Connecticut Children’s Medical Center - Policy and Procedure ManualProvision of Care, Treatment and Services Date Effective: August 10, 2011<strong>Endotracheal</strong> Tube Management Date of Origin: April 01, 1996Approved By: CCMC-UCHC NICU CollaborativeGroup, Clinical CouncilDate Approved: August 04, 20116.Prepare the ETT. Person performing intubation may choose cuffed or uncuffedETT depending on patient needs. To test the integrity of the cuffed ETT, inflatethe cuff with air, depress both the pilot balloon and cuff to test for any leakage,then remove all the air from the ETT cuff.7.Insert the stylet, if appropriate. Keep the end of the ETT inside the sterilepackaging to maintain sterility. Be sure the end of the stylet does not protrude fromthe tip of the ETT (end inserted into patient)8.Prepare tape strips (hydrocolloid barrier/securing device) to secure the ETT onceinserted. Strips should be long enough to reach across the child’s face from onecheek to the other.9.Prepare Tincture of Benzoin.10.Administer pain medication and/or sedation as ordered. This may includeadministration of a neuromuscular blocking agent (paralytic).11.Ventilate with positive pressure ventilation using anesthesia bag, self-inflating bag,or T-piece resuscitator and O 2 to maintain adequate saturation, heart rate andcolor.12.Pre-suction the patient’s airway prior to intubation, if indicated. Assist theintubating practitioner in positioning the child’s head, and handing equipment andsupplies during ETT insertion.13.Monitor the patient’s heart rate, respiratory rate, and oxygen saturations duringintubation. Notify intubating practitioner of any significant changes.14.Once the ETT has been placed, with manual ventilation in progress, one personholds the ETT in position, while the other person auscultates to confirm bilaterallyequal breath sounds, and visualizes to ensure symmetrical chest rise.15.An exhaled carbon dioxide (CO 2) detector is used to confirm that the ETT is in thetrachea and not in the esophagus. A CO detector is attached between the ETTand the anesthesia, self inflating bag, or T-piece resuscitator. The patient ismanually ventilated with several breaths. A device specific color change indicatesplacement in the trachea. A pediatric CO 2 detector is used for patients under15kg. The end tidal CO 2 detector is less reliable for extremely low birth weightinfants who have small tidal volumes, and is less reliable in patients incardiopulmonary arrest. For these situations alternate confirmation methods maybe indicated.16.Apply benzoin to both cheeks; let dry until it becomes tacky. Secure the ETT inposition using tape strips. In the NICU: Place thin hydrocolloid on cheeks; applybenzoin only to hydrocolloid—avoid direct use on skin whenever possible. Utilizesecuring device to stabilize ETT when appropriate.17.Measure the ETT from the end of the tube where the adapter is attached to thepatient’s lip or securing device. Record measurement on the patient’s flow sheet.Alternatively, make note of the ETT marking that appears at the patient’s lip, ifvisible, and document.18.Approximate insertion depth, in centimeters from midtrachea to lip:Page 4 of 10