Equipment should be tested prior to intubation. Magill forceps, appropriate-sized blade, and tube should be available. Efficient suction and a hand ventilation device – if possible with positive end expiratory pressure – supplied with oxygen should be readily available. Preoxygenation is usually recommended, although no trial ever evaluated it in newborns. However, the weight of experience from anesthesiology and the rapid occurrence of hypoxia in apneic infants (Patel et al. 1994) strongly support this practice. In the preterm infant, oxygen can have deleterious effects, especially causing retinopathy, and we do not recommend prolonged preoxygenation in this population. Experience is determinant in the success of the procedure for intubation in the delivery room (O’Donnell et al. 2006), but the use of a muscle relaxant in addition to a fast-acting opioid for nonemergent intubation has been reported as a facilitating factor for non-experienced personnel (Dempsey et al. 2006).

Both oral and nasal route can be used for intubation. A meta-analysis including only two randomized controlled trials concluded that neither route was superior to the other and that complications were comparable for both techniques (Spence and Barr 2000). Common sense certainly supports the use of the route the operator is most familiar with. However, a recent study evaluating intubation time in newborn mannequin for training found a significant reduction in intubation time when the oral route was used (Lenclen et al. 2009).

A recent review on the use of premedication prior to intubation concluded that “Tracheal intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or other life-threatening situations when intravenous access is unavailable” (Carbajal et al. 2007). In addition, recent recommendations from the American Academy of Pediatrics support the use of a premedication for nonemergent intubations (Kumar et al. 2010). Still, the most appropriate drug or drugs are still unknown. Association of an opioid and a muscle blocker is usually considered a traditional relatively safe and efficient combination (Carbajal et al. 2007; Kumar et al. 2010; Duncan et al. 2001). More recent works have shown that a single drug such as propofol (Ghanta et al. 2007) or remifentanil (Welzing et al. 2009) might be as well efficient and safe. Concerning propofol systemic hypotension has been reported in premature infants (Papoff et al. 2008; Welzing et al. 2010). However, these new protocols require careful clinical evaluation through large randomized controlled trials assessing long-term outcomes.