquired subglottic stenosis


Ensure the following equipment is available at the bedside:

  • Emergency trolley
  • Laryngoscope
  • Appropriate size endotracheal tubes (ETT)1
Tube Size (internal diameter)  Weight (g) Gestational Age
2.5 <1000 <26
3.0 1000-2000 27-34
3.5 2000-3000 35-40
3.5-4.0 >3000 >38
  • Appropriate stylet or introducer (only if required for oral intubation)
  • Hydrocortisone cream
  • Magill's forceps
  • Exhaled carbon dioxide detector (Pedi-Cap)2
  • Stethoscope
  • Appropriate sized suction catheters, including size 10Fr for oropharyngeal suction
  • Neopuff infant resuscitator or self-inflating Laerdal bag and appropriate size mask
  • Source of compressed air/oxygen with blender
  • Scissors
  • Duoderm base tapes - cut to appropriate size for infant
  • Leukoplast "trouser legs" - cut to appropriate size for infant
  • Ventilator - set up and checked
  • Cardio-respiratory and saturation monitor
  • Premedication for intubation

Process for Intubation

Nurse Responsibilities

  1. Explain procedure and rationale to family. Suggest that although optional for them to stay during procedure we would advise that they wait outside.
  2. Ensure standard precautions are adhered to
  3. Prepare and check all equipment
  4. Prepare infant in a supine position using muslin wrap to promote containment.
  5. Maintain infant warmth
  6. Ensure continuous monitoring of heart rate and saturation during procedure.
  7. Ensure suction equipment functioning
  8. Aspirate NG/OG tube if insitu
  9. Assist medical staff/NS-ANP with airway maintenance/ventilation as required
  10. Administer medications when requested by medical staff (ensure IV flushed fully to clear all medication from line)
  11. During the procedure you may be asked to apply: suction, cricoid pressure, or gently push endotracheal tube.
  12. Assess infant's tolerance of intubation attempt and inform medical staff/NS-ANP (Observe heart rate & saturation)
  13. Attach Neopuff to ETT
  14. Verify tube position with Pedi-Cap (yellow indicates carbon dioxide detected on exhalation)
  15. Examine chest for bilateral synchronous movement. Auscultate chest and ensure bilateral air entry detected
  16. Consider need to decompress stomach if prolonged bag mask ventilation required
  17. Assist with securing the ETT (see images below)
  18. Connect infant to ventilator
  19. Ensure a NG/OG tube inserted and connected to free drainage
  20. Ensure chest x-ray obtained to confirm correct tube placement
  21. Check blood gas within 1 hour of intubation if infant stable or earlier as requested by medical staff or NS-ANP
  22. Document on the infant's observation chart:
    - ETT size
    - Insertion depth
    - Date
    - Infant's tolerance of the procedure
    - Ventilator settings

N.B If possible for reintubation, consider leaving the existing ETT insitu for the medical person inserting the new ETT to use as a guide.

Process for endotracheal tube security

Endotracheal tube security is continually assessed and tapes are replaced as required (this is a two person procedure).

For nasal intubation: See images 1-6

The first length of leukoplast (image 1-3) is applied to the base tape on the side of the nose that the ETT has been inserted into, with the V of the tape butting against the nostril. The first securing length of tape goes across the upper lip and onto the base tape on the opposite side.

The second portion of the tape is then wrapped around and slightly up the tube at the requested depth of insertion. Ensure that the edge of the nostril is not pinched between the tape and ETT

1 2 3
Intubate 1  Intubate 2  Intubate 3 

The second length of leukoplast (image 3-6) is applied to the base tape on the opposite side of the face butting up against the free nostril and the first portion of the tape is secured up and over the nose.

The second portion of the tape is then wrapped around the tube up and over the first piece of the tape and up the tube slightly.

4 5 6
Intubate 4  Intubate 5  Intubate 6

For oral intubation

  • Follow the same procedure attaching the trouser legs to the corner of the mouth
  • The portion not attaching to the ETT is secured along the top or below the lips
  • Monitor the ETT closely as they are often more mobile with oral intubations.

Process for extubation

Unplanned extubation

  1. Ring the emergency bell
  2. Remove the tube (if indicated i.e. unable to achieve air entry)
  3. Maintain airway
  4. Suction if necessary
  5. Bag the infant

Planned extubation

Decision for extubation is made by medical staff and this is generally performed by the bedside nurse at a time negotiated with registrar or NS-ANP.

  1. Explain procedure and rationale to family
  2. Ensure that the resuscitation trolley is available at the bedside.
  3. Prepare and check all equipment is functioning.
  4. Prepare infant in a supine position using muslin wrap to promote containment.
  5. Consider loading infant with Caffeine prior to extubation as required
  6. Allow for at least an hour after infant's last feed before extubation. Consider withholding one feed following extubation, based on the infant's condition.
  7. If there has been a large volume of secretions, endotracheal tube may be suctioned 10-15 minutes prior to planned extubation, including oropharyngeal suctioning. (see suctioning policy)
  8. Allow infant to recover and re-establish lung volume and functional residual capacity after suctioning. Consider switching OFF the VG at this time, being mindful of peak inspiratory pressure setting.
  9. Ensure CPAP or other respiratory support, including bag and mask ventilation with Laerdal bag or Neopuff ready to be applied to infant after extubation
  10. Remove the endotracheal tube after gently removing the securing tapes from the infant's face - DO NOT APPLY SUCTION OR NEGATIVE PRESSURE TO THE ENDOTRACHEAL TUBE AS IT IS BEING REMOVED
  11. Suction oropharynx and/or nares as necessary
  12. Apply respiratory support as planned and position infant comfortably
  13. If possible registrar/NS-ANP to remain on NICU for 30 minutes following extubation
  14. Check blood gas within one hour after extubation if infant stable or earlier as requested by medical staff or NS-ANP
  15. Document date, time and infant's tolerance of extubation
  16. Assess for and document any signs of nasal pressure injury.

Related documents


  1. Wylie, J. Neonatal Endotracheal Intubation. Archives of Disease in Childhood - Education and Practice 2008; 93:44-49
  2. Wylie, J., Waldemar, A.C. The role of carbon dioxide detectors for confirmation of endotracheal tube position. 2006; 33 (1), 111-119

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Document Control

  • Date last published: 30 June 2010
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years