Neonatal airway management training using simulation-based educational methods and technology

Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.

Simulation-based Ultrasound Curriculum for Novice Clinicians to Assess Neonatal Endotracheal Tube Position

Background

To evaluate the efficacy of a simulation-based mastery curriculum to train clinicians with limited-to-no sonography experience how to use ultrasound (US) to assess neonatal endotracheal tube (ETT) positioning.

Methods

In a single-centered, prospective, educational study, 29 neonatology clinicians participated in a simulation-based mastery curriculum composed of a didactic lecture, followed by a one-on-one simulation session using a newly designed, three-dimensional (3D) printed US phantom model of the neonatal trachea and aorta. After mastery training, clinicians were evaluated with a performance checklist on their skills obtaining US images and assessing ETT positioning in the US phantom model. They also completed pre- and postcurriculum knowledge assessment tests and self-assessment surveys. The data were analyzed using Wilcoxon signed rank tests and repeated measures analysis of variance.

Results

The mean checklist score improved significantly during three attempts (mean difference: 2.6552; 95% confidence interval [CI]: 2.2578-3.0525; P < 0.0001). The mean time to perform US decreased significantly from the first to third attempt (mean difference: -1.8276 min; 95% CI: -3.3391 to - 0.3161; P = 0.0196). In addition, there was a significant improvement in median knowledge assessment scores (50% vs. 80%; P < 0.0001) and survey ratings on knowledge and self-efficacy (P < 0.0001).

Conclusion

Clinicians with limited-to-no sonography experience demonstrated improved knowledge and skill acquisition in using US to assess ETT positioning through simulation-based mastery training. The use of 3D modeling enhances simulation experiences and optimizes the quality of training during limited opportunities to achieve procedural competency in a controlled environment before further application into the clinical setting.

Comparison of a dichotomous versus trichotomous checklist for neonatal intubation

BACKGROUND

To compare validity evidence for dichotomous and trichotomous versions of a neonatal intubation (NI) procedural skills checklist.

METHODS

NI skills checklists were developed utilizing an existing framework. Experts were trained on scoring using dichotomous and trichotomous checklists, and rated recordings of 23 providers performing simulated NI. Videolaryngoscope recordings of glottic exposure were evaluated using Cormack-Lehane (CL) and Percent of Glottic Opening scales. Internal consistency and reliability of both checklists were analyzed, and correlations between checklist scores, airway visualization, entrustable professional activities (EPA), and global skills assessment (GSA) were calculated.

RESULTS

During rater training, raters gave significantly higher scores on better provider performance in standardized videos (both p < 0.001). When utilized to evaluate study participants' simulated NI attempts, both dichotomous and trichotomous checklist scores demonstrated very good internal consistency (Cronbach's alpha 0.868 and 0.840, respectively). Inter-rater reliability was higher for dichotomous than trichotomous checklists [Fleiss kappa of 0.642 and 0.576, respectively (p < 0.001)]. Sum checklist scores were significantly different among providers in different disciplines (p < 0.001, dichotomous and trichotomous). Sum dichotomous checklist scores correlated more strongly than trichotomous scores with GSA and CL grades. Sum dichotomous and trichotomous checklist scores correlated similarly well with EPA.

CONCLUSIONS

Neither dichotomous or trichotomous checklist was superior in discriminating provider NI skill when compared to GSA, EPA, or airway visualization assessment. Sum scores from dichotomous checklists may provide sufficient information to assess procedural competence, but trichotomous checklists may permit more granular feedback to learners and educators. The checklist selected may vary with assessment needs.

Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS)

INTRODUCTION

Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed.

METHODS

Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference).

RESULTS

Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11-0.30) for residents and 0.80 (95% CI: 0.51-1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation.

CONCLUSION

Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.

A quality appraisal using the AGREE II instrument of endotracheal tube suction guidelines in neonatal intensive care units

BACKGROUND

Endotracheal tube (ETT) suction is among the most common procedures performed in neonatal intensive care units (NICUs). Although necessary, it is associated with significant risks. To mitigate these risks, clinical practice guidelines are developed to provide evidence-based recommendations.

OBJECTIVE

The aim of the study was to appraise the quality of neonatal ETT suction guidelines from all NICUs in Australia and New Zealand.

METHODS

All level III NICUs in Australia and New Zealand were invited to participate. Three researchers graded the methodological quality of the received guidelines using the AGREE II instrument. Item and domain scores were calculated by scaling as a percentage of the total possible score out of 100%. A threshold score of <50% is considered to be of limited potential use.

RESULTS

Twenty-three (79.31%) clinical practice guidelines were received from 29 invited facilities. The scaled results of the AGREE II domains were as follows: Scope and Purpose, mean = 73%, 95% confidence interval (CI) = 63-83%; Stakeholder Involvement, mean = 23%, 95% CI = 15-31%; Rigour of Development, mean = 17%, 95% CI = 12-21%; Clarity of Presentation, mean = 63%, 95% CI = 56-70%; Applicability, mean = 5%, 95% CI = 20-30%; and Editorial Independence, mean = 50%, 95% CI = 50-50%. Overall assessment indicated low methodological quality (31%; 22-39%), with only five clinical practice guidelines scoring >50%, suggesting that they could be recommended for use with modifications. The remaining 18 could not be recommended for use.

CONCLUSIONS

Neonatal ETT suction guidelines are of a low methodological quality. All guidelines poorly incorporated latest evidence in guideline development. This appraisal highlights the need to improve the quality of neonatal ETT suction guidelines to promote optimal patient care.

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.

Effectiveness of a new sensorized videolaryngoscope for retraining on neonatal intubation in simulation environment

Background

In recent years, medical training has significantly increased the use of simulation for teaching and evaluation. The retraining of medical personnel in Italy is entrusted to the program of Continuous Education in Medicine, mainly based on theoretical training. The aim of this study is to assess whether the use of a new sensorized platform for the execution of the neonatal intubation procedure in simulation environment can complement theoretical retraining of experienced health professionals.

Methods

Neonatal intubation tests were performed using a commercial manikin and a modified video-laryngoscope by the addition of force and position sensors, which provide the user with feedback when the threshold is exceeded. Two categories carried out the simulation tests: anesthesiologists and pediatricians. The categories were divided into three groups each, and various configurations were tested: the first group of both specialists carried out the tests without feedback (i.e. control groups, gr. A and A1), the second groups received sound and visual feedback from the instrument (gr. B and B1) and the third ones had also the support of a physician expert in the use of the instrument (gr. C and C1). The instrumentation used by pediatricians was provided in a playful form, including a game with increasing difficulty levels.

Results

Both in the case with feedback only and in the case with humans support, anesthesiologists did not show a specific trend of improvement. Pediatricians, in comparison with anesthesiologists, showed a positive reaction to both the presence of feedback and that of experienced personnel. Comparing the performance of the two control groups, the two categories of experienced doctors perform similar forces. Pediatricians enjoyed the “Level Game”, through which they were able to test and confront themselves, trying to improve their own performance.

Conclusions

Our instrument is more effective when is playful and competitive, introducing something more than just a sound feedback, and allowing training by increasing levels. It is more effective if the users can adapt their own technique to the instrument by themselves, without any external help.