Neonatal Intubation Practice and Outcomes: An International Registry Study

Success and safety of neonatal endotracheal tube exchanges: a NEAR4NEOS multicentre retrospective cohort study

OBJECTIVES

To compare success and safety of endotracheal tube (ETT) exchanges with primary intubations and identify factors associated with ETT exchange outcomes.

DESIGN

Retrospective observational study of prospectively collected National Emergency Airway Registry for Neonates data. ETT exchanges are the placement of a new ETT when one is already in place, whereas primary intubations do not have a pre-existing ETT. The primary outcome was first-attempt success. Secondary outcomes included number of attempts, adverse tracheal intubation-associated events (TIAEs), severe TIAEs, desaturation and bradycardia. Descriptive statistics compared characteristics for ETT exchanges and primary intubations. Univariable and multivariable analyses compared primary and secondary outcomes and identified factors independently associated with ETT exchange outcomes.

RESULTS

A total of 1572 ETT exchanges and 9999 primary intubations across 21 sites were included from October 2014 to September 2022. ETT exchanges represented 2.3%-31.2% (mean 13.6%) of intubations across sites. Patient, provider and practice characteristics varied significantly between ETT exchanges and primary intubations. In univariable analyses, ETT exchanges were associated with higher first-attempt success (70.5% vs 53.6%; p<0.001) and fewer safety events. In multivariable analyses, ETT exchanges were associated with an increased adjusted OR (aOR) of first-attempt success (1.71; 95% CI 1.57 to 1.86; p<0.001). ETT exchanges were associated with lower aOR of all safety outcomes except severe TIAEs. Factors independently associated with ETT exchange first-attempt success included video laryngoscopy and paralytic premedication.

CONCLUSION

Compared with primary intubations, ETT exchanges were associated with higher first-attempt success and fewer safety events. Video laryngoscope and paralytic premedication were associated with improved ETT exchange outcomes.

Advances in neonatal resuscitation for the obstetric anesthesiologist

PURPOSE OF REVIEW

This review provides an updated overview of neonatal resuscitation practices relevant to obstetric anesthesiologists, with a focus on term and late preterm neonates (>34 weeks' gestation). Key topics include umbilical cord management, temperature regulation, airway strategies, and pharmacological interventions, emphasizing evidence-based approaches.

RECENT FINDINGS

Delayed cord clamping enhances neonatal outcomes, including improved blood volume and oxygenation. Positive pressure ventilation remains the cornerstone of neonatal resuscitation, with early initiation reducing mortality. Supraglottic airways are emerging as effective alternatives to face masks. Advances in epinephrine administration and dosing show promise, though evidence gaps persist. Simulation-based training, telemedicine, and artificial intelligence are advancing skill retention and resuscitation support.

SUMMARY

Recent advancements in neonatal resuscitation focus on precision in ventilation, thermoregulation, and airway management. Obstetric anesthesiologists play a critical role in neonatal emergencies, underscoring the need for continuous training and the integration of emerging technologies like artificial intelligence to optimize neonatal outcomes.

Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training

OBJECTIVES

Tracheal intubation (TI) is a critical skill for PICU attending physicians to maintain. We hypothesize that attendings perform fewer TIs and have lower success rate in PICU programs with a Pediatric Critical Care Medicine (PCCM) fellowship.

DESIGN

Retrospective study using the National Emergency Airway Registry for Children (NEAR4KIDS) from July 2016 to June 2020. Exposures were presence of PCCM fellowship and attending TI skill maintenance program (SMP). The primary outcome was attending's first attempt success and the secondary outcome was adverse airway outcome in the first attempt.

SETTING

Thirty-three PICUs in North America.

PATIENTS

Children receiving TI.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall, 23 of 33 PICUs had a PCCM fellowship with three of 23 having an attending TI SMP. Attendings performed TI in 24.1% (2,728/11,323): 13.9% (13.8 TI/yr per PICU) in PICUs with a fellowship vs. 66.0% (36.6 TI/yr per PICU) without a fellowship (p < 0.001). Attending first attempt success in PICUs with vs. without fellowships was 70.5% vs. 81.3% (difference, 10.8% [95% CI, 7.6-14.0%]; p < 0.0001). After controlling for confounders, attendings in a PICU with a fellowship had lower odds for first attempt success (adjusted odds ratio [aOR], 0.65 [95% CI, 0.47-0.90]). We failed to find an association between attending first attempt success and PICU program type, with vs. without a TI SMP (74.0% vs. 69.5%; p = 0.146). The adverse airway outcome rate of the TI with attending's first attempt was lower in PICU programs with vs. without a TI SMP (32.8% vs. 40.3%; p = 0.020). However, after adjusting for confounders, we failed to exclude the possibility of near halving of odds of adverse outcome (aOR, 0.75 [95% CI, 0.55-1.01]; p = 0.058).

CONCLUSIONS

Attendings in PICU programs with a fellowship have fewer opportunities to perform TI and lower first attempt success rates. Opportunities exist for attending TI skill maintenance, especially in PICUs with a PCCM fellowship.

