surfactant therapy for newborns · web viewrespiratory distress syndrome in preterm newborns

Surfactant Therapy for Newborns

CHS19/194

Canberra Health Services

Clinical Guideline

Surfactant Therapy for Newborns

Contents

Contents1

Guideline Statement2

Background2

Key Objective2

Alerts2

Scope2

Section 1 – Indications for surfactant administration3

Respiratory distress syndrome (RDS)3

Meconium aspiration syndrome (MAS)4

Pulmonary haemorrhage and Pneumonia4

Section 2 – Which surfactant4

Section 3 – Method of administration5

Intubation and ventilation5

Intubation, surfactant treatment then rapid extubation (INSURE)5

Surfactant administration via a thin catheter (LISA/MIST)6

Section 4 – Respiratory management after surfactant administration6

Implementation7

Related Policies, Procedures, Guidelines and Legislation7

References7

Search Terms9

Attachments9

Attachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newborn11

Attachment 2: INSURE technique12

Attachment 3: Thin catheter technique14

Guideline Statement

Background

There is variation in international, national and state guidelines relating to surfactant use in newborn infants. This guideline outlines Canberra Hospital consensus, relating to the use of surfactant in newborns.

Key Objective

The purpose of this procedure is to provide clinicians with information on the safe and effective management of newborns requiring surfactant at Canberra Hospital.

Alerts

Aim to stabilise newborns with respiratory distress syndrome on Continuous Positive Airway Pressure (CPAP) in the delivery room and provide them with early rescue surfactant if required.

Newborns <28 weeks gestation with respiratory distress syndrome and increased work of breathing, may be treated with poractant (curosurf) once they require a Positive End-Expiratory Pressure (PEEP) of 7cmH20 or greater and require any oxygen therapy in the first 24 hours of life.

Newborns >/=28 weeks gestation with respiratory distress syndrome and increased work of breathing, may be treated with beractant (survanta) once they require a PEEP of 7cmH20 or greater and requiring >/=30% oxygen therapy in the first 24-48 hours of life

Consider treating any ventilated newborn with severe respiratory failure secondary to meconium aspiration, pneumonia or pulmonary haemorrhage with beractant (survanta)

Use less invasive methods of surfactant administration, such as INSURE (INtubation, Surfactant treatment then Rapid Extubation) or Minimally Invasive Surfactant Administration (MIST)/ Less Invasive Surfactant Administration (LISA) where able.

Take cultural considerations into account when using beractant (derived from a bovine source) or poractant (derived from porcine lung extract)

Back to Table of Contents

Scope

This document pertains to newborns cared for by CHS staff in the Neonatal Intensive Care Unit (NICU).

This document applies to the following CSH staff working within their scope of practice:

Medical Officers

Nurses

Midwives


Section 1 – Indications for surfactant administration

Pulmonary surfactant is naturally produced by the body. It lines the alveoli reducing surface tension and preventing alveolar collapse at end expiration. It is made up of a mixture of proteins and lipids. There are several clinical scenarios in which surfactant is either not being produced by the newborn in adequate quantities (respiratory distress syndrome) or has been inactivated (meconium aspiration syndrome/pulmonary haemorrhage) in which exogenous surfactant administration is indicated.

Respiratory distress syndrome (RDS)

Surfactant has been shown to improve short term outcomes in newborns with respiratory distress syndrome by reducing the need for mechanical ventilation, decreasing the incidence of pneumothorax and pulmonary interstitial emphysema, death and the combined outcome of death or chronic lung disease[1].

Respiratory distress syndrome in preterm newborns <28 weeks gestation

Stabilising newborns on CPAP and then providing those who need it with early rescue surfactant, has been shown to improve survival and reduce chronic lung disease when compared to electively intubating to provide prophylactic surfactant at birth [2-4]. Newborns who require surfactant, benefit from receiving this at <2 hours of age, resulting in less air leak from lungs, reduced chronic lung disease and likelihood of death [5]. An Australian study demonstrated that newborns requiring >30% oxygen at 2 hours of age is predictive of CPAP failure [6]. There is little evidence to guide practice around optimal timing of surfactant administration. Taking the current evidence into account it is recommended at CHS:

· Whenever possible stabilise preterm newborns on CPAP in the delivery room. Avoid intubating newborns for the purpose of surfactant administration at birth, unless this is unavoidable (i.e. unable to achieve appropriate saturation levels with standard resuscitation).

· Newborns who are intubated for the purpose of resuscitation should be given surfactant as soon as possible after intubation.

· Have a low threshold for providing surfactant to newborns, with clinically significant respiratory distress syndrome.

