Neonatal intubation made SUPER EASY// Step-by-step instructions!!

And the trick is here is we need to get that epiglottis out of the way so that we can then thread the endotracheal tube down into the trachea. Hello, before we go over some great tips on how to intubate babies, I want to go over some really basic anatomy so you understand what we're actually trying to do when we intubate. Obviously, as you all know, when we're intubating, we're trying to pass an endotracheal tube down into the lungs. So through the vocal cords and down the trachea. What is the trachea? The trachea is one of the tubes that goes down from the back of the mouth or the oropharynx, and it's the blue tube in this scenario, and it goes down into the lungs. That's where we're trying to pass the endotracheal tube. As you all know, there's another tube that leaves the back of the oropharynx, and that's the esophagus, which goes down into the stomach. Again, to emphasize, the trachea is anterior to the esophagus, which means that the trachea is closer to the front of the face than the esophagus. So for example, on an actual baby, this is what the anatomy would be like. You can see that the trachea is in front of the esophagus. A couple more anatomical things that you need to understand. The vocal cords are like the flaps of curtains that are at the top of the trachea. So on either side of the trachea, there's vocal cords, which kind of open and close to speak or to protect the airway, and you have to be able to pass the endotracheal tube through those vocal cords. And you're probably all wondering what this little white tissue here is. Well, logically, when you eat or drink, you don't want any of that fluid or food to go down into the trachea, down into your lungs. It could be very dangerous, and you would choke. So when you eat or drink, there is a little flap of tissue that covers the trachea and therefore protects it. And as you all know, this little flap of tissue is called the epiglottis. The epiglottis is a small leaf-shaped sheet of elastic cartilage that protects your larynx or voice box and helps you swallow. So basically, the epiglottis covers the larynx or basically covers the vocal cords while you're eating to make sure that none of the food goes down the wrong tube. That's why you shouldn't talk and eat at the same time because then that will be left open and the food could go down the wrong tube. So when you're actually intubating, what you're trying to do is to pass the endotracheal tube down through the vocal cords into the trachea, which obviously goes towards the lungs so that you can then ventilate the lungs. If the intubation goes wrong, then very often what's happening is that the endotracheal tube is going too posteriorly and it's going down into the esophagus and into the stomach. Now let's look at the position of those tubes when you're actually intubating a baby flat. So like we said, when the baby is upright, these are the directions of the tubes. Again, you've got the trachea anteriorly and the esophagus posteriorly. So now let's lay the baby on its side so you can see again that you've got the vocal cords and the trachea anteriorly and the esophagus posteriorly. So basically we're trying to intubate in this position. And the trick is here is we need to get that epiglottis out of the way so that we can then thread the endotracheal tube down into the trachea. And as you all know, what we use for this is something called a laryngoscope or a blade. So what you're using the blade for obviously is opening the mouth so that you can actually see it all. But what you're trying to do is trying to get the epiglottis out of the way so that you can then thread that endotracheal tube down through the vocal cords and into the trachea. There are two different ways to try to get that epiglottis out of the way. In the tiny babies, there isn't a lot of room in the mouth. So what you're doing with the blade is pretty much catching the edge of the epiglottis so that the vocal cords can drop into view. So you're just lifting up the epiglottis towards the ceiling. In the older babies, what you're actually doing is going for the space directly above the epiglottis, which is called the vollecular. So when you pull up on that space, the epiglottis will also pull up with it. Therefore, the vocal cords will drop into view. Now to reiterate, let's look at that positioning again on the baby. So again, you're going to put the blade into the mouth and you're heading towards the back of the oropharynx, obviously, and what you're trying to do is to get that epiglottis out of the way. In this baby, which is a bigger baby, we would be pulling up right here in the space above the epiglottis, hoping that then the vocal cords would come into view just like that. So how do you proceed with the actual intubation? Obviously, there's a lot of equipment that needs to be set up. There's loads of steps that you should be going through before you're actually physically intubating the baby. But I'm going to talk about all of that in the next video. For now, I'm gonna go through the exact intubation