Iowa Neonatology Fellows
Revised: John Dagle MD, PhD
Peer Review Status: Internally Peer Reviewed


  • Provide airway for mechanical ventilatory support.
  • Administration of surfactants or other medications directly into the lungs.
  • Relieve critical upper airway obstruction.
  • Provide route for selective bronchial ventilation.
  • Assist in pulmonary hygiene when secretions cannot be otherwise cleared.
  • Obtain direct tracheal cultures.

The correct endotracheal tube (ETT) size and length of insertion (tip to lip distance) can be estimated from the infant's weight.

Correct endotracheal tube (ETT) size and length of insertion table
Weight ETT Depth of Insertion (cm)
1 kg 2.5 7
2 kg 3.0 8
3 kg 3.5 9
4 kg 4.0 Add 1 cm for each additional kg of body weight.
Insertion Depth (cm) = 6 + wt (kg)

The tube should not fit tightly between the vocal cords in order to minimize upper airway trauma.

In most cases an infant can be adequately ventilated by bag and mask so that endotracheal intubation can be done as a controlled procedure. The ONE IMPORTANT EXCEPTION is in cases of known or suspected congenital diaphragmatic hernia.

Preparation is important to performing successfully. Check availability of following equipment prior to procedure - suction, laryngoscope with functioning light source, appropriate laryngoscope blade size (Miller 0 or Miller 1), supply of ETTs, CO2 detector, stethoscope, tape and adhesive. Premedication of the infant (sedation and analgesia) should be considered in all cases of elective intubations.


  • Prior to attempting the insertion of an ETT and as indicated by clinical condition, one should ventilate the infant with bag and mask using 80-100% oxygen. If unable to insert the ETT within 30 seconds, ventilate the infant again for 30-60 seconds before reattempting intubation.
  • Infant's head should be slightly extended (in the sniffing position) with the body aligned straight.
  • The laryngoscope is held with the left hand. Pushing down gently on the larynx with the fifth finger of the left hand (or having an assistant do it) to provide slight cricoid pressure may help to visualize the vocal cords. Avoid extreme tension or tilt of the laryngoscope.
  • The ETT is held in the right hand and inserted between the vocal cords so that the tip is 1-2 cm below the vocal cords.
  • Ensure endotracheal position by the use of a CO2 detector- this has become a standard of care. The detector should change color (purple to yellow) by 5-6 breaths.
  • Check tube position by auscultation of the chest (and abdomen) to ensure equal aeration of both lungs and observation of chest movement with positive pressure inflation.
  • Secure ETT with two pieces of 1/4 inch adhesive tape placed on lip and securely around ETT.
  • Verify the position of the ETT by chest x-ray.

Whenever a stylet is used for intubation, be sure that the stylet tip does NOT extend beyond the end of the ETT.

If the infant will require intubation for greater than 10- 14 days, consider the use of a palate plate to prevent formation of a palatal groove. Palate plates can be obtained by requesting a consultation from Pediatric Dentistry.