Newborns <28 weeks gestation

Give surfactant to newborns with RDS who require >/= 30% oxygen in the first 24-48 hours of life.

Surfactant may be given (ideally using a less/minimally invasive technique or INSURE – see section 3) to newborns <28 weeks gestation requiring a PEEP of 7cmH20 or greater with increased work of breathing and chest X-ray evidence of moderate to severe respiratory distress syndrome requiring any amount of oxygen therapy in the first 24 hours of life.

RDS in newborns >/= 28 weeks gestation

As outlined above, providing surfactant to those who require it as early as possible reduces the risk of pneumothorax[5]. An Australian group have shown a reduction in pneumothorax by almost 50% after changing their local guidelines to provide minimally invasive surfactant to newborns requiring a PEEP of >/=7cmH20 and >/=35% oxygen therapy [6]. A reduction in pneumothorax was also demonstrated in a small Canadian randomised control trial (RCT), randomising newborns 32 weeks and older to minimally invasive surfactant once they were requiring a PEEP of >6cmH20 and >35% oxygen [7].

Newborns >/= 28 weeks gestation

Give surfactant to newborns >/= 28 weeks gestation on a PEEP of 7cmH20 or greater, with increased work of breathing and CXR evidence of moderate to severe respiratory distress syndrome in >/= 30% oxygen in the first 24-48 hours of life.

Surfactant may be given to newborns with severe increased work of breathing and a chest X-ray (CXR) consistent with severe RDS requiring any amount of oxygen therapy.

Meconium aspiration syndrome (MAS)

Meconium aspiration syndrome can lead to surfactant inactivation. There have been two meta-analyses examining the role of surfactant in MAS; one demonstrating a reduction in duration of ventilation and hospital stay without reduction in mortality or pneumothorax[8] and the other showing a reduction in the need for extra-corporeal membrane oxygenation[9].

Consider administering surfactant to newborns who require ventilation for MAS

Pulmonary haemorrhage and Pneumonia

There is some evidence to support that the presence of pulmonary haemorrhage and pneumonia lead to surfactant inactivation [10, 11]. In a small trial, surfactant administration was shown to improve oxygenation in newborns with pneumonia[12]. There is limited evidence for the use of surfactant in newborns with pulmonary haemorrhage, although some observations studies have reported an apparent short term clinical benefit in ventilatory index[13].

Consider giving surfactant to ventilated newborns with severe respiratory failure in the context of pulmonary haemorrhage or pneumonia, recognising there is limited evidence to support this practice.


Section 2 – Which surfactant

When the initial dose of poractant is >100mg/kg, there is some evidence that the use of poractant results in less death or chronic lung disease and a reduction in the requirement for a second dose of surfactant when compared to beractant [14]. There was no comparison between dose equivalent poractant and beractant in the meta-analysis and there was a moderate risk of bias in included studies. A more recent RCT has not shown any advantage to the use of poractant over beractant[15]. Consider the cultural values of families when choosing which surfactant to administer (Curosurf is porcine and Survanta is bovine).

For infants <28 weeks use poractant (Curosurf)

For infants >/=28 weeks use beractant (Survanta)

Repeated dosing in respiratory distress syndrome

Consider giving repeated doses (second or third dose)[16] of surfactant in newborns with ongoing increased work of breathing and an oxygen requirement of >/= 30% oxygen.

6-12 hours - Consider repeated dosing 6 hours after the first dose in newborns who require continued mechanical ventilation and are unable to be extubated secondary to respiratory distress syndrome

12 hours - Consider repeated dosing after 12 hours in newborns who remain on CPAP in >30% oxygen.

Dosing of surfactant:

Please refer to NICU drug manual (Curosurf (poractant) and Survanta (beractant))


Section 3 – Method of administration

Intubation and ventilation

Newborns who require intubation and ventilation for the purposes of: resuscitation, apnoea, sepsis, hydrops, severe anaemia or severe respiratory acidosis, should receive surfactant via an endotracheal tube (ETT) and remain ventilated until they demonstrate that they can be extubated based on clinical parameters.

Refer to Attachment 1 for a step by step guide to performing this procedure.

Intubation, surfactant treatment then rapid extubation (INSURE)

The INSURE method aims to keep newborns on non-invasive support and has been shown to reduce the need for mechanical ventilation when compared to intubation and ventilation and showed a trend towards less air leak and chronic lung disease[17].

· Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsis may not be good candidates for INSURE as they are likely to require ventilatory support rather than just surfactant.

Refer to Attachment 2 for a guide to performing INSURE.

