ANZCOR Guideline Update

ANZCOR Guideline Update: Tracheal Intubation and Ventilation of the Newborn (Guideline 13.5)

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The Australian and New Zealand Committee on Resuscitation (ANZCOR) has released an updated version of Guideline 13.5 – Tracheal Intubation and Ventilation of the Newborn, current as of 6 February 2026.

This guideline supports clinicians involved in neonatal resuscitation, particularly in environments where advanced airway equipment and medications are available (such as hospitals).

This update improves alignment with contemporary neonatal resuscitation evidence, including Neonatal Life Support 2020, ILCOR CoSTR recommendations, and the 2020 AHA Guidelines.

Key Changes and Practical Takeaways

1) Clearer decision-making for when to intubate

The guideline reinforces that the decision to perform tracheal intubation depends on multiple factors including:

  • gestation and degree of respiratory depression

  • response to facemask or supraglottic ventilation

  • skill and experience of the resuscitator

Importantly, preterm gestation or very low birth weight should not be the only factor driving the decision to intubate.

The guideline also highlights situations where intubation should be considered early, including:

  • unsuccessful or prolonged facemask (or supraglottic) ventilation

  • congenital diaphragmatic hernia

  • extremely low birth weight

  • newborns born without a detectable heartbeat

2) Endotracheal tube (ETT) size guidance is reinforced

The guideline restates a practical approach to selecting ETT internal diameter:

  • 2.5 mm for infants <1 kg

  • 3.0 mm for infants 1–2 kg

  • 3.5 mm for infants 2–3 kg

  • 3.5–4.0 mm for infants >3 kg

It also includes the gestational age formula:
ETT size (mm) ≈ gestational age (weeks) ÷ 10.

3) More precise ETT depth recommendations

The guideline continues to provide a simple estimation formula:

Depth (cm) = weight (kg) + 6

However, it emphasises that a gestation-and-weight table is likely to be more precise, especially for:

  • extremely low birth weight infants

  • preterm infants after the newborn period

The table provides recommended ETT lip markings (to the nearest 0.5 cm), ranging from 5.5 cm at 23–24 weeks to 9.0 cm at 41–43 weeks.

4) Stronger emphasis on confirming tube placement

The guideline reinforces that effectiveness of ventilation via an ETT should be confirmed using the following sequence:

  1. chest movement with each inflation

  2. heart rate increases to >100 bpm

  3. oxygen saturation improves

If chest movement is absent and heart rate does not rise, tube position and technique must be reassessed.

It also reinforces the role of a colourimetric CO₂ detector as the most reliable method for confirming ETT placement in neonates who have spontaneous circulation.

The guideline includes practical cautions:

  • false negatives may occur with very low pulmonary blood flow

  • false positives may occur if the device is contaminated with adrenaline (epinephrine) or surfactant

5) Flow/volume monitoring is not recommended routinely

Although monitoring devices can improve mask ventilation performance in simulation settings, ANZCOR advises there is currently insufficient evidence of clinical benefit to support routine use of:

  • flow and volume monitoring

  • end-tidal CO₂ monitoring

during newborn resuscitation.

6) Supraglottic airway guidance remains, with clear thresholds

ANZCOR suggests that a supraglottic airway should be considered in:

  • term and near-term newborns (>34 weeks, approximately ≥2000 g)

  • when facemask ventilation is unsuccessful

It also highlights supraglottic airway use as an alternative when:

  • facemask ventilation fails

  • intubation is unsuccessful or not feasible

A size 1 supraglottic airway is considered suitable for newborns up to 5 kg.

Why this update matters

Neonatal airway management is a high-risk, time-critical skill. This update improves clinical clarity in several areas, including:

  • when to escalate to intubation

  • practical ETT sizing and depth guidance

  • structured confirmation of placement

  • appropriate use of supraglottic airways

  • consistent terminology aligned with GRADE methods

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Training implications

For clinicians and educators delivering neonatal resuscitation training, the most important takeaways are:

  • intubation decisions must be based on ventilation response and clinical trajectory, not gestation alone

  • tube depth should be verified using both markings and a structured method (formula or table)

  • CO₂ detection is valuable but must be interpreted cautiously in low-flow states

  • supraglottic airways remain a key rescue option in near-term and term newborns

Reference

ANZCOR. Guideline 13.5 – Tracheal Intubation and Ventilation of the Newborn, accessed 6 February 2026.

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