To the Editor:
We have read with great interest the magnificent review by Ms Volsko, recently published by Respiratory Care.1 We would like to congratulate the author for her article. We would also like to make some observations regarding endotracheal intubation of the newborn in particular, including newborns of very low birthweight, < 1,500 g. A brief introduction is needed. In Italy, the respiratory therapist does not exist; both intubation procedures and the choice of ventilation parameters are the responsibility of the physician caring for the patient. In our department, we carry out assistance in the delivery room, in neonatal intensive care, and in neonatal emergency transport, therefore having experience of the conditions that the author describes in her review (ie, endotracheal intubations performed emergently, urgently, and electively). We have repeatedly faced the problem of intubation of the newborn, especially evaluating the most difficult condition in which one can find oneself, which is neonatal transport.2,3
A first observation relates to Table 3 of Ms Volsko’s article.1 The author refers to the neonatal resuscitation program and to pediatric advanced life support. The problem is that very generally an age range<28 d and < 1 y, respectively, was indicated. This is, obviously, not acceptable for the newborn, especially at birth. The title Depth Calculation is shown in the third column of Table 3, which, however, referred to the “mark at the lip,” evidently ignoring the nasal route for intubation, widely used in neonatology.3,4 We obviously agree with Ms Volsko, who has chosen to refer to the internal diameter of the endotracheal tube. However, we believe that reporting the value 3 mm can be misleading. It is known to all colleagues involved in neonatal intensive care and neonatal transport that the use of tubes with an internal diameter 2 or 2.5 mm is widespread and often necessary.
The author cited Peterson4 and Chung,5 noting that both found neonatal intubations that were too deep. Ms Volsko also cited Bartle’s6 beautiful article, which we have previously criticized,7 at least in part. We deliberately omit the historic article by Tochen8 from the 1970s, now outdated but which, in any case, we have largely assessed its effective (scarce) validity, at least referring to the nasal route for intubation.3
The observation we would like to make is related to the fact that the review ignores the nasal route of intubation of the newborn. Although we are aware that there are no clear advantages or disadvantages to choose the oral or nasal route,3,9 making the choice more a matter of training, it cannot be denied that the nasal route is in any case widely used.
We have proposed a very easy-to-memorize formula (Genoa formula),3 usable for the correct nasal tracheal intubation in extremely premature newborns, weighing < 500 g. We believe our experience is of value as it was obtained during neonatal emergency transport, which is certainly the most complex circumstance for intbuation.2,3
We also believe that it is extremely complicated to evaluate in a single context such different situations, such as that of the newborn, even premature, at birth, up to the adolescent, which, obviously, remains in the pediatric realm but which has very little in common with the infant. The anatomical and physiological differences so admirably summarized by Ms Volsko confirmed, if ever there was a need, this last statement.
In conclusion, we reiterate our great appreciation for the important and thoroughly detailed work of Ms Volsko. We believe only that it may be useful to emphasize these reported aspects relating to the endotracheal intubation of the newborn.
Footnotes
- Correspondence: Carlo Bellini MD PhD, Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Gaslini, Largo G Gaslini, 5, 16147 Genoa, Italy. E-mail: carlobellini{at}gaslini.org
The authors have disclosed no conflicts of interest.
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