Surfactant administration via a thin catheter (LISA/MIST)

LISA and MIST techniques aim to provide surfactant to a spontaneously breathing newborn on CPAP via a thin catheter without delivering positive pressure breaths. The use of premedication is controversial.

When compared to INSURE, LISA has been shown to reduce the composite outcome of death or chronic lung disease, reduce chronic lung disease among survivors[18] and reduce the need for mechanical ventilation[19].

When compared to intubation and ventilation, LISA resulted in a reduction in pneumothorax and severe intra-ventricular haemorrhage in newborns <27 weeks gestation [20].

Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsis may not be good candidates for thin catheter surfactant.

Refer to Attachment 3 for further information.

We recommend giving surfactant either via INSURE or thin catheter depending on patient need and clinician preference. We recommend avoiding positive pressure ventilation in a spontaneously breathing newborn, even when administering surfactant via an ETT.

Only use INSURE or thin catheter surfactant in a patient who requires surfactant rather than ventilation. Do not use either of these methods in a rapidly deteriorating patient with respiratory failure needing lung recruitment using positive pressure or support on a ventilator.

The decision regarding how to administer surfactant should be made in consultation with the fellow/consultant on call


Section 4 – Respiratory management after surfactant administration

Surfactant administration leads to rapid changes in lung compliance.

It is common to need a slightly higher peak inspiratory pressure, oxygen and inspiratory time in the minutes following surfactant administration. It’s important to carefully monitor clinical response to a surfactant bolus and modify ventilation settings accordingly. After a few minutes, lung compliance improves, and it becomes necessary to wean peak inspiratory pressure and oxygen in order to maintain normal tidal volumes and saturation targets. Aim to maintain a tidal volume of 4-6ml/kg.

Aim to manage newborns with respiratory distress syndrome who require surfactant on volume targeted ventilation when able and review them every 15 minutes in the first hour after surfactant administration.


Implementation

This guideline will be discussed at relevant clinical and management meetings. This guideline has previously been discussed and reviewed by our clinician team. Its use will be audited after it has been implemented as part of a clinical practice improvement project aimed at reducing the incidence of pneumothorax and as part of standard benchmarking performed routinely in NICU for preterm infants.


Related Policies, Procedures, Guidelines and Legislation

Policies

· Medication Handling

· Consent and Treatment

· Patient Identification and Procedure Matching

Procedures

Neonatal Routine Care

Pulse Oximetry Screening – Neonates

Care of the Extremely Preterm and Low Birth Weight Baby – The Golden Hour

Patient Identification and Procedure Matching

Vital Signs and Early Warning Scores

Guidelines

Management of Neonatal Pneumothorax

Birth Requiring the Presence of a Neonatal Team Member

Legislation

· Health Records (Privacy and Access) Act 1997

· Human Rights Act 2004

· Work Health and Safety Act 2011


References

1. Seger N, Soll R. Animal derived surfactant extract for treatment of respiratory distress syndrome. Cochrane Database Syst Rev. 2009(2):CD007836. doi:10.1002/14651858.CD007836.

2. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics. 2011;128(5):e1069-76. doi:10.1542/peds.2010-3848.

3. Network SSGotEKSNNR, Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med. 2010;362(21):1970-9. doi:10.1056/NEJMoa0911783.

4. Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012(3):CD000510. doi:10.1002/14651858.CD000510.pub2.

5. Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev. 2012;11:CD001456. doi:10.1002/14651858.CD001456.pub2.

6. Dargaville PA, Ali SKM, Jackson HD, Williams C, De Paoli AG. Impact of Minimally Invasive Surfactant Therapy in Preterm Infants at 29-32 Weeks Gestation. Neonatology. 2018;113(1):7-14. doi:10.1159/000480066.

7. Olivier F, Nadeau S, Belanger S, Julien AS, Masse E, Ali N et al. Efficacy of minimally invasive surfactant therapy in moderate and late preterm infants: A multicentre randomized control trial. Paediatr Child Health. 2017;22(3):120-4. doi:10.1093/pch/pxx033.

8. Natarajan CK, Sankar MJ, Jain K, Agarwal R, Paul VK. Surfactant therapy and antibiotics in neonates with meconium aspiration syndrome: a systematic review and meta-analysis. J Perinatol. 2016;36 Suppl 1:S49-54. doi:10.1038/jp.2016.32.

9. El Shahed AI, Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term and late preterm infants. Cochrane Database Syst Rev. 2014(12):CD002054. doi:10.1002/14651858.CD002054.pub3.

10. Jasani B, Kabra N, Nanavati R. Surfactant Replacement Therapy Beyond Respiratory Distress Syndrome in Neonates. Indian Pediatr. 2016;53(3):229-34.