Nasal Intermittent Positive Pressure Ventilation During Neonatal Endotracheal Intubation: A Randomized Controlled Trial

BACKGROUND

This prospective, multicenter, randomized controlled trial aimed to determine whether the use of nasal intermittent positive pressure ventilation (NIPPV) during neonatal endotracheal intubation increased the rate of successful intubation without physiological instability during all intubation attempts.

MATERIAL AND METHODS

In total, 150 infants were randomly assigned to either an NIPPV or standard care group (n = 75 each). The primary outcome was successful intubation without physiological instability (defined as ≥ 20% decline in the peripheral oxygen saturation [SpO2] from preintubation value or bradycardia with a heart rate < 100 beats/min) during all intubation attempts.

RESULTS

The mean postmenstrual age of the infants was 32.5 weeks, with a median weight of 1552 g at the time of intubation. The incidence of successful intubation without physiological instability during all intubation attempts was significantly higher in the NIPPV group (64%) than that in the standard care group (42.7%) (p = 0.009). This difference was particularly significant when inexperienced practitioners were involved. In the NIPPV group, the rates of bradycardia (18.7% vs. 41.3%) and severe desaturation (30.7% vs. 49.3%) were significantly lower, whereas the lowest SpO2 (85% vs. 76%) and lowest heart rate (118 vs. 105 beats/min) were significantly higher.

CONCLUSION

NIPPV during endotracheal intubation increased the incidence of successful intubation without physiological instability during intubation attempts in neonates while reducing the rate of hypoxia and bradycardia.

Glottic opening detection using deep learning for neonatal intubation with video laryngoscopy

OBJECTIVE

This study aimed to develop an artificial intelligence (AI) method to augment video laryngoscopy (VL) by automating the detection of the glottic opening in neonates, as a step toward future studies on improving intubation outcomes.

STUDY DESIGN

A deep learning model, YOLOv8, was trained on 1623 video frames from 84 neonatal intubations to detect the glottic opening and evaluated using 14-fold cross-validation on metrics like precision and recall. Additionally, it was compared with 25 medical providers of varied intubation experience to assess its relative performance.

RESULTS

The model demonstrated a precision of 80.8% and a recall of 75.3% in identifying the glottic opening, detecting it 0.31 s faster than the average medical provider. It performed comparably or better than novice and intermediate providers, and slightly slower than experts.

CONCLUSION

AI-powered tools can aid VL by providing real-time guidance, potentially enhancing neonatal intubation safety and efficiency for less experienced users.

Factors influencing confidence in tracheal intubation among neonatal trainees: A questionnaire-based study

AIM

Tracheal intubation (TI) is pivotal in managing critically ill neonates. This study aims to investigate the disparities in exposure and training techniques that affect self-perceived confidence in neonatal fellows concerning TI.

METHODS

A comprehensive, structured questionnaire-based survey was conducted among neonatal trainees from October to November 2022. Self-perceived confidence in TI was evaluated using a Likert scale, ranging from 1 to 10. The trainees who scored below seven were categorised as under-confident, while those who scored seven or more were considered confident in TI. An analysis was done to assess the differences in exposure, training and clinical policies related to TI in both groups. A P-value <0.05 was considered significant.

RESULTS

The final dataset consisted of 93 trainees. Confidence was higher among those who had independently performed TI on more than 30 neonates during their postgraduate training (relative risk (RR) 1.5 (1.03-2.1), P = 0.02) and super-specialty training (RR 1.5 (1.20-1.93), P = 0.0004). Confidence was also significantly associated with training programmes that incorporated written checklists for intubation instruments and policies (RR 1.4 (1.1-1.8), P = 0.006), conducted debriefing sessions after each TI attempt (RR 1.3 (1.03-1.6), P = 0.005), and implemented regular simulation programmes (RR 1.4 (1.1-1.8), P = 0.0006).

CONCLUSIONS

Trainees with increased opportunities for intubation and training programmes featuring regular simulations and debriefing sessions tend to possess higher self-perceived confidence in TI.

Feasibility and safety of surfactant administration via laryngeal mask airway as first-line therapy for a select newborn population: results of a standardized clinical protocol

OBJECTIVES

(1) To demonstrate feasibility and safety of surfactant administration via laryngeal mask airway (LMA) as a first-line therapy. (2) To measure treatment success, defined as avoidance of intubation/invasive mechanical ventilation, and determine if specific clinical variables could predict success/failure.

STUDY DESIGN

Observational cohort with eligible infants given surfactant using one type of LMA via standardized protocol. Data was captured prospectively followed by retrospective chart review.

RESULTS

120 infants ≥1250 g and 28.3-41.1 weeks gestation were included. First-line LMA surfactant therapy was successful in 70% of the infants and those infants weaned to room air significantly quicker than infants requiring subsequent intubation/mechanical ventilation (p = 0.002 by 72 h, p = 0.001 by 96 h). Clinical variables assessed could not predict treatment success/failure. Complications were infrequent and did not differ between groups.

CONCLUSION

First-line LMA surfactant is feasible and safe for certain infants. Prediction of treatment success was not possible in our cohort.

