A randomized trial of stylets for intubating newborn infants

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

OBJECTIVE

To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.

DESIGN

Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS).

SETTING

Eighteen academic NICUs in NEAR4NEOS.

PATIENTS

Neonates requiring two or more attempts at intubation between October 2014 and December 2021.

MAIN OUTCOME MEASURES

The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice.

RESULTS

5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs.

CONCLUSIONS

Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.

A stylet use may be beneficial for elective and rescue intubation of prematurely born infants < 30 weeks

BACKGROUND

Recent studies have reported that using a stylet does not provide any advantages during intubation within a diverse infant population. Our research focuses on the issue, specifically in premature infants who undergo elective or rescue intubation (EI or RI) in the delivery room (DR).

METHODS

We conducted a single-center retrospective observational study comparing the number of intubation attempts, the duration of intubation procedure until successful, and the rate of associated desaturations exceeding 20%. We derived outcomes from video recordings and performed statistical analyses.

RESULTS

We have analyzed 104 intubation attempts in 70 infants with a mean gestational age and birth weight of 25±1.9 weeks and 736±221 grams, respectively; 39 of these attempts involved stylet use, and 65 did not. 75% of infants requiring intubation were less than 26 weeks of gestational age. The use of a stylet increased the rate of successful initial attempts [OR (95% CI) 4.3 (1.3-14.8), P=0.019], reduced the duration of the intubation procedure [median (IQR) seconds: 43 (30-72) vs 140 (62-296), P<0.001], and decreased the occurrences of desaturation exceeding 20% (13% vs 50%, P=0.003).

CONCLUSION

The benefits of using a stylet during rescue and elective intubations of premature infants in the delivery room outweigh the potential harms. Its use may be advantageous in settings where proactive approaches are implemented for periviable infants.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Success rates and adverse events during neonatal intubation: Lessons learned from an international registry

Neonatal endotracheal intubation is a challenging procedure with suboptimal success and adverse event rates. Systematically tracking intubation outcomes is imperative to understand both universal and site-specific barriers to intubation success and safety. The National Emergency Airway Registry for Neonates (NEAR4NEOS) is an international registry designed to improve neonatal intubation practice and outcomes that includes over 17,000 intubations across 23 international sites as of 2023. Methods to improve intubation safety and success include appropriately matching the intubation provider and situation and increasing adoption of evidence-based practices such as muscle relaxant premedication and video laryngoscope, and potentially new interventions such as procedural oxygenation.

Predictors of extubation outcomes among extremely and very preterm infants: a retrospective cohort study

OBJECTIVE

To explore the clinical or sociodemographic predictors for both successful and failed extubation among Chinese extremely and very preterm infants METHODS: A retrospective cohort study was carried out among extremely and very preterm infants born at less than 32 weeks of gestational age (GA).

RESULTS

Compared with the infants who experienced extubation failure, the successful infants had higher birth weight (OR 0.997; CI 0.996-0.998), higher GA (OR 0.582; 95% CI 0.499-0.678), a caesarean section delivery (OR 0.598; 95% CI 0.380-0.939), a higher five-minute Apgar score (OR 0.501; 95% CI 0.257-0.977), and a higher pH prior to extubation (OR 0.008; 95% CI 0.001-0.058). Failed extubation was associated with older mothers (OR 1.055; 95% CI 1.013-1.099), infants intubated in the delivery room (OR 2.820; 95% CI 1.742-4.563), a higher fraction of inspired oxygen (FiO₂) prior to extubation (OR 5.246; 95% CI 2.540-10.835), higher partial pressure of carbon dioxide (PCO₂) prior to extubation (OR 7.820; 95% CI 3.725-16.420), and higher amounts of lactic acid (OR 1.478;95% CI 1.063-2.056).

CONCLUSIONS

Higher GA, higher pre-extubation pH, lower pre-extubation FiO₂ and PCO, and lower age at extubation are significant predictors of successful extubation among extremely and very preterm infants.

The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study

Objectives

To investigate whether the use of adjuncts such as stylet, railroaded bougie, and preloaded bougie increases first‐pass success rate and decreases time to successful intubation when intubating simulated infant airways using direct laryngoscopy.