itself. Okay, let's film this baby from the side. So this is the baby that we're about to intubate. And as you can see, the head is obviously towards you. The baby is very nice and flat, so not kind of leaning to one side or the other. The baby is in a good sniffing position, not too hyper-extended, but also not kind of with his chin squashed towards his chest. Okay, now let's grab the blade. So whether you're right-handed or left-handed, all blades are made to be held in the left hand. There are no right-handed blades. So the best way to hold the blade with your left hand is by using the three fingers spaced out apart on this actual holder, and then use the thumb on the other side. That leaves your pinky finger to be able to apply cricoid pressure. So look at the way that I'm holding this laryngoscope. And again, I want to show it without my gloves just so that you can really see how I'm holding the blade. So one thumb on that side, and then the three fingers spaced out. This gives you excellent control of being able to move the blade exactly how you want it to. And again, I've got my little pinky there for the cricoid pressure. Okay, let's go through with the actual intubation, and you should be wearing gloves for this, but I'm not so that you can see more clearly. So you've got your blade in your left hand. The first thing that you do is that you open the mouth of the baby with your right hand, and then you put the blade starting on the right side of the mouth into the baby's mouth, like that, and then sweep up under the tongue and start pushing the blade up towards the ceiling, like that. And let's see this from the side. So I'm using my right hand to open the baby's mouth. I put the blade in on the right side, and then I sweep under the tongue and upwards like that. And once you have the blade inside the baby's mouth, you don't want the blade kind of completely flat with the bed. So this is like at zero degrees. You also don't want it at 90 degrees, which is kind of more like this. Really, you want it somewhere around 60 degrees with the bed. So say this is 30, and then further up and 60. So you're really at quite an angle from the bed here. So at this point, you're really kind of trying to advance the blade until you can see the vallecular, or at least the epiglottis. Sometimes you go in too far and you have to kind of pull back a bit to see the epiglottis kind of drop into view. Often, especially if the vocal cords are really anterior, you have to pull up on the entire blade towards the ceiling. Do not rock. So don't kind of go backwards and forwards like this. Really, it's a motion where the whole blade is being lifted up towards the ceiling like that. Then once you identify the vocal cords, put the endotracheal tube in from the right side of the mouth and thread it down until you can see it pass through the vocal cords. Don't put it down the middle of the blade because then that will actually block your view of the vocal cords. So put it down from the side of the mouth and thread it through like this. And obviously I'm at home, so I don't have a way to kind of pump this up, but I think you can actually see this endotracheal tube go down into the lungs here. Okay, so once again, from another angle. So I use my right hand to open the mouth. I put the blade in on the right side and kind of sweep up under the tongue. So then I'm really just trying to get a good view of the vocal cords. So the things that I can do, kind of push forward and back with the blade, hoping that the cords are going to drop into view. I can push up towards the ceiling. So really the head of the blade is trying to go to where the ceiling and the wall meet. You can see that that's kind of 60 degrees. If I still can't see anything, then I'll try to use cricoid pressure. So you can see how my pinky, my baby finger there is available to kind of push down on the cricoid, hoping that it will help them drop into view. And now as it happens, I have a perfect position of the vocal cords. So I put the tube in on the right side of the mouth. Again, I don't want to do it down the middle of the barrel because then I'll lose my view of the vocal cords. We don't want to go like this. We want to go like that. So I put the ET tube down on the right side and I try to thread it through the vocal cords until it's far enough down. So in this baby, let's assume he's about two kilos. So we probably wanted it in about eight centimeters. We'll talk about that next time. So I'll pull it back to eight centimeters. Obviously I went in way too far. So here we are at eight centimeters. Now the key thing is that you're holding on to this endotracheal tube while you're making sure that it's in the right position and then the RT and everybody else is securing it. So normally what I do is I grip it with my index finger and my thumb against the roof of the mouth like that. Okay, if this has all been helpful for you, then please like this video and remember to tell us where you're from if you comment. Also, before we go on with our tips, then please write your own tips for intubation at the bottom. Thank you.