Neonatal Intubation - Standard Operating Protocol

Publication: 16/03/2012  --
Last review: 30/01/2020  
Next review: 28/02/2021  
Standard Operating Procedure
ID: 2877 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Standard Operating Protocol for Neonatal Intubation

This protocol summarises the approach to safe intubation of neonates on the neonatal unit and delivery suite. It incorporates information in the previous sedation for intubation guideline, the intubation chapter of the previous neonatal procedures book and the intubation and extubation checklists, as well as emergency non-intubation protocol.


  • To standardise and optimise the safe intubation of neonates within the Leeds Neonatal Service.

Background and indications for standard operating procedure/protocol

To be used for all endotracheal intubation of babies by neonatal staff. Emergency intubation of a newly born baby or unconscious collapsed baby can be performed by an experienced practitioner without iv access or sedation. In all other cases of semi-elective or elective intubation this protocol should be followed.


Indications for intubation include

  • Mechanical ventilation
  • Administration of surfactant
  • Protecting the airway (anatomical anomalies)
  • Suctioning of meconium / secretions from below the cords

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Please use the Intubation checklist. A team member should be assigned to check off against this list. other_versions/2877Checklist.doc

Equipment you will need includes:

  • Gloves
  • ET tubes (a range of sizes, usually 2.5, 3.0 and 3.5- see table)
  • Introducer (if soft tubes, for oral intubation) lubricated with gel
  • Laryngoscope (straight bladed, the longest that will fit in the baby’s mouth)
  • Suction device (suction catheter and Yankauer)
  • Oxygen/Air mix gas supply
  • Bag and mask / T-piece
  • CO2 detector (NeoStat for <1Kg, Pedicap or NeoStat for older)
  • [EMMA electronic CO2 detectors are also available in crash bags]
  • Stethoscope to check position
  • NeoFit securing device to secure the tube once in place (or Elastoplast if intubating for MRI scan)

Confirm IV access is working and patient monitoring is in place and baseline observations recorded.

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Prepare premedication:

Notes on Propofol:

  • Propofol can cause hypotension. Always have a fluid bolus of 10ml/kg 0.9% saline drawn up.
  • Propofol 0.5% must be given SLOWLY over 1 to 2 minutes as undiluted followed by slow IV flush (2 ml of 0.9% sodium chloride) over 1 to 2 minutes to avoid risk of hypotension and localised muscle twitching.
  • If needed repeat premedication - propofol can be repeated once more (a maximum of 2 doses or 4 mg/Kg propofol in 24 hours).
  • Propofol is available in 2 strengths: 0.5% propofol vial containing 5 mg per 1 mL and 1% propofol vial containing 10 mg per 1 mL. Routinely we will be using 0.5% strength of propofol in the neonatal units.
  • Beware of 2 strengths of propofol and small volume needed while withdrawing from a 20 mL vial.

Check blood pressure soon after giving propofol and re-check blood pressure at 15 and 30 minutes after giving propofol.

The most important thing about intubation is to ensure that adequate oxygenation occurs of the baby is achieved before, during and after intubation.
Before you start, whilst you are checking your equipment, the baby should be receiving good mask ventilation. If intubation is difficult or delayed more than 30 seconds or the saturations / heart rate drop significantly, then stop and recommence mask ventilation until the baby (and you) are ready for a second attempt.

The escalation policy for appropriate practitioners and numbers of attempts per practitioner is in Appendix 4.

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Intubation technique:

  • Wash hands and put on gloves and apron. The laryngoscope should always be held in the LEFT hand and the ET tube in the right hand (even if you are left handed).
  • Insert the tip of the blade into the right hand corner of the mouth so that the blade pushes the tongue over to the left. Be careful to protect the upper gum from trauma.
  • Insert the blade into the oesophagus and then gradually withdraw (keeping in the midline) until the tracheal opening drops into view. The blade of the laryngoscope is now holding the epiglottis out of the way. With gentle cricoid pressure (from a helper) the tracheal opening becomes more obvious.
  • Use the curve of the tube to insert the ET tube into the tracheal opening, without getting the body of the tube in your line of vision. (Imagine coming in from the 3 o’clock position on a clock face)
  • Insert the tube to the depth such that the black mark on the sde of the tube is just below the vocal cords. No force should be necessary. Remember you are inserting a tube within a tube, not pushing a tube into a hole. If you push too hard the ET tube will kink and will then often end up in the oesophagus.
  • The following table gives a guide to the size and depth of the ET tube that should be used. Generally Weight (Kg) +6 cm = oral length