Methods

A crossover study using experienced practitioners (who were required to carry out emergency pediatric intubations as part of their usual practice) was completed. Participants completed a random sequence of 4 intubations in simulated “easy” airways and 4 intubations in simulated “difficult” airways, using naked endotracheal tube, stylet, railroaded bougie, and preloaded bougie on standardized infant airway manikins. First‐pass success rates and times to successful intubations were measured.

Results

From June 1 to December 30, 2019, 109 participants performed a total of 872 intubation attempts. In the easy airway, both naked endotracheal tube (mean 96.3% [95% confidence interval 90.9%–99.0%]) and stylet (mean 98.2% [95% confidence interval 93.5%–99.8%]) had higher first‐pass success rates than railroaded bougie and preloaded bougie. In the difficult airway, stylet (mean 76.1% [95% confidence interval 67.0%–83.8%]) had the highest first‐pass success rate, followed by the naked endotracheal tube, and then both the railroaded bougie and preloaded bougie. Differences in first‐pass success rates were independent of the participants’ numbers of previous pediatric intubations.

Conclusion

Results of this simulation‐based study suggest that stylet should be used as the first attempt technique for infant intubations regardless of the presence or absence of predicted airway difficulty. This finding needs further validation using alternative models and in non‐simulation settings.

Respiratory setback associated with extubation failure in extremely preterm infants

BACKGROUND AND OBJECTIVES

Extubation failure in preterm infants is associated with an increased risk of mortality and morbidity. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status.

METHODS

This was a retrospective study of infants with birth weight ≤ 1250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score (RSS), and ventilation index (VI) were used to assess the respiratory status of infants.

RESULTS

Out of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77%, and 56% infants remained intubated at 24 h, 72 h, and 7 days, respectively. Respiratory status was worse at 24 and 72 h after re-intubation when compared to pre-extubation levels. The median times for RSS and VI to reach pre-extubation levels were 4 and 7 days, respectively.

CONCLUSION

Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.

Endotracheal Intubation in a Difficult Neonatal Airway: A Case Report of a 16-Gauge Intravenous Catheter for Use as an Intubating Stylet

Neonatal airways present unique management challenges that can be compounded by limitations of an underresourced facility. While little clinical data exist on the safety and efficacy of stylet use, they are commonly utilized to facilitate endotracheal intubation in neonates and anticipated difficult airways. As pediatric airway equipment is often understocked in hospitals, innovative thinking can provide creative solutions to these shortages. We present the use of a 16-gauge intravenous catheter as an intubating stylet for a 2.0-millimeter endotracheal tube in the management of a difficult airway in the neonatal intensive care unit.

Augmented Reality-Assisted Video Laryngoscopy and Simulated Neonatal Intubations: A Pilot Study

BACKGROUND

For novice providers, achieving competency in neonatal intubation is becoming increasingly difficult, possibly because of fewer intubation opportunities. In the present study, we compared intubation outcomes on manikins using direct laryngoscopy (DL), indirect video laryngoscopy (IVL) using a modified disposable blade, and augmented reality-assisted video laryngoscopy (ARVL), a novel technique using smart glasses to project a magnified video of the airway into the intubator's visual field.

METHODS

Neonatal intensive care nurses (n = 45) with minimal simulated intubation experience were randomly assigned (n = 15) to the following 3 groups: DL, IVL, and ARVL. All participants completed 5 intubation attempts on a manikin using their assigned modalities and received verbal coaching by a supervisor, who viewed the video while assisting the IVL and ARVL groups. The outcome and time of each attempt were recorded.

RESULTS

The DL group successfully intubated on 32% of attempts compared to 72% in the IVL group and 71% in the ARVL group (P < .001). The DL group intubated the esophagus on 27% of attempts, whereas there were no esophageal intubations in either the IVL or ARVL groups (P < .001). The median (interquartile range) time to intubate in the DL group was 35.6 (22.9-58.0) seconds, compared to 21.6 (13.9-31.9) seconds in the IVL group and 20.7 (13.2-36.5) seconds in the ARVL group (P < .001).

CONCLUSIONS

Simulated intubation success of neonatal intensive care nurses was significantly improved by using either IVL or ARVL compared to DL. Future prospective studies are needed to explore the potential benefits of this technology when used in real patients.

Associations of Stylet Use during Neonatal Intubation with Intubation Success, Adverse Events, and Severe Desaturation: A Report from NEAR4NEOS

INTRODUCTION

Intubations are frequently performed procedures in neonatal intensive care units (NICU) and delivery rooms (DR). Unsuccessful first attempts are common as are tracheal intubation-associated events (TIAEs) and severe desaturations. Stylets are often used during intubation, but their association with intubation outcomes is unclear.