Laryngeal Mask for Minimally-invasive Surfactant Administration: A Narrative Review

The cornerstone of treatment for respiratory distress syndrome in preterm infants is surfactant administration, traditionally performed through an invasive procedure involving tracheal intubation and mechanical ventilation. Consequently, there has been a growing interest in exploring less invasive methods of surfactant delivery to mitigate the associated risks. Currently, several techniques are under evaluation, including intratracheal instillation using a thin catheter, aerosolized or nebulized administration, and guided administration by supraglottic airway devices. One such method is surfactant administration through laryngeal or supraglottic airway, which involves placing a laryngeal mask without the need for laryngoscopy and administering surfactant through the device. The simplicity of laryngeal mask insertion could potentially streamline the surfactant delivery process, eliminating the necessity for advanced skills. This narrative review aimed to assess the current evidence in the literature regarding the benefits and risks associated with surfactant administration through a laryngeal supraglottic airway.

Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial

OBJECTIVE

Neonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow during Intubation of NEonates randomised trial aimed to identify the factors associated with successful intubation on the first attempt without physiological stability of the infant.

METHODS

In this secondary analysis, demographic factors were compared between infants intubated by inexperienced operators and those intubated by experienced operators. Following this, for inexperienced operators only, predictors of successful intubation without physiological instability were analysed.

RESULTS

A total of 251 intubations in 202 infants were included in the primary intention-to-treat analysis of the main trial. Inexperienced operators were more likely to perform intubations in larger and more mature infants in the neonatal intensive care unit where premedications were used. When intubations were performed by inexperienced operators, the use of nasal high flow therapy (nHF) and a higher starting fraction of inspired oxygen were associated with a higher rate of safe, successful intubation on the first attempt. There was a weaker association between premedication use and first attempt success.

CONCLUSIONS

In inexperienced operators, this secondary, non-randomised analysis suggests that the use of nHF and premedications, and matching the operator to the infant and setting, may be important to optimise neonatal intubation success.

TRIAL REGISTRATION NUMBER

ACTRN12618001498280.

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study

OBJECTIVE

To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL).

DESIGN

Prospective single-centre observational study.

SETTING

Quaternary neonatal intensive care unit.

PATIENTS

Infants requiring NTI at the Children's Hospital of Philadelphia.

INTERVENTIONS

VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location.

MAIN OUTCOME MEASURE

VL NTI attempt success.

RESULTS

A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009).

CONCLUSION

We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.

Approaches to neonatal intubation training: A scoping review

Introduction

Neonatal intubation is a lifesaving skill that a variety of clinicians need to establish as it can be required anywhere babies are born or hospitalised and cannot depend on the immediate availability of an experienced senior clinician. However, neonatal intubation is complex and risky, requiring technical and non-technical skill competence. Studies report that rates of successful neonatal intubation by junior clinicians are low, providing a mandate to examine the best methods to improve skill acquisition, retention, and transfer.

Method

We utilised PRISMA-ScR methodology to capture the range of training approaches in the simulation and clinical settings, and to assess the range of technical and non-technical skill outcome measures that were used in the included studies. Databases were searched from inception to August 2024 to identify studies reporting outcomes for medical practitioners-in-training, nurses, and nurse practitioners. Identified studies meeting inclusion criteria underwent data charting with study characteristics tabulated.

Results

Twenty-six studies (involving 1449 participants) were included. Training methodology was diverse and included self-directed learning, didactic education, demonstration, simulation-based training (SBT), instructor feedback, debriefing and supervised clinical practice. Most of the studies (96 %) used multiple training methods with education and SBT most frequently used. Thirteen studies reported outcomes in clinical settings, including seven that demonstrated changes in technical skills following education and SBT. Two studies that assessed transfer of skills failed to show successful transfer from simulation to a clinical setting. Two articles reported the transfer of skills between direct and video laryngoscope devices. Only one study evaluated skill retention (at 6-9 months) but did not demonstrate proficiency after initial training or at follow up. No studies described the effects of training on non-technical skills.

Conclusion

No included studies or combination of studies seems likely to provide a high-certainty evidence-basis for optimal training methodology. Results suggested using a training bundle including education, SBT and supervision. Knowledge gaps remain, including the most effective methodology for non-technical skill training. In addition, the evidence of technical skill retention beyond the immediate training episode, and transfer to a variety of clinical environments is very limited. Given the importance of successful neonatal intubation, more research in these areas is justified.

Ventilation practices and preparedness of healthcare providers in term newborn resuscitation: A comprehensive survey study in Austrian hospitals

Aim of the study

Although neonatal resuscitation is rare, and high-risk births usually occur in specialised centres, unexpected resuscitation measures may be necessary during births that are initially considered low-risk. This survey assessed the practices of healthcare providers in Austrian hospitals for postnatal resuscitation and evaluated their self-assessed airway management skills for newborns.

Methods

An online survey was distributed to all staff members responsible for the postnatal care of newborns in hospitals with obstetrics in Austria through the heads of departments (paediatrics, obstetrics, and anaesthesiology). The results are presented in terms of hospital care level and birth volume.

