Airway

 1.7.1. Airway

Positioning the infant to open the airway

• Lay the infant supine on the resuscitaire with the head in a neutral position

• Place a rolled towel under the shoulders if the newborn has extensive caput to bring the head into a neutral position

• Extend the head slightly to the “sniffing” position if the infant is breathing (but ineffectively) as the airway may be obstructed

• If the infant is making spontaneous efforts to breathe but the heart rate is not rising >100 bpm, the airway may be obstructed. Try manoeuvres such as supporting the lower jaw, opening the infant’s mouth, or suctioning the upper airway.

Clearing the airway

• Suctioning the mouth and/or nasopharynx should not be performed unless there is obvious signs of obstruction

• Pharyngeal suction may be required to view the vocal cords during intubation

• Use a Fg 10 or Fg 12 suction catheter

• The negative suction pressure used should not exceed 100 mmHg (13 kPa, 133 cmH₂O, 1.9 Psi)

• Suction the mouth first

• Be quick (no more than 5 – 6 seconds) and gentle, as over vigorous suctioning can cause laryngeal spasm, bradycardia, trauma and delay the onset of spontaneous breathing

Management of the infant born through meconium stained amniotic fluid

Intrapartum pharyngeal suctioning 

• Suctioning the infant’s mouth & pharynx before delivery of the shoulders (intrapartum suctioning) does not reduce the incidence of meconium aspiration syndrome (Vain, et al., 2004)
• It is not recommended.

Endotracheal suctioning

1. The vigorous newborn: Breathing or crying, good muscle tone

• Suctioning the trachea of a vigorous infant born through meconium stained amniotic fluid is discouraged
• It does not alter the infant’s outcome, and may cause harm
• It does not result in a decreased incidence of respiratory distress and is associated with transient complications (Wiswell, et, al., 2000)
• It is not recommended.

2. The non-vigorous newborn: Not breathing or crying, low muscle tone

• Emphasis should be placed on initiating ventilation rapidly
• Studies have shown no benefit for routine endotracheal suctioning for important outcomes, including:
  • Incidence of meconium aspiration syndrome
  • Need for chest compressions
  • Need for management of pulmonary hypertension
  • Survival
  • Neurodevelopmental outcome

3. Routine direct laryngoscopy:  All newborns

ANZCOR (2021) state:

We suggest against routine direct laryngoscopy immediately after birth, with or without tracheal suctioning for all newborns  (Guideline 13.4, April 2021)