11. Polin RA, Carlo WA, Committee on F, Newborn, American Academy of P. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014;133(1):156-63. doi:10.1542/peds.2013-3443.

12. Tan K, Lai NM, Sharma A. Surfactant for bacterial pneumonia in late preterm and term infants. Cochrane Database Syst Rev. 2012(2):CD008155. doi:10.1002/14651858.CD008155.pub2.

13. Amizuka T, Shimizu H, Niida Y, Ogawa Y. Surfactant therapy in neonates with respiratory failure due to haemorrhagic pulmonary oedema. Eur J Pediatr. 2003;162(10):697-702. doi:10.1007/s00431-003-1276-x.

14. Singh N, Halliday HL, Stevens TP, Suresh G, Soll R, Rojas-Reyes MX. Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2015(12):CD010249. doi:10.1002/14651858.CD010249.pub2.

15. Lemyre B, Fusch C, Schmolzer GM, Rouvinez Bouali N, Reddy D, Barrowman N et al. Poractant alfa versus bovine lipid extract surfactant for infants 24+0 to 31+6 weeks gestational age: A randomized controlled trial. PLoS One. 2017;12(5):e0175922. doi:10.1371/journal.pone.0175922.

16. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update. Neonatology. 2017;111(2):107-25. doi:10.1159/000448985.

17. Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev. 2007(4):CD003063. doi:10.1002/14651858.CD003063.pub3.

18. Aldana-Aguirre JC, Pinto M, Featherstone RM, Kumar M. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2017;102(1):F17-F23. doi:10.1136/archdischild-2015-310299.

19. Lau CSM, Chamberlain RS, Sun S. Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis. Glob Pediatr Health. 2017;4:2333794X17696683. doi:10.1177/2333794X17696683.

20. Kribs A, Roll C, Gopel W, Wieg C, Groneck P, Laux R et al. Nonintubated Surfactant Application vs Conventional Therapy in Extremely Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(8):723-30. doi:10.1001/jamapediatrics.2015.0504.


Search Terms

NICU, Neonatology, Surfactant, MIST, LISA, INSURE, Neonate, Newborn, Pre-term, Baby, Administration, Therapy


Attachments

Attachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newborn

Attachment 2: INSURE technique

Attachment 3: Thin catheter technique

Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

30/10/2019

New Document

Tina Bracher, ED WY&C

CHS Policy Committee

This document supersedes the following:

Document Number

Document Name

Attachment 1: Surfactant administration via an endotracheal tube (ETT) in a ventilated newborn

Person performing procedure:

Medical officer and/or nursing staff within their scope of practice

Equipment:

Sterile dressing pack and sterile gloves

Angiocath 16GA

5 or 10 mL sterile syringe, drawing up needle, surfactant

Working Neopuff and suction equipment

Cautions:

Lung compliance may change rapidly following surfactant administration

Watch for signs of pneumothorax

Observe closely and titrate FiO2/Positive inspiratory pressure (PIP) to maintain normal ventilation targets (oxygen saturations of 90-95% and tidal volume of 4-6mL/kg)

Procedure:

1. Ensure the newborn’s parents have had the procedure explained to them if able depending on the acuity of the situation. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.

2. Warm surfactant prior to administration as this makes it more effective (to body/room temperature)

3. Check the newborn’s neopuff is set appropriately and the suction is working

4. Check the ETT position on a recent chest X-ray and ensure that there is equal air entry/ an ETT above the carina both clinically and on X-ray.

5. Suction the newborn airways prior to the procedure

6. Open dressing pack, sterile angiocath and syringe onto the sterile field, maintaining asepsis

7. Wash hands and don sterile gloves

8. Remove the needle from the angiocath and place it in a sharps bin

9. Draw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringe)

10. Connect the surfactant syringe to the angiocath

11. Disconnect the newborn from the ventilator

12. Place the angiocath in the ETT

13. Administer the surfactant slowly into the angiocath via ETT over 20-30 seconds

14. Reconnect the ventilator to the newborn

15. The medical officer and nurse caring for the newborn will need to carefully monitor the need for increases and decreases in ventilation parameters, as lung compliance changes. Target normal oxygen saturations and a tidal volume of 4-6 mL/kg.

16. Avoid suctioning the newborn for at least 1 hour after the procedure where possible to avoid removing surfactant from the lungs.

