Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. So I called for the pediatric glidescope to be brought. The team asked to have the surgeon on call come in case we needed to intervene with a surgical airway.

While waiting, we tried the one thing that allowed us to see the larynx well enough to succeed with the intubation: we placed the baby’s head in the optimal,  neutral position. Since we didn’t have a small towel to place under the shoulders, I lifted the shoulders about an inch off the bed with my fingers and held the baby rock steady while the neonatologist slid the endotracheal tube into the trachea. The tube was secured and the baby was transferred to the neonatal ICU.

Illustration showing how the infant head tends to roll and a method of stabilizing it make intubation faster and easier.

The infant head tends to roll and stabilizing it make intubation faster and easier.

Ten percent of the 4 million babies born each year in the United States need some assistance to make the transition from fetus to newborn, and about 1% need more complex resuscitation, including ventilation and intubation (1).

Newborns are at high risk of hypoxia, and if suffering hypoxia are much more prone to cardiac arrest. Care during the first minute of life is often referred to as the “Golden Minute”. Within one minute of birth, a baby should be breathing well or should be ventilated with a bag and mask. Neonatal resuscitation protocols recognize this need for speed by requiring assessment at 30-second intervals during the first two minutes of life, with interventions indicated as early as 30 seconds. However, you do not have to wait 30 seconds or more to intervene if the newborn is obviously depressed (2).

While neonatal airway management and intubation is usually routine, this case is proof that you always have to be prepared for the difficult intubation, regardless of where you are.

Always Prepare for Failure

Have The Airway Equipment You Might Need For Difficult Neonatal Intubation Available

Delivery rooms should have laryngoscopes, oral airways, endotracheal tubes and masks of appropriate neonatal and premature sizes available. This can either be in the room or in a cart/airway box that can be quickly brought to the resuscitation site. A ventilation device such as a NeoPuff or a bag-valve-mask device should be immediately available. Seconds count in a newborn.

In the event of an unanticipated difficult neonatal intubation, it’s important that all staff knows how to obtain more advanced equipment such as a glidescope or fiberoptic, as well as summon the providers expert in their use.

Have The Expertise You Need Ready

If you expect that a particular neonate will have a difficult airway because of known congenital abnormalities or other information, then prepare a plan using the people you would need to manage an airway emergency. The obstetricians, neonatologists, midwives, anesthesiologists, head and neck surgeons, respiratory therapists must all know the plan ahead of time. While you may have certain people arranged to be there for the delivery, a baby can come at any time and therefore all department staff needs to know the plan. Arrange for the delivery to be during normal working hours if you can.

We weren’t expecting problems in our case. For managing the unexpectedly difficult airway, you should able to rapidly summon expert help, as we did with our Code White call.

Difficult Ventilation

Ventilation is key. In any neonatal resuscitation when the baby is not breathing well, or not breathing at all, you must ventilate the baby. But what do you do if you’re having difficulty ventilating? You  need to follow the same steps you would take in an older child or adult, but modify those steps for an infant.

Call For Help Quickly

Call for help as soon as you encounter difficulty that is not easy to resolve. It takes time for help to arrive. Seconds count in resuscitation. If it turns out that you have already solved the problem by the time the help arrives then smile, thank people for coming, and send them on their way.

Place the Head in a Neutral Position

Use the same position you would use to intubate a patient of that age. Unlike an older child, opening the airway in a neonate means placing the head and neck a neutral position. The shape of the neonatal head, with its large occiput, tends to flex the head forward, obstructing the airway. It also makes the larynx appear more anterior, and difficult to see, during laryngoscopy.

Illustration contrasting how to open the airway of a child vs a baby. When preparing for intubation, head and neck positioning can be key. For an infant, placing a small rolled towel under the shoulders lifts the body and compensates for the large round occiput, bringing the ear canal into alignment with the sternal notch.Older children may need a towel under their head. C. Whitten

When preparing for intubation, head and neck positioning can be key. For an infant, placing a small rolled towel under the shoulders lifts the body and compensates for the large round occiput, bringing the ear canal into alignment with the sternal notch.Older children may need a towel under their head.

A small rolled towel or support under the shoulders can help open the airway if needed. Apply the ventilation mask to the infant’s face, tilt the head slightly into extension. Obtain a good seal by pulling the face into the mask. Avoid pressing on the soft tissue under the chin, which can obstruct the airway.

Photo of how to use a mask to ventilate a small infant, showing optimal finger placement and neutral head position.

Use a small rolled towel to lift shoulders to place head in neutral position. Obtain a good mask seal. Don’t press on soft tissue under the chin, which can obstruct the airway. Tilt head back slightly.

Use Two Handed Ventilation

If you are still having difficulty, use two hands to perform a jaw thrust with a tight mask seal and have a knowledgeable assistant squeeze the bag or use the NeoPuff. To avoid barotrauma, your assistant must know that tidal volumes needed in a neonate are tiny. When in doubt, you can always have your assistant hold the mask while you ventilate.

Illustration show how to use both your hands to seal a mask while an assistant squeezes the bag to ventilate.

Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

Insert an Oral Airway

Just like with an adult, you can insert an oral airway. Oral airways come in sizes to match the smallest micropremie, but you need to have them available.

Photo of placing an oral airway in an infant

Have the correct size oral airways available for newborn as well as premature infants.

Consider A Nasal Airway

If an oral airway is not working you can use a nasal airway, as long as the nasal passages are patent. You may not have a manufactured nasal airway small enough for your baby. However, you can use a cut endotracheal tube. Estimate the length by measuring the distance from the nares to the ear tragus, cut the tube, reinsert the adapter, and gently insert the tube.