Results

In total, 79.5 % of all hospitals with maternity units in Austria participated in the survey. Preparedness was found to be improved with the level of care provided by the hospital. Overall, 50.4 % of the respondents did not feel adequately prepared for neonatal emergencies, and 35.0 % rated their face mask ventilation skills as insufficient. According to the survey results in 61.3 % of included hospitals or 52.5 % of births in Austria, safe endotracheal intubation cannot be provided.

Conclusion

A significant proportion of healthcare workers in Austria responsible for postnatal newborn care do not feel adequately prepared for newborn emergencies.

Implementation mapping to plan for the Supraglottic Airway for Resuscitation (SUGAR) trial

BACKGROUND

Positive pressure ventilation (PPV) is an essential component of neonatal resuscitation. Meta-analytic evidence suggests that, among late preterm and term newborn infants who require resuscitation after birth, a supraglottic airway (SA) device is more effective than a face mask at reducing the probability of PPV failure and reducing the need for endotracheal intubation. However, SA devices are rarely used in routine practice in hospital delivery room settings within the United States.

METHODS

In preparation for a pragmatic hybrid effectiveness-implementation trial, we used implementation mapping to identify barriers and facilitators to SA use; develop a logic model; identify and operationalize implementation strategies targeting key barriers and facilitators; and refine strategies based on iterative feedback from clinicians and administrators (e.g., physicians, nurse practitioners, nurse managers, and respiratory therapists). We used the Consolidated Framework for Implementation Research (CFIR) to organize barriers and implementation strategies.

RESULTS

Across open-ended survey responses and focus groups, identified barriers included: (1) mixed perceptions of the advantages or disadvantages of SA compared to alternatives; (2) insufficient education and training in SA use; and (3) lack of perceived need for an alternative to intubation as a standard practice. The research team's understanding of these barriers and selection of implementation strategies to address them were refined throughout the iterative implementation mapping process, which resulted in the selection of two sets of implementation strategies to be tested in a hybrid trial.

CONCLUSIONS

The implementation mapping process described in this paper provides an exemplar of a systematic and partner-engaged process to identify and select implementation strategies for the purpose of hybrid trial design.

Video laryngoscopy in neonate and infant intubation-a systematic review and meta-analysis

We aimed to analyze the effect of video laryngoscopy on intubation success, time to intubation, and adverse events in infants and neonates. A systematic review and meta-analysis was performed, for which a neonates (age less than 29 days) and infants (age less than 365 days) needing to be intubated were included. The main outcomes were first attempt success rate in the intubation, time to intubation, and adverse events. Evidence certainty was assessed according to GRADE. We included 13 studies. Seven studies with 897 patients focused on neonates, and the first attempt success rate was higher in the video laryngoscopy group (RR 1.18, CI: 1.03-1.36). Six studies included 1039 infants, and the success rate was higher in the video laryngoscopy group (RR 1.06, CI: 1.00-1.20). Time to intubation was assessed in 11 trials, and there was no difference between the groups (mean difference 1.2 s, CI - 2.2 s to + 4.6 s). Odds of desaturation (OR 0.62, CI 0.42-0.93) and nasal/oral trauma (OR 0.24, CI 0.07-0.85) were lower in the video laryngoscopy group. Evidence certainties varied between moderate and low.

CONCLUSION

We found moderate certainty evidence that the use of video laryngoscopy improves first attempt success rates in neonate and infant intubations, while the time to intubation did not differ between video and direct laryngoscopy groups. Further studies are still needed to improve the first intubation success rates in neonates.

WHAT IS KNOWN

• Video laryngoscopy has been shown to improve first-pass intubation success rates and reduce time to intubation in adults and older children.

WHAT IS NEW

• Video laryngoscopy improved the first attempt intubation success rates both in neonates and in infants. • Video laryngoscopy did not increase the time to intubation, and it was associated with less adverse events than direct laryngoscopy.

Evaluating the Impact of Elective Endotracheal Tube Replacement on Postoperative Outcomes in Esophageal Atresia: A STROBE-guided Study

Background

Elective ventilation and paralysis have been shown to decrease the anastomosis-related complications following primary repair of esophageal atresia (EA). Repeated endotracheal tube (ETT) block and replacement can increase these complications. We evaluated the results of our strategy of electively changing the ETT just before shifting the patient to the postoperative ward for elective ventilation.

Materials and Methods

A retrospective study was conducted using the case records of patients from July 2015 to February 2024 including all the patients of EA with tracheoesophageal fistula who underwent primary repair with end-to-end esophageal anastomosis. The patients were divided into two groups Group A: ETT was changed and Group B: ETT was not changed immediately before shifting. The groups were compared for anastomotic leak and ETT tube block in the first 48 h.

Results

Ninety-one patients were included in the study, 36 in Group A and 55 in Group B. Elective replacement of ETT decreased the tube block rates in the first 48 h following surgery (P = 0.032). Tension in the anastomosis was associated with a higher leak rate. The leak was present in 58.3% and 3.6% in cases with and without tension in the anastomosis (P = 0.001). Overall, the anastomotic leak was similar in both groups. In the subgroup of patients with anastomosis under tension, the rate of anastomotic leak was higher in patients with ETT block (P = 0.028).