OBJECTIVE

To compare intubation success, rate of relevant TIAEs, and severe desaturations in neonates intubated with and without stylets.

METHODS

Tracheal intubations of neonates in the NICU or DR from 16 centers between October 2014 and December 2018, performed by neonatology or pediatric providers, were collected from the NEAR4NEOs international registry. Primary oral intubations with a laryngoscope were included in the analysis. First-attempt success, the occurrence of relevant TIAEs, and severe oxygen desaturation (≥20% saturation drop from baseline) were compared between intubations performed with versus without a stylet. Logistic regression with generalized estimate equations was used to control for covariates and clustering by sites.

RESULTS

Out of 5,292 primary oral intubations, 3,877 (73%) utilized stylets. Stylet use varied considerably across the centers with a range between 0.5 and 100%. Stylet use was not associated with first-attempt intubation success, esophageal intubation, mainstem intubation, or severe desaturations after controlling for confounders. Patient size was associated with these outcomes and much more predictive of success.

CONCLUSIONS

Stylet use during neonatal intubation was not associated with higher first-attempt intubation success, fewer relevant TIAEs, or less severe desaturations. These data suggest that stylets can be used based on individual preference, but stylet use may not be associated with better intubation outcomes.

Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis

CONTEXT

The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF).

OBJECTIVE

To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF.

DATA SOURCES

Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019.

STUDY SELECTION

Studies were selected by pairs of independent reviewers in 2 stages.

DATA EXTRACTION

Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome.

RESULTS

Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome.

LIMITATIONS

The certainty of evidence was low for survival at discharge and very low for all other outcomes.

CONCLUSIONS

For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning.

PROSPERO

CRD42019122778.

CLINICAL TRIALS REGISTRATION

PROSPERO; CRD42019122778.

Adding value to core outcome set development using multimethod systematic reviews

Trials evaluating the same interventions rarely measure or report identical outcomes. This limits the possibility of aggregating effect sizes across studies to generate high-quality evidence through systematic reviews and meta-analyses. To address this problem, core outcome sets (COS) establish agreed sets of outcomes to be used in all future trials. When developing COS, potential outcome domains are identified by systematically reviewing the outcomes of trials, and increasingly, through primary qualitative research exploring the experiences of key stakeholders, with relevant outcome domains subsequently determined through transdisciplinary consensus development. However, the primary qualitative component can be time consuming with unclear impact. We aimed to examine the potential added value of a qualitative systematic review alongside a quantitative systematic review of trial outcomes to inform COS development in neonatal care using case analysis methods. We compared the methods and findings of a scoping review of neonatal trial outcomes and a scoping review of qualitative research on parents', patients', and professional caregivers' perspectives of neonatal care. Together, these identified a wider range and greater depth of health and social outcome domains, some unique to each review, which were incorporated into the subsequent Delphi process and informed the final set of core outcome domains. Qualitative scoping reviews of participant perspectives research, used in conjunction with quantitative scoping reviews of trials, could identify more outcome domains for consideration and could provide greater depth of understanding to inform stakeholder group discussion in COS development. This is an innovation in the application of research synthesis methods.

Neonatal Intubation Practice and Outcomes: An International Registry Study

BACKGROUND AND OBJECTIVES

Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety.

METHODS

We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression.

RESULTS

We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57).

CONCLUSIONS

We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.

Use and perceived safety of stylets for neonatal endotracheal intubation: a national survey

OBJECTIVE

To examine the use and perceived safety of stylets for neonatal intubation in a cohort of providers in the United States.

STUDY DESIGN

A cross-sectional survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine.

RESULT

A total of 640 responses were received. 57% reported using a stylet 'every time' or 'almost every time' they intubated. The preferred stylet bend was a smooth bend of <30 degrees. 71% of respondents believed that stylets were safe. Reported complications from stylet use included tube dislodgement during stylet removal (32%), airway injury with bleeding (9%), and tracheal perforation (2%).

CONCLUSION

Stylet use was common. There was fair consistency on preference for stylet bend and position. Stylet use was believed to be safe, but complications were observed by many respondents. Additional studies are needed to examine the risks and benefits of stylet use during neonatal intubation.

