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A 3 week old infant that is positive for RSV has had several prolonged episodes of apnea requiring BVM ventilation. The decision is made to intubate the baby. It is a difficult intubation, although the tube is finally observed to pass through the cords on video laryngoscopy. A 3.5 uncuffed tube has been placed and taped at 12cm at the lip. After several positive pressure breaths on 100% FiO2, the pulse oximetry has fallen to 85% and fails to rise. The ETCO2 waveform is normal and reading 46 mm Hg. Heart rate is 170, BP is 62/30. On auscultation breath sounds are decreased on the left side. Trachea is midline.
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July 21, 2020 at 6:27 pm
E) Pull the tube back 1cm and give additional PPV breaths
A 3.5 uncuffed ETT (or 3.0 cuffed ETT) is an appropriate size for a neonate, and the depth can be approximated by 3 x the uncuffed ETT size = 3 x 3.5 = 10.5cm. At 12cm, the tube is likely too deep, and would be most likely to go down the right mainstem bronchus, resulting in decreased breath sounds on the left. Because the intubation was difficult, attempting to pull the tube back first is preferable to extubating. The normal ETCO2 and decreased breath sounds on only one side makes obstruction amenable to suctioning unlikely to be the culprit. Needle thoracostomy would be indicated if tension pneumothorax on the left was suspected, but with no hypotension or tracheal shift, this is unlikely. The ventilator should not be attached while still troubleshooting the hypoxia + decreased breath sounds on one side.