Conclusion

Elective replacement of EET decreases the tube block rates and anastomotic leak rates in cases with anastomosis under tension.

Video-Based Study of the Progression of Pediatric Emergency Medicine Fellows' Tracheal Intubation Performance During Training

BACKGROUND

The lower clinical exposure of Pediatric Emergency Medicine (PEM) fellows to critical procedures may impede skill acquisition. We sought to determine the tracheal intubation learning curve of PEM fellows during training and compared PEM fellow success against standards for tracheal intubation success.

METHODS

This was a retrospective, video-based study of a cohort of PEM fellows at a single academic pediatric emergency department (PED). All forms of tracheal intubation were included (rapid sequence intubation and crash or no medication). The cohort consisted of 36 PEM fellows from all or part of 5 consecutive fellowship classes. Data were collected by structured review of both existing ceiling-mounted videos and the electronic medical record. The main outcome was PEM fellows' success on the first or second attempt. We used cumulative summation to generate tracheal intubation learning curves. We specifically assessed the proportion of PEM fellows who reached 1 of 4 thresholds for procedural performance: 90% and 80% predicted success on the first and the first or second attempt.

RESULTS

From July 2014 to June 2020, there were 610 patient encounters with at least 1 attempt at tracheal intubation. The 36 PEM fellows performed at least 1 attempt at tracheal intubation for 414 ED patient encounters (65%). Median patient age was 2.1 years (interquartile range, 0.4-8.1). The PEM fellows were successful on the first attempt for 276 patients (67%) and on the first or second attempt for 337 (81%). None of the 36 PEM fellows reached the 90% threshold for either first or second attempt success. Four fellows (11%) met the 80% threshold for first attempt success and 11 (31%) met the 80% threshold for first or second attempt success.

CONCLUSIONS

Despite performing the majority of attempts, PEM fellows often failed to reach the standard thresholds for performance of tracheal intubation. Clinical exposure alone is too low to ensure acquisition of airway skills.

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.

Usability Testing Via Simulation: Optimizing the NEAR4PEM Preintubation Checklist With a Human Factors Approach

OBJECTIVES

To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist.

METHODS

This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist.

RESULTS

Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist.

CONCLUSIONS

Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.

Laryngeal Mask Airway Clinical Use and Training: A Survey of North American Neonatal Health Care Professionals

OBJECTIVE

The aim of this study was to explore North American neonatal health care professionals' (HCPs) experience, confidence, skill, and training with the laryngeal mask airway (LMA).

STUDY DESIGN

This was a cross-sectional survey.

RESULTS

The survey was completed by 2,159 HCPs from Canada and the United States. Seventy nine percent had no clinical experience with the LMA, and less than 20% considered the LMA an alternative to endotracheal intubation (EI). The majority had received LMA training; however, 28% of registered nurses, 18% of respiratory therapists, 17% of physicians, and 12% of midwives had never inserted an LMA in a mannequin. Less than a quarter of respondents agreed that the current biennial Neonatal Resuscitation Program instruction paradigm is sufficient for LMA training. All groups reported low confidence and skill with LMA insertion, and compared with all other groups, the respiratory therapists had the highest reported confidence and skill.

CONCLUSION

This survey study, which is the first of its kind to include midwives, demonstrates that neonatal HCPs lack experience, confidence, skill, and training with the LMA, rarely use the device, and in general, do not consider the LMA as an alternative to EI. These findings contribute to, and support the findings of previous smaller studies, and in conjunction with the diminishing opportunities for EI, highlight the need for programs to emphasize the importance of the LMA for neonatal airway management and prioritize regular LMA training, with focus that parallels the importance placed on the skills of EI and mask ventilation.

KEY POINTS

· Lack of training for laryngeal mask airway use in neonatal resuscitation.. · Neonatal health care professionals rarely use the laryngeal mask airway as an alternate airway device.. · Neonatal health care professionals lack confidence and skill with the laryngeal mask airway..

Continuous improvement of non-emergent neonatal intubations in a level IV NICU

OBJECTIVE

We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit.

STUDY DESIGN

A multidisciplinary team created guidelines for non-emergent neonatal intubations. In period 1, premedication practices were standardized. In period 2, paralytic use and video laryngoscope use were recommended. Premedication and video laryngoscopy practices were assessed along with number of intubation attempts and frequency of bradycardia and desaturation.

RESULTS

636 intubations performed by neonatology fellows and neonatal advanced practice providers were reviewed over six academic years. Two academic years were included in each of the following study periods: baseline, period 1, and period 2. In our unit, compliance with recommended premedication practices and administration of paralytic medication has increased considerably, and video laryngoscopy is now utilized in most of our procedures. The frequency of intubation success on the first attempt has increased, and the frequency of both bradycardia and desaturation during intubation has decreased. In our analysis, paralytic use (AOR 2.41, 95 CI (1.53, 3.81)) and the combination of paralytic and video laryngoscopy (AOR 4.07, 95 CI (2.09, 7.92)) are associated with increased odds of intubating successfully on the first attempt.

CONCLUSIONS

This initiative increased the use of standardized premedication, paralytic medication and video laryngoscopy for non-emergent neonatal intubations with temporally associated improvement in patient outcomes including fewer intubation attempts and reduction in physiologic instability.