Analysis of unsuccessful intubations in neonates using videolaryngoscopy recordings

OBJECTIVES

Neonatal intubation is a difficult skill to learn and teach. If an attempt is unsuccessful, the intubator and instructor often cannot explain why. This study aims to review videolaryngoscopy recordings of unsuccessful intubations and explain the reasons why attempts were not successful.

STUDY DESIGN

This is a descriptive study examining videolaryngoscopy recordings obtained from a randomised controlled trial that evaluated if neonatal intubation success rates of inexperienced trainees were superior if they used a videolaryngoscope compared with a laryngoscope. All recorded unsuccessful intubations were included and reviewed independently by two reviewers blinded to study group. Their assessment was correlated with the intubator's perception as reported in a postintubation questionnaire. The Cormack-Lehane classification system was used for objective assessment of laryngeal view.

RESULTS

Recordings and questionnaires from 45 unsuccessful intubations were included (15 intervention and 30 control). The most common reasons for an unsuccessful attempt were oesophageal intubation and failure to recognise the anatomy. In 36 (80%) of intubations, an intubatable view was achieved but was then either lost, not recognised or there was an apparent inability to correctly direct the endotracheal tube. Suctioning was commonly performed but rarely improved the view.

CONCLUSIONS

Lack of intubation success was most commonly due to failure to recognise midline anatomical structures. Trainees need to be taught to recognise the uvula and epiglottis and use these landmarks to guide intubation. Excessive secretions are rarely a factor in elective and premedicated intubations, and routine suctioning should be discouraged. Better blade design may make it easier to direct the tube through the vocal cords.

Retrospective Consent in a Neonatal Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

The requirement for prospective consent in clinical trials in acute settings may result in samples unrepresentative of the study population, potentially altering study findings. However, using retrospective consent may raise ethical issues. We assessed whether using retrospective consent affected recruitment, participant characteristics, and outcomes within a randomized controlled trial.

METHODS

We conducted a secondary analysis of a randomized trial, which compared nasal high flow (nHF) with nasal continuous positive airway pressure (CPAP) for primary respiratory support in preterm infants. In Era 1, all infants were consented prospectively; in Era 2, retrospective consent was available. We assessed inclusion rates of eligible infants, demographic data, and primary trial outcome (treatment failure within 72 hours).

RESULTS

In Era 1, recruitment of eligible infants was lower than in Era 2: 111 of 220 (50%) versus 171 of 209 (82%), P < .001; intrapartum antibiotic administration was lower: 23 of 111 (21%) versus 84 of 165 (51%), P < .001; full courses of antenatal steroids were higher: 86 of 111 (78%) versus 103 of 170 (61%), P = .004; and more infants received pre-randomization CPAP: 77 of 111 (69%) versus 48 of 171 (28%), P < .001. In Era 1, nHF failure (15 of 56, 27%) and CPAP failure (14 of 55, 26%) rates were similar, P = .9. In Era 2, failure rates differed: 24 of 85 (28%) nHF infants versus 13 of 86 (15%) CPAP infants, P = .04. The χ² interaction test was nonsignificant (P = .20).

CONCLUSIONS

The use of retrospective consent resulted in greater recruitment and differences in risk factors between eras. Using retrospective consent altered the study sample, which may be more representative of the whole population. This may improve scientific validity but requires further ethical evaluation.

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

OBJECTIVES

To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.

STUDY DESIGN

This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 24^0/7 to 27^6/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.

RESULTS

Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).

CONCLUSIONS

Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00233324.

Orotracheal intubation in infants performed with a stylet versus without a stylet

BACKGROUND

Neonatal endotracheal intubation is a common and potentially life-saving intervention. It is a mandatory skill for neonatal trainees, but one that is difficult to master and maintain. Intubation opportunities for trainees are decreasing and success rates are subsequently falling. Use of a stylet may aid intubation and improve success. However, the potential for associated harm must be considered.

OBJECTIVES

To compare the benefits and harms of neonatal orotracheal intubation with a stylet versus neonatal orotracheal intubation without a stylet.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and previous reviews. We also searched cross-references, contacted expert informants, handsearched journals, and looked at conference proceedings. We searched clinical trials registries for current and recently completed trials. We conducted our most recent search in April 2017.

