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Attended Delivery of Neonate with Difficult Airway (EXIT Procedure)

last modified on: Fri, 08/25/2023 - 16:23

See: Pediatric Airway


  • Attended delivery: Surgical team should be present at delivery and ready to intervene off placental support (Puricelli 2020)

  • Delivery on placental support: Delivery on placental support [ex utero intrapartum treatment (EXIT), operation on placental support (OOPS), vaginal delivery with sustained placental support (VSPS)] (Puricelli 2020)


  • The International Pediatric Otolaryngology Group (IPOG) recommends attended delivery consideration in cases of micrognathia, congenital high airway obstructive syndrome (CHAOS) and fetal head and neck mass. 

  • Other potential indications include mandibular anomaly, mediastinal mass, congenital diaphragmatic hernia, tracheal stenosis/compression, skeletal abnormality and pulmonary airway malformation (Puricelli 2020)


  1. Upon diagnosis of anticipated neonatal airway distress, an EPIC order for Oto:OR – Laryngoscopy -> Attended Delivery will be placed in the Mother’s chart.

    1. Oto team coordination should include the Labor and Deliver (L&D) OR, Stead Family Children's Hospital (SFCH) OR, Maternal Fetal Medicine (MFM) fellow, and Neonatal Intensive Care Unit (NICU) fellow

      1. Determination of delivery route and role of surgical delivery is a complex decision making process and needs to involve the patient and all pertinent teams

    2. Discussion should be held RE pediatric otolaryngology staff coverage should the patient develop preterm labor

  2. Once notified of signs/symptoms of labor, the on-call otolaryngology team member should enact the following plan (triggered and listed by EPIC order):

    1. Notify (if not already done): OB/MFM Chief Resident/staff. 

    2. If OB determines that the expectant mother has symptoms of preterm labor or premature rupture of membranes, the MFM staff or OB chief resident should contact the on-call otolaryngology and NICU team members

    3. On-call OTO resident will notify OTO senior resident, Peds OTO fellow and staff.

    4. Delivery with NICU and Oto team present in L&D OR as determined at the time of planning and EPIC order entry.

  3. The on-call otolaryngology team member will work with the Peds OR to gather the following equipment which should be delivered to the Labor and Delivery OR:

    1. Olympus AV tower (as pictured, power button indicated by red arrow)

    2. Peds Emergency airway cart (as pictured, bottom drawer to include Bivona trachs 2.5, 3.0, 3.5)

    3. From SFCH OR 1 – nonsterile Olympus camera, light cord, N20 black camera cord (as pictured)

    4. N20 Olympus bronchoscope from cabinet (as pictured)

    5. (2) Headlights

    6. Glidescope

  4. The children’s OR should also be requested to assess ability to assign pediatric surgical technician and nurse to the procedure

  5. The otolaryngology on-call team member should be sure that the Main OR has been contacted to borrow the Main OR peds emergency airway cart while the Peds OR cart is off the unit

  6. At the time of delivery, a set of progressive steps to securing the neonatal airway includes:

    1. NICU to lead initial resuscitation efforts

      1. Possibly performs first attempt at orotracheal intubation if indicated

      2. This is typically performed without medications as NICU routine

      3. NICU to obtain IM medications for surgical airway if indicated

    2. Peds otolaryngology would then take over, and proceed with one or more of the following:

      1. Glidescope/CMAC intubation (CMAC video screen and intubating blade pictured; also pictured is a CMAC camera adapter compatible with standard Karl Storz rigid and flexible scopes for projecting onto CMAC video screen)

      2. Transnasal fiberoptic intubation using the N20 bronchoscope as demonstrated in included figure from Fuentes et al. and as pictured

      3. Seldinger assisted videotelescopic intubation using rigid telescope through weight appropriate laryngoscope (as pictured)

        1. 2.7 mm scope works with 3-0 tubes (as pictured)

        2. 2.1 mm scope works with 2-5 tubes

      4. Fiberoptic intubation via LMA

        1. N20 bronchoscope

      5. Rigid bronchoscopy for ventilation and subsequent tracheostomy

      6. Bag valve mask ventilation and tracheostomy

    3. Special note regarding surgeon time reimbursement. In the United States, CPT 99360 is applicable in addition to procedural codes for each 30-minute time interval present on standby when another physician documents the request for standby service and no other patient care activities are performed.

      1. Reminder should be given to the OB/MFM team to document in the medical record their request for otolaryngology team standby to facilitate this reimbursement