Illustration showing how to Measure the distance from nares to tragus to predict correct nasal airway size. When substituting a cut endotracheal tube, use this length to estimate the length to cut the tube before insertion.

Measure the distance from nares to tragus to predict correct nasal airway size. When substituting a cut endotracheal tube, use this length to estimate the length to cut the tube before insertion.

Insert A Supraglottic Airway

You can use a supraglottic airway like an LMA in neonatal resuscitation. See chart below for sizing.  LMAs have been shown to be useful in neonatal resuscitation in both term and pre-term infants. I recommend adding small LMAs to the emergency airway “kit” for your delivery suite.

Difficult Intubation

In our baby, we could manually ventilate, but we couldn’t intubate. It is paramount during difficult intubation that you

In the middle of a difficult intubation, it is very easy for the intubator to lose track of time.  The intubator can easily convince themselves that they are “almost there”, just a few more seconds of manipulation will permit those cords to fall into view and allow intubation to succeed. I highly recommend that someone other than the intubator keep track of time and to  monitor both oxygen saturation as well as heart rate. If you don’t have a pulse oximeter, the person monitoring should watch skin color and feel the pulse at the umbilical stump.

Don’t wait until the baby desaturates to stop the attempt. Limit the time of arena attempts to 30 seconds or less to avoid inducing or worsening hypoxia and hypercarbia. Between attempts: stop, ventilate, regroup. Ventilation and maintenance of adequate oxygenation are the important factors, not intubation.

Change something to better optimize the next attempt – don’t keep doing the same thing over and over. Try again. Have someone else try.  Prolonged attempts can also increase the risk of injury, bleeding, and edema.  A prolonged difficult intubation attempt can unfortunately turn into a “can’t intubate/can’t ventilate” scenario.

Intubation Through An LMA

You can often ventilate a neonate well using an LMA (3,4). This can buy you time to obtain more advanced equipment or to just continue resuscitating the baby with an adequate, if not perfect airway. While anesthesia providers often use LMAs on an almost daily basis, neonatologists and midwives have less experience. Inserting an LMA is easy to learn.  Practice on a manikin has been shown to increase successful placement in neonates (5).

It’s possible to perform blind intubation through an LMA, however there is a risk of trauma, esophageal intubation, plus it requires more time — time that a neonate in trouble may not have. If you have a pediatric bronchoscope, you can use a combined technique of passing a pediatric fiberoptic bronchoscope loaded with an ETT as small as 2.5 though the LMA into the trachea. This technique is too involved to discuss here. Follow links 6 and 7 in the references to articles discussing the use of the fiberoptic via an LMA technique in children as well as a novel technique for removing the LMA safely after intubation in an infant. (6,7)

Pediatric Glidescope

Glidescope blades are now available for infants and young children. They have been used for difficult neonatal intubations. A good review of pediatric glidescope use and the modifications of technique recommended for pediatric patients can be found in reference 8.

Can’t Intubate/Can’t Ventilate

You never know when you will encounter difficult ventilation or intubation, even in a newborn. You must always be prepared with a plan and the equipment and people  you need to carry out that plan.

Difficult Airway Algorithm from the Clnical Guideline for Management of a neonate with difficult airway.

Difficult Airway Algorithm from the Clnical Guideline for Management of a neonate with difficult airway (9).

May The Force Be With You

Christine Whitten MD. Author
Pediatric Intubatin: a Step-by-Step Guide
Anyone Can Intubate : a Step-by-Step guide to Intubation and Airway Management


Cover of book Pediatric Airway management: A Step-by-Step Guide by Christine Whitten

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(Unless otherwise indicated, all illustrations are from Pediatric Airway Management: A Step-by-Step guide, Whitten MD)


  1. Helping babies breathe: The golden minute. www.helpingbabiesbreathe.org/index.html.
  2. Chapter 8, Neonatal resuscitation in Pediatric Airway Management: a Step-by-Step Guide. Christine Whitten MD, Mooncat Publications 2018. pp 169-193
  3. Grein AJ, Weiner GM Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev. 2005 Apr ;(2):CD003314.
  4. Gandini D., Brimacombe J.R. Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anaesth Analg 1999; 89:642-43
  5. Weiss M., Engelhardt T.  Proposal For The Management Of The Unexpected Difficult Pediatric Airway. Pediatric Anesthesia 2010 20: 454–464. doi:10.1111/j.1460-9592.2010.03284.x
  6. Gandini D, Brimacombe J. Manikin training for neonatal resuscitation with the laryngeal mask airway. Pediatric Anesthesia. 20 May 2004 https://doi.org/10.1111/j.1460-9592.2004.01247.x
  7. Greenberg M., Merritt S., Brzenski A. A Novel Method Of Intubation Using A Laryngeal Mask Airway And A Bronchoscope In A Premature Infant. International Journal of Innovative Medicine and Health Science, Volume 6, 2016, 5-8
  8. Lee, J: A Comparative Trial of the GlideScope® Video Laryngoscope to Direct Laryngoscope in Children with Difficult Direct Laryngoscopy and an Evaluation of the Effect of Blade Size. Anesthesia & Analgesia:July 2013 – Volume 117 – Issue 1 – p 176–181
  9. Muthukumar P., Mauro A. Clinical Guideline for: Management of a neonate with difficult airway.  , . Approved by: CGAP Date approved: 28/03/2017 Review date: 28/03/2020

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