Diameter (mm)

Nasal (cm)

Oral (cm)


0.6 kg





0.75 kg





1.0 kg





1.5 kg





1.7 kg





2.0 kg





2.5 kg

3.0 – 3.5




3.0 kg

3.0 – 3.5




3.5 kg




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Post insertion (see Intubation checklist)

  • Confirm correct placement using CO2 colour monitor-remember you may not get colour change in cardiac arrest as no CO2 circulated to lungs.
  • Look at the colour- is the baby pink/ are saturations good/ improving ?
  • Check the heart rate- is it good or increasing?
  • Listen at the mouth for a large leak. If the baby is crying the tube is not in the trachea.
  • Look at the chest- are both sides moving equally?
  • Listen to both axillae AND over the stomach- If breath sounds are louder over the stomach than the chest then the tube is probably in the oesophagus and should be removed.
  • If there is unilateral expansion and the breath sounds are louder on that side then tube may be inserted too far. Check length and carefully withdraw by 1cm and reassess.
  • Make sure the tube is well secured using NeoFit. Once Velcro secured gently try to push the tune further in to check it is not loose.
  • After you are clinically satisfied with the tube position always confirm with a CXR
  • Once ET position is confirmed on CXR (ideally T1-T2 and 1cm above carina) flag the tube adjacent to the top of the harness. This provides a visual aid to notice if the ET tube is slipping out in the future.

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Repeat observations (especially BP) immediately and at 30 mins and document on observation charts.

Complete and sign the intubation checklist documentation, including the grade of view, and file contemporaneously in notes. Document any complications.

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Deciding when to extubate a baby is a clinical decision that should be made by an experienced practitioner. Before extubation please consult and follow the Neonatal Extubation Checklist (see appendix 2).


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Appendix 1

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Appendix 2

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Appendix 3 Propofol Pharmacology

Premedication pharmacology (Please see e-formulary for further details):

Propofol is available in 2 strengths: 0.5% propofol vial containing 5 mg per 1 mL and 1% propofol vial containing 10 mg per 1 mL.

Pharmacokinetics: Following a bolus dose propofol is rapidly cleared from body (half-life: 30 to 60 minutes). Clearance occurs mainly in the liver to form inactive conjugates of Propofol which are excreted in urine. A single slow bolus effect should last 3 -10 minutes.

Reported side effects: Persistent hypoxaemia, bradycardia, hypotension, clonic convulsion, localised muscle twitching (usually self-limiting) and pain at injection site.

Muscle twitching is more frequently observed after rapid and / or repeated doses but these are self-limiting and not harmful. Propofol should be given SLOWLY over 1 to 2 minutes followed by SLOW IV flush (2 ml of 0.9% sodium chloride) over 1 to 2 minutes to minimise the side effects.

Safety profile of propofol in neonates: In a recent randomised controlled trial by Ghanta et al propofol was more effective as an induction agent with less hypoxia and reducing the time to achieve successful intubation. Propofol should not be used for maintenance of sedation in neonates. There is no evidence that short term use of propofol is dangerous in neonates.

Summary of common premedication drugs for neonatal intubation



Onset of action

Duration of action

Common adverse effects and comments


2 - 4 mg/Kg

Within 30 sec

3 -10 min

Apnoea, hypotension, bronchospasm, bradycardia; often causes pain at injection site, localised muscle twitching
Given slowly over 1-2 minutes followed by slow flush over 1-2 minutes to minimise risk of hypotension and localised muscle twitching


1 - 4 microgram/Kg

Almost immediate

30 - 60 min

Apnoea, hypotension, CNS depression, chest wall rigidity
Give slowly (preferably over 3–5 min, at least over 1–2 min) to avoid chest wall rigidity which can be treated with naloxone / muscle relaxants


1 - 2 mg/Kg

30 - 60 sec

4 - 6 min

Hypertension/hypotension, tachycardia, arrhythmias, bronchospasm, hyperkalemia, myoglobinemia, malignant hyperthermia
Contraindicated in presence of hyperkalemia and family history of malignant hyperthermia


10 - 20 microgram/Kg

1-2 min

30 -120 min

Tachycardia, dry hot skin

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Appendix 4 Appropriate personnel


Record: 2877
Clinical condition:

Elective and semi-elective neonatal intubation

Target patient group: Neonates at the Leeds Teaching Hospitals NHS Trust
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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