Rescue nasopharyngeal tube for preterm infants non-responsive to initial ventilation after birth

BACKGROUND

Physiological changes during the insertion of a rescue nasopharyngeal tube (NPT) after birth are unclear.

METHODS

Observational study of very preterm infants in the delivery room. Data were extracted at predefined timepoints starting with first facemask placement after birth until 5 min after insertion of NPT. End-expiratory lung impedance (EELI), heart rate (HR) and SpO2/FiO2-ratio were analysed over time. Changes during the same time span of NIPPV via facemask and NIPPV via NPT were compared.

RESULTS

Overall, 1154 inflations in 15 infants were analysed. After NPT insertion, EELI increased significantly [0.33 AU/kg (0.19-0.57), p < 0.001]. Compared with the mask period, changes in EELI were not significantly larger during the NPT period [median difference (IQR) = 0.14 AU/kg (-0.14-0.53); p = 0.12]. Insertion of the NPT was associated with significant improvement in HR [52 (33-96); p = 0.001] and SpO2/FiO2-ratio [161 (69-169); p < 0.001] not observed during the mask period.

CONCLUSIONS

In very preterm infants non-responsive to initial facemask ventilation after birth, insertion of an NPT resulted in a considerable increase in EELI. This additional gain in lung volume was associated with an immediate improvement in clinical parameters. The use of a NPT may prevent intubation in selected non-responsive infants.

IMPACT

After birth, a nasopharyngeal tube may be considered as a rescue airway in newborn infants non-responsive to initial positive pressure ventilation via facemask. Although it is widely used among clinicians, its effect on lung volumes and physiological parameters remains unclear. Insertion of a rescue NPT resulted in a considerable increase in lung volume but this was not significantly larger than during facemask ventilation. However, insertion of a rescue NPT was associated with a significant and clinically important improvement in heart rate and oxygenation. This study highlights the importance of individual strategies in preterm resuscitation and introduces the NPT as a valid option.

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study

OBJECTIVE

To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL).

DESIGN

Prospective single-centre observational study.

SETTING

Quaternary neonatal intensive care unit.

PATIENTS

Infants requiring NTI at the Children's Hospital of Philadelphia.

INTERVENTIONS

VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location.

MAIN OUTCOME MEASURE

VL NTI attempt success.

RESULTS

A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009).

CONCLUSION

We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.

Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service

OBJECTIVE

To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service.

METHODS

We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians.

RESULTS

Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively.

CONCLUSIONS

On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.

Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants

BACKGROUND

Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain.

METHODS

In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection.

RESULTS

Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively.

CONCLUSIONS

Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).

Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet

INTRODUCTION

Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates.

METHODOLOGY

This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes.

RESULTS

The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet.

CONCLUSION

Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.

Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks

Although positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation for delivering PPV has a high failure rate due to mask leaks, airway obstruction, or gastric inflation. Furthermore, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions, resulting in a lower PPV failure rate compared to that of face masks in neonatal resuscitation. In addition, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and mortality rates do not differ between the 2 methods. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or with a birth weight >2 kg, in cases of unsuccessful face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended when endotracheal intubation fails as well as when PPV cannot be achieved. Although laryngeal masks are commonly used in anesthetized pediatric patients, they are infrequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness among the healthcare providers. Thus, healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve their outcomes, resulting in decreased morbidity and mortality rates.

Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework

OBJECTIVE

This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU).

STUDY DESIGN

Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication.

RESULTS

Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences.

CONCLUSION

Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain.

KEY POINTS

· Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.. · Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.. · Several factors influence premedication for nonemergent NI..

Dependence of Successful Airway Management in Neonatal Simulation Manikins on the Type of Supraglottic Airway Device and Providers' Backgrounds

Supraglottic airway devices such as laryngeal masks and i-gels are useful for airway management. The i-gel is a relatively new device that replaces the air-inflated cuff of the laryngeal mask with a gel-filled cuff. It remains unclear which device is more effective for neonatal resuscitation. We aimed to evaluate the dependence of successful airway management in neonatal simulators on the device type and providers' backgrounds. Ninety-one healthcare providers performed four attempts at airway management using a laryngeal mask and i-gel in two types of neonatal manikins. The dependence of successful insertions within 16.7 s (75th percentile of all successful insertions) on the device type and providers' specialty, years of healthcare service, and completion of the neonatal resuscitation training course was assessed. Successful insertion (p = 0.001) and insertion time (p = 0.003) were associated with using the i-gel vs. laryngeal mask. The providers' backgrounds were not associated with the outcome. Using the i-gel was associated with more successful airway management than laryngeal masks using neonatal manikins. Considering the limited effect of the provider's specialty and experience, using the i-gel as the first-choice device in neonatal resuscitation may be advantageous. Prospective studies are warranted to compare these devices in the clinical setting.

Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation

BACKGROUND AND OBJECTIVES

Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations.

METHODS

Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups.

RESULTS

Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89).

CONCLUSIONS

For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.