17. Document the procedure in the newborns clinical record.

Attachment 2: INSURE technique

Person performing technique:

Medical officer within their scope of practice

Equipment:


Angiocath 16GA

5 or 10 mL sterile syringe and drawing up needle, surfactant

Working Neopuff and suction equipment

Intubation equipment including ETT and laryngoscope, airway adjuncts, stethoscope, CO2 detector

Atropine available

Cautions:



Observe closely and titrate Fio2

Intubation may cause a vagal response. Have atropine available.

Exclusion criteria:

· Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsis

· Newborns who are deteriorating rapidly and have lung de-recruitment requiring invasive ventilation

Procedure:

1. Ensure the newborn’s parents have had the procedure explained to them and consent has been obtained for the procedure. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.

2. Warm surfactant prior to administration as this makes it more effective

3. Prepare equipment for intubation. Avoid using intubation drugs where possible. If the newborn is distressed during the procedure, they may require analgesia/intubation drugs. Discuss this with the fellow/consultant on call.

4. Set the neopuff to a PIP/PEEP of 20/6 and an FiO2 appropriate to the newborns’ condition

5. Check suction equipment is working

6. Remove the CPAP and place the newborn on the neopuff

7. Swaddle the newborn and provide sucrose

8. Intubate the newborn, ensuring that the ETT is positioned above the carina (good bilateral air entry clinically and an ETT that is at the expected depth of insertion for age/size)

9. Draw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringe)

10. Place the angiocath in the ETT

11. Administer the surfactant slowly into the angiocath via ETT over 20-30 seconds

12. Where possible allow the newborn to breath in the surfactant over approximately 15-20 seconds

13. Place newborn directly back on CPAP via the ETT and avoid giving positive pressure ventilation if able. You may need to increase the FiO2 or the PEEP to aid recovery. Only provide positive pressure ventilation if the newborn is apnoeic and desaturating.

14. Aim to extubate within 5 minutes of surfactant administration, if the newborn is breathing spontaneously and has saturations within the target range, without a significantly increased Fio2 >20% from baseline

15. Place the newborn directly back on CPAP and observe their clinical status closely.


Attachment 3: Thin catheter technique

Person performing technique:

Medical officer within their scope of practice

Equipment:


Angiocath 16GA

Lip liner pencil

5 or 10 mL sterile syringe, drawing up needle, surfactant

Working neopuff and suction equipment

Intubation equipment including ETT and laryngoscope, airway adjuncts, stethoscope, CO2 detector

Hudson CPAP prongs appropriate to newborn size. These are the only brand that allow intubation of the cords without removal of the prongs.

Atropine available

Cautions:



Observe closely and titrate FiO2

Intubation may cause a vagal response. Have atropine available.

Exclusion criteria:

· Newborns with significant apnoea, those who receive extensive resuscitation at birth and those with associated medical problems such as hydrops, anaemia or sepsis

· Newborns who are deteriorating rapidly and have lung de-recruitment requiring invasive ventilation

Procedure:

1. Ensure the newborn’s parents have had the procedure explained to them and consent has been obtained for the procedure. Confirm the newborn’s identity as per the Patient Identification and Procedure Matching procedure.

2. Warm surfactant to body or room temperature prior to administration as this makes it more effective

3. Set the Neopuff to a PIP/PEEP of 20/6 and FiO2 appropriate to the newborns ’s condition

4. Check the suction equipment is working

5. Ensure intubation equipment and atropine are available, in case of an acute deterioration during the procedure.

6. Place the newborn on Hudson prong CPAP

7. Swaddle the newborn and provide sucrose

8. Open dressing pack, sterile angiocath and syringe onto the sterile field, maintaining asepsis

Wash hands and don sterile gloves

Mark the insertion depth, based on the newborns weight, on the thin catheter using a lip liner (distance from the tip to the insertion point):

a. <1000g = 1.5cm

b. 1000-2000g = 2.0 cm

c. 2000-3000g = 2.5cm

d. >3000g = 3cm

9. Introduce a slight curve to the catheter at the desired insertion depth

18. Draw up the surfactant into the syringe, ensuring there is an additional 2mL of air in the syringe (to facilitate flushing all surfactant out of the syringe

10. Using a laryngoscope, insert the thin catheter to the desired depth (see above).

11. Remove the laryngoscope whilst anchoring the thin catheter in situ

12. Connect the surfactant to the catheter and administer the surfactant in 3-4 boluses over 15-20 seconds.

13. Remove the thin catheter and continue CPAP

14. If catheterisation of the trachea is not possible within 20–30 seconds, remove the laryngoscope and allow recovery on CPAP before attempting tracheal catheterisation again.

15. Consider abandoning the procedure after three unsuccessful attempts


Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHS19/194

1

04/12/2019

01/11/2022

WY&C - NICU

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Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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