SELECTION CRITERIA

All randomised, quasi-randomised, and cluster-randomised controlled trials comparing use versus non-use of a stylet in neonatal orotracheal intubation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed results of searches against predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used the standard methods of the Cochrane Collaboration, as documented in the Cochrane Handbook for Systemic Reviews of Interventions, and of the Cochrane Neonatal Review Group.

MAIN RESULTS

We included a single-centre non-blinded randomised controlled trial that reported a total of 302 intubation attempts in 232 infants. The median gestational age of enrolled infants was 29 weeks. Paediatric residents and fellows performed the intubations. We judged the study to be at low risk of bias overall. Investigators compared success rates of first-attempt intubation with and without use of a stylet and reported success rates as similar between stylet and no-stylet groups (57% and 53%) (P = 0.47). Success rates did not differ between groups in subgroup analyses by provider level of training and infant weight. Results showed no differences in secondary review outcomes, including duration of intubation, number of attempts, participant instability during the procedure, and local airway trauma. Only 25% of all intubations took less than 30 seconds to perform. Study authors did not report neonatal morbidity nor mortality. We considered the quality of evidence as low on GRADE analysis, given that we identified only one unblinded study.

AUTHORS' CONCLUSIONS

Current available evidence suggests that use of a stylet during neonatal orotracheal intubation does not significantly improve the success rate among paediatric trainees. However, only one brand of stylet and one brand of endotracheal tube have been tested, and researchers performed all intubations on infants in a hospital setting. Therefore, our results cannot be generalised beyond these limitations.

Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial

BACKGROUND

Neonatal endotracheal intubation is a necessary skill. However, success rates among junior doctors have fallen to <50%, largely owing to declining opportunities to intubate. Videolaryngoscopy allows instructor and trainee to share the view of the pharynx. We compared intubations guided by an instructor watching a videolaryngoscope screen with the traditional method where the instructor does not have this view.

METHODS

A randomized, controlled trial at a tertiary neonatal center recruited newborns from February 2013 to May 2014. Eligible intubations were performed orally on infants without facial or airway anomalies, in the delivery room or neonatal intensive care, by doctors with <6 months' tertiary neonatal experience. Intubations were randomized to having the videolaryngoscope screen visible to the instructor or covered (control). The primary outcome was first-attempt intubation success rate confirmed by colorimetric detection of expired carbon dioxide.

RESULTS

Two hundred six first-attempt intubations were analyzed. Median (interquartile range) infant gestation was 29 (27 to 32) weeks, and weight was 1142 (816 to 1750) g. The success rate when the instructor was able to view the videolaryngoscope screen was 66% (69/104) compared with 41% (42/102) when the screen was covered (P < .001, OR 2.81, 95% CI 1.54 to 5.17). When premedication was used, the success rate in the intervention group was 72% (56/78) compared with 44% (35/79) in the control group (P < .001, OR 3.2, 95% CI 1.6 to 6.6).

CONCLUSIONS

Intubation success rates of inexperienced neonatal trainees significantly improved when the instructor was able to share their view on a videolaryngoscope screen.

Predicting neonatal intubation competency in trainees

BACKGROUND AND OBJECTIVES

Pediatric residency training programs are graduating residents who are not competent in neonatal intubation, a vital skill needed for any pediatrician involved in delivery room resuscitations. However, a precise definition of competency during training is lacking. The objective of this study was to more precisely define the trajectory toward competency in neonatal intubation for pediatric residents, as a framework for later evaluating complementary training tools.

METHODS

This is a retrospective single-center observational study of resident-performed neonatal intubations at Duke University Medical Center between 2005 and 2013. Using a Bayesian statistical model, intubation competency was defined when the resident attained a 75% likelihood of intubating their next patient successfully.

RESULTS

A total of 477 unique intubation attempts by 105 residents were analyzed. The path to proficiency was defined by a categorical or milestone learning event after which all learners move toward competency in a similar manner. In our cohort, 4 cumulative successes were needed to achieve competency. Only 24 of 105 (23%) achieved competency during the study period. Residents who failed their first 2 opportunities, compared with those successful on their first 2 opportunities, needed nearly double the intubation exposure to achieve competency.

CONCLUSIONS

Bayesian statistics may be useful to more precisely describe neonatal intubation competency in residents. Achieving competency in neonatal intubation appears to be a categorical or milestone learning event whose timing varies between residents. The current educational environment does not provide adequate procedural exposure to achieve competency for most residents.