Rapid Sequence Intubation/Nasal intubation

[vintage_RN, BSN, RN]

Just curious as to the practice at other hospitals, whether this is standard or not. Here we do RSI (rapid sequence intubation) for all intubations....Atropine, Fentanyl and Rocuronium (or Succinylcholine if intubating for surfactant only) given prior to the intubation attempt (unless for some reason its too emergent and we dont have time). Also I would say 95% of our babies are nasally intubated unless they cant get it....we hate oral tubes! I'm in Canada in a level 3 (highest level) tertiary centre.

[NICU Guy, BSN, RN]

7 hours ago, vintage_RN said:

Also I would say 95% of our babies are nasally intubated unless they cant get it....we hate oral tubes!

We do 0% nasal intubations. It is difficult enough to get an NG in most preemie's noses, I can't imagine trying to nasally intubate them.

50% of the time (depends on the doctor) we do RSI.

[babyNP., APRN]

RSI is the way to go, it helps improve first time intubation rates dramatically. This puts the infant at less risk of complications from intubation. If only fentanyl could be pushed! It's also something to consider that we (the royal we) providers are getting less proficient at intubating than in decades past because we are keeping more babies off the ventilator and we used to intubate all meconiums, then just the non-vigorous ones, now not unless indicated after initial resuscitation. But we can't intubate babies that don't need it just for the practice. Similar to I guess in years past a ton of babies got chest tubes before surfactant. Now chest tubes are on the rare side and proficiency has gone down. But you wouldn't wish a chest tube on a baby, of course.

I was reading an abstract about giving surfactant via nasogastric tube which would preclude the need to intubate those babies- game changer.

[NICU Guy, BSN, RN]

3 hours ago, babyNP. said:

I was reading an abstract about giving surfactant via nasogastric tube which would preclude the need to intubate those babies- game changer.

You use a laryngoscope to insert the NG tube orally into the lungs? That would be less traumatic then an ETT. Are they using a 5f PICC line or 5f NG using an oral syringe?

[adventure_rn, MSN, NP]

11 hours ago, babyNP. said:

I was reading an abstract about giving surfactant via nasogastric tube which would preclude the need to intubate those babies- game changer.

That's fascinating. I'm guessing you'd have to do it with a laryngoscope so it would enter the lungs instead of the stomach, right? Seems like it would decrease the chance of blowing a pneumo, too (most of our surfed kids are left on the vent for at least a short period before extubation).

11 hours ago, babyNP. said:

Similar to I guess in years past a ton of babies got chest tubes before surfactant.

Seriously? That's pretty wild to hear, but I guess I understand the rhetoric.

[babyNP., APRN]

I don't know the details, I did find this "guide" (link below) but unfortunately my hospital doesn't have access to this journal so I wasn't able to read it. Apparently hospitals use NG and IV catheters to do it. Doing some more digging, I found references to it as far back as 2013. Not sure why it's not widely adopted as it seems to not only reduce time on the ventilator, but reduces the BPD rate. Could be something I'm missing that makes the data not good or something like the threshold it would take to teach providers how to do it/inertia to make such a huge practice change. If you guys are game, ask your docs about it and see if they've heard about it/what they think.

https://pubmed.ncbi.nlm.nih.gov/31461712/

[NICU Guy, BSN, RN]

9 hours ago, babyNP. said:

. If you guys are game, ask your docs about it and see if they've heard about it/what they think.

That is on my agenda for the weekend when I work.

[babyNP., APRN]

I finally remembered and got a chance to ask our division head about this method of surfactant administration- it's called the LISA method (less invasive surfactant administration). Essentially she told me that you have to have very experienced people who can intubate in order to do it, which makes sense, a nasogastric tube or central line tubing is super flexible and without a stylet, would be pretty hard to do. Would be good to do with a video laryngoscope, I bet. Might be good at level 3 community NICUs where it's just all attendings, but not so good when you have a unit with residents & fellows who aren't experienced. And if you don't let them intubate, then they don't learn.

She did say she thinks it will become more standard later. There's also inhaled surfactant, which I had first heard about when I was in grad school 6 years back, not sure how that's going.