Less invasive surfactant administration methods: Who, what and how

Surfactant administration via an endotracheal tube (ETT) has been the standard of care for infants with respiratory distress syndrome for decades. As non-invasive ventilation has become commonplace in the NICU, methods for administering surfactant without use of an ETT have been developed. These methods include thin catheter techniques (LISA, MIST), aerosolization/ nebulization, and surfactant administration through laryngeal (LMA) or supraglottic airways (SALSA). This review will describe these methods and discuss considerations and implementation into clinical practice.

Neonatal intubation: what are we doing?

How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope.    Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.

The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation

BACKGROUND

Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation.

METHODS

This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer.

DISCUSSION

The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , trial identifier NCT05446272 , registered July 6, 2022.

Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors

Aim

Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth.

Methods

A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression.

Results

Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns.

Conclusion

Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

Background

The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications.

Methods

Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications.

Findings

First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications.

Interpretation

In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety.

Funding

None.

Current Practices and Safety of Medication Use During Pediatric Rapid Sequence Intubation

OBJECTIVES

This study aimed to characterize medication-related practices during and immediately -following rapid sequence intubation (RSI) in pediatric care units across the United States and to evaluate adverse drug events.

METHODS

This was a multicenter, observational study of medication practices surrounding intubation in pediatric and neonatal intensive care unit (NICU) and emergency department patients across the United States.

RESULTS

A total of 172 patients from 13 geographically diverse institutions were included. Overall, 24%, 69%, and 50% received preinduction, induction, and neuromuscular blockade, respectively. Induction and neuromuscular blocking agent (NMBA) use was low in NICU patients (52% and 23%, respectively), whereas nearly all patients intubated outside of the NICU received both (98% and 95%, respectively). NICU patients who received RSI medications were older and weighed more. Despite infrequent use of atropine (21%), only 3 patients developed bradycardia after RSI. Of the 119 patients who received an induction agent, fentanyl (67%) and midazolam (34%) were administered most frequently. Hypotension and hypertension occurred in 23% and 24% of patients, respectively, but were not associated with a single induction agent. Etomidate use was low and not associated with development of adrenal insufficiency. Rocuronium was the most used NMBA (78%). Succinylcholine use was low (11%) and administered despite hyperkalemia in 2 patients. Postintubation sedation and analgesia were not used or inadequate based on timing of initiation in many patients who received a non-depolarizing NMBA.

CONCLUSIONS

Medication practices surrounding pediatric RSI vary across the United States and may be influenced by patient location, age, and weight.

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis

BACKGROUND

Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.

METHODS

This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.

RESULTS

After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.

CONCLUSION

This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.

CLINICAL TRIAL REGISTRATION

Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.

Comparison of laryngeal mask airway and endotracheal tube placement in neonates

OBJECTIVE

We hypothesize that the time, number of attempts, and physiologic stability of placement of an LMA would be superior compared to ETT.

STUDY DESIGN

Videotape and physiologic parameters of LMA (n = 36) and ETT (n = 31) placement procedures for infants 28-36 weeks gestation were reviewed.

RESULTS

Duration of attempts (32 vs 66 s, p < 0.001) and mean total airway insertion time (88 vs 153 s, p = 0.06) was shorter for LMA compared to ETT. Mean number of attempts for successful placement was fewer for LMA (1.5 vs 1.9, p = 0.11). Physiologic parameters remained near baseline in both groups despite very different degrees of premedication.

CONCLUSION

Placement of an LMA required less time and fewer number of attempts compared to ETT. Physiologic stability of an LMA was maintained without the use of an analgesic and muscle relaxant. Use of an LMA is a favorable alternative to ETT placement for surfactant delivery in neonates.

TRIAL REGISTRATION

NCT01116921.

Factors that determine first intubation attempt success in high-risk neonates

BACKGROUND

Approximately 50% of all neonatal endotracheal intubation attempts are unsuccessful and associated with airway injury and cardiorespiratory instability. The aim of this study was to describe intubation practice at a high-risk Neonatal Intensive Care Unit (NICU) and identify factors associated with successful intubation at the first attempt.

METHODS

Retrospective cohort study of all infants requiring intubation within the Royal Children's Hospital NICU over three years. Data was collected from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Outcomes were number of attempts, level of operator training, equipment used, difficult airway grade, and clinical factors. Univariate and multivariate analysis were performed to determine factors independently associated with first attempt success.

RESULTS

Three hundred and sixty intubation courses, with 538 attempts, were identified. Two hundred and twenty-five (62.5%) were successful on first attempt, with similar rates at subsequent attempts. On multivariate analysis, increasing operator seniority increased the chance of first attempt success. Higher glottic airway grades were associated with lower chance of first attempt success, but neither a known difficult airway nor use of a stylet were associated with first attempt success.

CONCLUSION

In a NICU with a high rate of difficult airways, operator experience rather than equipment was the greatest determinant of intubation success.

IMPACT

Neonatal intubation is a high-risk lifesaving procedure, and this is the first report of intubation practices at a quaternary surgical NICU that provides regional referral services for complex medical and surgical admissions. Our results showed that increasing operator seniority and lower glottic airway grades were associated with increased first attempt intubation success rates, while factors such as gestational age, weight, stylet use, and known history of difficult airway were not. Operator factors rather than equipment factors were the greatest determinants of first attempt success, highlighting the importance of team selection for neonatal intubations in a high-risk cohort of infants.

Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units

BACKGROUND

Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States.

STUDY DESIGN

A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems.

RESULTS

Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent.

CONCLUSION

 Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.

Outcomes of Unplanned Extubations in a Large Children's Hospital

BACKGROUND

Unplanned extubation (UE) is defined as unintentional dislodgement of an endotracheal tube (ETT) from the trachea. UEs can lead to instability, cardiac arrest, and may require emergent tracheal re-intubation. As part of our hospital-wide quality improvement (QI) work, a multidisciplinary committee reviewed all UEs to determine contributing factors and evaluation of clinical outcomes to develop QI interventions aimed to minimize UEs. The objective was to investigate occurrence, contributing factors, and clinical outcomes of UEs in the pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU) in a large academic children's hospital. We hypothesized that these would be substantially different across 3 ICUs.

METHODS

A single-center retrospective review of UEs in the PICU, CICU, and NICU was recorded in a prospective database for the last 5 y. Consensus-based standardized operational definitions were developed to capture contributing factors and adverse events associated with UEs. Data were extracted through electronic medical records by 3 respiratory therapists and local Virtual Pediatric Systems (VPS) database. Consistency of data extraction and classification were evaluated.

RESULTS

From January 2016-December 2021, 408 UEs in 339 subjects were reported: PICU 52 (13%), CICU 31 (7%), and NICU 325 (80%). The median (interquartile range) of age and weight was 2.0 (0-4.0) months and 5.3 (3.0-8.0) kg. Many UE events were not witnessed (54%). Common contributing factors were routine nursing care (no. = 70, 18%), ETT retaping (no. = 62, 16%), and being held (no. = 15, 3.9%). The most common adverse events with UE were desaturation < 80% (33%) and bradycardia (22.8%). Cardiac arrest occurred in 12%. Sixty-seven percent of UEs resulted in re-intubation within 72 h. The proportion of re-intubation across 3 units was significantly different: PICU 62%, CICU 35%, NICU 71%, P < .001.

CONCLUSIONS

UEs occurred commonly in a large academic children's hospital. Whereas UE was associated with adverse events, re-intubation rates within 72 h were < 70% and variable across the units.

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).

Less Invasive Surfactant Administration: A Viewpoint

The standard of care in treating respiratory distress syndrome in preterm infants is respiratory support with nasal continuous positive airway pressure or a combination of continuous positive airway pressure and exogenous surfactant replacement. Endotracheal intubation, the conventional method for surfactant administration, is an invasive procedure associated with procedural and mechanical ventilation complications. The INSURE (intubation, surfactant administration, and extubation soon after) technique is an accepted method aimed at reducing the short-term complications and long-term morbidities related to mechanical ventilation but does not eliminate risks associated with endotracheal intubation and mechanical ventilation. Alternative methods of surfactant delivery that can overcome the problems associated with the INSURE technique are surfactant through a laryngeal mask, surfactant through a thin intratracheal catheter, and aerosolized surfactant delivered using nebulizers. The three alternative methods of surfactant delivery studied in the last two decades have advantages and limitations. More than a dozen randomized controlled trials have aimed to study the benefits of the three alternative techniques of surfactant delivery compared with INSURE as the control arm, with promising results in terms of reduction in mortality, need for mechanical ventilation, and bronchopulmonary dysplasia. The need to find a less invasive surfactant administration technique is a clinically relevant problem. Before broader adoption in routine clinical practice, the most beneficial technique among the three alternative strategies should be identified. This review aims to summarize the current evidence for using the three alternative techniques of surfactant administration in neonates, compare the three techniques, highlight the knowledge gaps, and suggest future directions. KEY POINTS: · The need to find a less invasive alternative method of surfactant delivery is a clinically relevant problem.. · Clinical trials that have studied alternative surfactant delivery methods have shown promising results but are inconclusive for broader adoption into clinical practice.. · Future studies should explore novel clinical trial methodologies and select clinically significant long term outcomes for comparison..

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).

Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication

Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.

Recommendations for creating a collaborative NICU environment to support teamwork and trainee education

In a 2022 survey, a majority of neonatology program directors reported regular conflict between neonatal-perinatal fellows and frontline providers (FLPs) (i.e., neonatal nurse practitioners (NNPs), neonatal physician assistants (PAs), and neonatal hospitalists). This paper reviews recommendations of a multidisciplinary workgroup for creating a more collaborative unit environment that supports teamwork and education. The self-study framework is a helpful tool to identify specific pressure points at individual institutions. Implementing clear guidelines for procedural distribution and role clarification are often critical interventions. FLPs and Pediatric Physician Trainees may benefit from conflict management coaching and communication training. At the same time, we recommend that respective leaders support a psychologically safe environment for team members to feel safe to solve problems on their own. Going forward, more work is important to optimize teamwork in the setting of anticipated staffing shortages, limitations to resident neonatology exposure, changes in training requirements, and ongoing development of the FLP role.