Equipment Checklist

  1. Resuscitation:

    1. Table to place baby upon

    2. Instrument table 

    3. Sterile (EXIT only) and warm sheets

    4. Baby bag (EXIT only)

    5. Mapleson resuscitation setup

    6. Shoulder Roll

    7. Suction machine

    8. Suction tubing

    9. Flexible and rigid laryngeal suctions

    10. Reflectance pulse oximeter

      1. Normal fetal oxygen ranges from 60-70% and even levels as low as 40% represent adequate oxygenation

      2. Simultaneous fetal echocardiography may be performed

    11. Manometer

    12. EKG scope

    13. IV catheters (24 ga)

    14. IV fluid warmer

    15. Penrose catheter for tourniquet

    16. Oxygen source

    17. Oxygen tubing/canulae

    18. Oral airway

    19. Nasal Airway

    20. Bag valve mask

    21. Intubation capable LMA

    22. Uncuffed ET tubes 2, 2.5, 3, 3.5. x 2 each.

      1. Less than 500 grams/less than 24 weeks: 2.0 endotracheal tube

      2. 500-1000 grams/24-28 weeks: 2.5 endotracheal tube

      3. 1000-2000 grams/28-34 weeks: 3.0 endotracheal tube

      4. 2000-3000 grams/34-38 weeks: 3.5 endotracheal tube

    23. Armored endotracheal tubes if concern for compression

    24. Stylet x 2

    25. Capnography indicator

    26. Equipment for needle pneumothorax decompression

    27. Medications: ketamine and dexmetaodomidine

      1. Muscle relaxant (example vecuronium 0.1-0.4 mg/kg), analgesic (example fentanyl 5-15 mcg/kg), and anticholinergic medications (example atropine 20 mcg/kg)

      2. Low and high dose epinephrine

      3. O negative blood

  2. Video Laryngoscope:

    1. Video monitor

    2. Selection of straight and curved neonatal blades

  3. Operative laryngoscopy:

    1. Weight appropriate intubation laryngoscope(s) (Examples: Karl Storz, Parsons, Holinger-Benjamin, Benjamin-Lindholm)

    2. Light source

    3. Light cord

    4. Laryngeal suction

    5. Small Magill

    6. Sickle knife

  4. Intubation using a rigid telescope as a stylet (Seldinger assisted videotelescopic intubation):

    1. For endotracheal tubes size 2, 2.5, 3

    2. 2.1 mm telescope (size 2.5 endotracheal tube)

    3. 2.7 mm telescope (size 3 endotracheal tube)

    4. Defog

    5. Light source

    6. Light cable

    7. Video camera

    8. Video monitor

  5. Rigid ventilating bronchoscopes:

    1. Size 2.5 and 3 (size 2 is available in some countries)

    2. Appropriately sized telescopes

    3. Bridge(s)

    4. Ventilation accordion/adaptor

    5. Suction port adaptor and rubber seal

    6. Light prism

    7. Light source

    8. Light cables

    9. Flexible suction tubing

    10. Rigid suction

    11. Video camera

    12. Video monitor

    13. Topical patties

    14. Defog

  6. Transnasal fiberoptic intubation/Intubation through LMA/bronchoscopy if ventilation difficulty:

    1. 2.2 mm flexible laryngoscope/bronchoscope (2.5 and 3.0 endotracheal tubes)

    2. 2.8 mm flexible laryngoscope/bronchoscope (3.5 endotracheal tube)

    3. Video camera

    4. Video monitor

    5. Light cable

    6. Light Source

    7. Defog

  7. Tracheostomy:

    1. Tracheostomy instrument tray (including scalpel blade)

    2. Tracheostomy tubes 2.5, 3, 3.5 cuffed

    3. Headlight x2

    4. Cautery machine

    5. Cautery pad

    6. Bipolar forceps (with cord)

    7. 3 ml syringe with small needle for topical injection

    8. Neck skin prep solution and 4x4 package

    9. Sterile gowns

    10. Sterile gloves

    11. Sterile towels

    12. Skin marker

    13. Suction tubing

    14. Suction

    15. Gauze

    16. Kittners

    17. 3 ml syringe for aspiration with various needle sizes

    18. Small nasal speculum/trach spreader

    19. Sutures (stay, maturation, faceplate per surgeon preference)

    20. Lubricant

    21. Irrigation

    22. Drugs: lidocaine with epinephrine, afrin, lidocaine plain

    23. Flexible laryngoscope/bronchoscope to confirm position with light and camera

    24. Foam dressing, trach tie


Cash H, Bly R, Masco V, Dighe M, Cheng E, Delaney S, Ma K, Perkins JA. Prenatal Imaging Findings Predict Obstructive Fetal Airways Requiring EXIT. Laryngoscope. 2020 Aug 8. doi: 10.1002/lary.28959. Epub ahead of print. PMID: 32770766.

Puricelli MD, Rahbar R, Allen GC, Balakrishnan K, Brigger MT, Daniel SJ, Fayoux P, Goudy S, Hewitt R, Hsu WC, Ida JB, Johnson R, Leboulanger N, Rickert SM, Roy S, Russell J, Rutter M, Sidell D, Soma M, Thierry B, Trozzi M, Zalzal G, Zdanski CJ, Smith RJH. International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction. Int J Pediatr Otorhinolaryngol. 2020 Nov;138:110281. doi: 10.1016/j.ijporl.2020.110281. Epub 2020 Aug 8. PMID: 32891939.

Fuentes R, De la Cuadra JC, Lacassie H, González A. Intubação traqueal difícil com fibra óptica em bebê de um mês de idade com síndrome de Treacher Collins [Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome]. Braz J Anesthesiol. 2018 Jan-Feb;68(1):87-90. doi: 10.1016/j.bjan.2015.09.008. Epub 2016 Sep 28. PMID: 27692368; PMCID: PMC9391677.