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Advice on intubating preterms

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I open this thread for the member sasa, who originally posted this topic in the Blog section.

In our house-keeping of 99nicu.org, we aim at publishing all discussion topics in the forums, whereas the Blogs are meant for more personal reflections.


I am a qualified neonatologist, very skilled in nasal intubation but moved to place with oral intubation with no M.forceps available and I have great problem with oral intubation of extreme preterms.

I find the small tubes (2&2.5) very floppy to manage to insert without stylet.

For those who are used to nasal intubation, we control the tube close to the larynx with M.forceps.

Any advice/tricks of inserting floppy tube orally to preterms without stylet/forceps.

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Guest dr hazeena


We routinely place endotracheal tubes orally only even for 500 gram babies and I always wonder how difficult it would to be place a nasal tube.Moreover if placed for longer duration doesn't it cause necrosis and injury .Besides its practice which makes one perfect.

After keeping equipments ready,we place the babies head end slightly lowered ,head needs to be more extended for extreme preterms as the vocal cords are placed deeper than usual.Once you see the vocal cords ,introducing the tube becomes a rather easy job. This positioning will definitely help in introducing the tube without difficulty.The length of the vocal cord guide needs to be below the vocal cord.

Usually only the incredibily low birthweight babies require 2 and 2.5 mm tubes .Even the 1 kg babies can be managed comfortably with 3 mm tube.

And then different products might have different degrees of floppiness.We use the RUSCH company tube which is comparatively stiffer than ROMSONS.

These are my suggestions.



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Hi Leonara desposito

I havent heard of keeping Et tube in freezer to stiffen it up . Do you use straight out of freezer for intubating .. or just keep it there for some time and then warm it up .... Seems interesting ..

I wonder whether it could cause laryngospasm during insertion . Since , we have not done it , I am not able to comment on the same .

Looking forward to hear from you



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Hi Gopan

We use to take the ETs ,out of the freezer just a few minutes before using them. With the laryngoscope in place, wait for the vocal cords to open ( without touching them ) to insert the ET. I share your concern about laryngospasm, but we don't see it often. That way we intubate succesfully ( oral or nasal ), without stylet. Regards Leonora

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This is off-topic but relates to the freezer-advice.

Up till the early 2000s we used a rather stiff tube. To make intubation easier the tube was boiled and then taped to a curved form where it was kept until it had cooled.

When we used the tube it had the "right" curvature and could be put in place with great ease!

Now, we use softer tubes. And instruments to steer it into the trachea too.

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