Neonatal Intubation and RSI

Congratulations! You have made it successfully to 2021! While 2020 was challenging for EVERYONE, and may have required some brute force to endure, let us take this opportunity to consider avoiding using brute force (“Brutane“) when intubating our smallest of patients – neonates. Certainly, I have used more brutane in my training and career than I should care to admit… but I am old… but, unfortunately, we all know that this is still taught and depicted today. Why? There are a variety of explanations, after all neonates are kinda scary, but we have better resources and interventions today. Let us review Neonatal Intubation and Medications for RSI:

Neonatal Intubation: It isn’t Comfortable for Anyone

Neonates epitomize all of the characteristics of a “Difficult Airway.”

  • Challenging anatomy
    • VERY Small, compressible airway
    • Relatively large tongue and occipital area
  • Challenging physiology
    • Low Functional Residual Capacity
    • High metabolic rate and oxygen consumption

Often an anticipated “Difficult Airway” may make clinicians reluctant to administer medications like paralytics or sedatives…

  • With an elective procedure, this may make sense, but when we consider intubating a patient (of any age) in the ED, it is not typically related to an “elective case” that can be cancelled and rescheduled… and we need to make our first attempt the best attempt.
  • With neonates, specifically, not using medications may actually make it MORE Difficult! (actually, kinda true for all ages.) [Foglia, 2019; Ozawa, 2019; Fiadjoe, 2019]

Neonates do feel pain! [McPherson, 2020]

  • The notion that neonates are too small, too young, and too immature to perceive pain or have it lead to lasting consequences has long been refuted…
  • We have previously discussed this with respect to performing LPs.
  • Certainly, having a laryngoscope shoved down a neonate’s throat would cause more than just bradycardia!
  • Don’t be cruel.

Neonatal intubations are difficult: [Foglia, 2019]

  • Data from an international registry from 10 academic neonatal centers shows that:
    • First attempt success rate were 49% in NICUs and 46% in Delivery Rooms
    • Complications and adverse events are not uncommon (18% in NICUs and 17% in Delivery Rooms).
    • Severe Desaturations rates ranged from 29% to 69%, depending on individual sites.
  • This data set does not include Emergency Departments (and there really isn’t much literature specifically including the ED), focusing instead on NICUs and Delivery Rooms.

There is CONSIDERABLE variation in practice amongst providers during neonatal intubations. [Wheeler, 2012]

Neonatal Intubation: Brutane vs Brains

While brawn may overpower a neonate’s jaw muscles, it does not make intubation easier… as it is more complex than just getting past the mouth. [Foglia, 2019; Ozawa, 2019; Fiadjoe, 2019]

Let’s consider what is known and use our brains instead:

  • In 2736 neonatal intubations, [Ozawa, 2019]
    • 36% used NO medications.
    • 47% of the intubations used paralytic and sedative.
    • Those intubations performed with both paralytic and sedative had statistically significant fewer adverse events than either sedative alone or no medication.
  • The international registry found modifiable, independent factors associated with reduced odds of adverse events to be : [Foglia, 2019]
    • Paralytic use
    • Video laryngoscopy use
  • Sedative use ALONE, without paralytic [Foglia, 2019]
    • is NOT protective against adverse events.
    • is associated with increase odds of severe oxygenation desaturations.
  • “Paralytic use, when appropriate, is an important component of a procedural premedication regimen to improve the safety of neonatal intubation.” [Foglia, 2019]

Moral of the Morsel

  • Don’t be a Brute! It may seem easier, but in the end, “Brutane” makes your job more difficult and makes the child suffer!
  • Don’t go half way. Using only a sedative is not better! Use both paralytic and sedative concurrently.
  • HAPPY NEW YEAR! Let’s continue to remain vigilant and strive to care for all of our patients with the respect and compassion each of us deserves.


Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 583


  1. You mentioned video laryngoscopy in passing. I have always used a Miller blade with DL given the anatomy of neonates’ airways. There just is not that curve/corner to get around in a neonate (very nearly the raison d’etre for the video laryngoscope). I am afraid to try the glide scope in a neonate because I am worried that I just will not get the wonderful view with the glide neonate blade that I always get with a DL Miller blade. I wish we could get blades for the glide scope in the shape of 0 Miller blades. There already make the MacIntosh blade for the glide scope which I love. Anyone with experience using glidescope for a neonate?

    • Dr. Gamboa,
      Thank you for this comment! Yes, there is literature that support the use (and benefit of using) video laryngoscopes (not only in adults, but also in our young neonates!).

      I personally prefer video laryngoscopes over traditional DL, particularly because I supervise residents during intubations and this assists me in assisting them instead of just “taking over.”

      Video methods also have the benefit in helping me make adjustments for myself I find.

      So the question is which video laryngoscope tool do you actually have… as they are not all created equal for certain. Most of the commonly used one (ex, STORZ or GLIDESCOPE) have not only the hyperangulated blades, but also blades in the shape of various Miller and Mac sizes. Glidescope also has very small hyperangulated blades for tiny patients. My preference, because I still like the options that Miller and Mac blades give me is to use video laryngoscopes that have Miller and Mac options. For a Neonate, I have the fortune of being able to select from Miller 0 videoscopic blades. If I needed a 00, I’d need to use a traditional DL.

      Hope that that helps.
      Stay well,

Comments are closed.