The lost art of intubation: assessing opportunities for residents to 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.

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.

Provision of bubble continuous positive airway pressure for the stabilisation of extremely and very preterm infants after birth: A single-centre experience

AIM

To describe the effect of resuscitation with bubble CPAP (bCPAP) versus T-piece device at birth on early clinical parameters and hospital outcomes in infants born <32 weeks gestation.

METHODS

This is a single-centre pre- and post-implementation study comparing outcomes in two epochs. In epoch 1 (1 July 2013-31 December 2014), infants were managed with non-humidified gas using Neopuff® T-piece devices to support breathing after birth. In epoch 2 (1 March 2020-31 December 2021), routine application of bCPAP with humidified gas was introduced at birth.

RESULTS

Three hundred fifty-seven patients were included (176 epoch 1, 181 epoch 2). The mean gestational age was 28 ± 2 weeks. The demographics of the two epochs were comparable. There were significant improvements in outcomes of infants in epoch 2 with less infants intubated at delivery (16% vs. 4%, P ≤ 0.001), improved 5 min Apgar (7 vs. 8, P ≤ 0.001), reduced need for ventilation (21% vs. 8.8%, P ≤ 0.001), duration of ventilation in the first 72 h (9.6 vs. 4.6 h) and mortality (10.8% vs. 1.7%, P ≤ 0.001). There was, increased incidence of chronic lung disease (30% vs. 55%, P = 0.02) but no increase in infants discharged on oxygen (3.8% vs. 5%, P = 0.25). Similar findings were observed in a subgroup of infants born <25 weeks' gestation with no increase in the incidence of CLD.

CONCLUSION

Introducing application of bCPAP from the first breaths in infants <32 weeks' gestation was associated with better short-term outcomes and mortality, albeit with increased incidence of CLD. The subgroup of infants born <25 weeks' gestation showed similar change in outcomes, with no increase in CLD.

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.

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.).

Experience informed procedural skills training

BACKGROUND

Paediatric critical care (PCC) physicians must perform several emergent procedures independently and competently-requiring transition from novice to competent over a 3-year fellowship. However, skill acquisition is not uniform. Individualised training, adapted to the unique experiences and requirements of each trainee, may enhance competency.

APPROACH

An individualised, longitudinal critical procedure course was initiated at a large academic paediatric medical centre in July 2022 for PCC fellows (n = 5). The course, informed by procedural performance profiles (P3) generated through real-time clinical assessments in the paediatric intensive care unit (PICU), was split into three phases: (1) an Initial Simulation Bootcamp-a 2-day introductory session; (2) Quarterly Structured Booster Sessions (QSBS)-spaced repetition of deliberate practice training individualised to each fellow; and (3) an Annual Refresher Training-a core skills and advanced technique training day.

EVALUATION

Fellows began with minimal experience, which formed their initial P3s. Ninety-two percent (166/180) of bedside procedures received real-time feedback, enabling longitudinal P3 modification, which identified focus areas for the QSBS. The sessions were well attended and received. Eighty-nine percent (QSBS #1 5/5, QSBS #2 3/4) of respondents reflected positively on the course's impact on procedural understanding. The course was perceived as more effective than traditional modalities, except bedside training.

IMPLICATION

Implementation of a spaced repetition, deliberate practice course informed by longitudinally tracked real-life performance data is feasible for educators and preferred by trainees. This educational construct can be applied to other clinical skills, bringing precision medicine approach to training.

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.

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.

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

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

Cerebral Oxygenation during Neonatal Intubation with Nasal High Flow: A Sub-Study of the SHINE Randomized Trial

INTRODUCTION

Nasal high flow (nHF) improves the likelihood of successful neonatal intubation on the first attempt without physiological instability. The effect of nHF on cerebral oxygenation is unknown. The aim of this study was to compare cerebral oxygenation during endotracheal intubation in neonates receiving nHF and those receiving standard care.

METHODS

A sub-study of a multicentre randomized trial of nHF during neonatal endotracheal intubation. A subset of infants had near-infrared spectroscopy (NIRS) monitoring. Eligible infants were randomly assigned to nHF or standard care during the first intubation attempt. NIRS sensors provided continuous regional cerebral oxygen saturation (rScO2) monitoring. The procedure was video recorded, and peripheral oxygen saturation and rScO2 data were extracted at 2-second intervals. The primary outcome was the average difference in rScO2 from baseline during the first intubation attempt. Secondary outcomes included average rScO2 and rate of change of rScO2.

RESULTS

Nineteen intubations were analyzed (11 nHF; 8 standard care). Median (interquartile range [IQR]) postmenstrual age was 27 (26.5-29) weeks, and weight was 828 (716-1,135) g. Median change in rScO2 from baseline was -1.5% (-5.3 to 0.0) in the nHF group and -9.4% (-19.6 to -4.5) in the standard care group. rScO2 fell more slowly in infants managed with nHF compared with standard care: median (IQR) rScO2 change -0.08 (-0.13 to 0.00) % per second and -0.36 (-0.66 to -0.22) % per second, respectively.

CONCLUSIONS

In this small sub-study, regional cerebral oxygen saturation was more stable in neonates who received nHF during intubation compared with standard care.

A tiny baby intubation team improves endotracheal intubation success rate but decreases residents' training opportunities

OBJECTIVE

To assess the educational and clinical impact of a tiny baby intubation team (TBIT).

STUDY DESIGN

Retrospective study comparing endotracheal intubation (ETI) performed: pre-implementation of a TBIT (T1), 6 months post-implementation (T2), and 4 years post-implementation (T3).

RESULTS

Post-implementation (T2), first-attempt success rate in tiny babies increased (44% T1; 59% T2, p = 0.04; 56% T3, p = NS) and the proportion of ETIs performed by residents decreased (53% T1; 37% T2, p = 0.001; 45% T3, p = NS). After an educational quality improvement intervention (prioritizing non-tiny baby ETIs to residents, systematic simulation training and ETI using videolaryngoscopy), in T3 residents' overall (67% T1; 60% T2, p = NS; 79% T3, p = 0.02) and non-tiny baby ETI success rate improved (72% T1; 60% T2, p = NS; 82% T3, p = 0.02).

CONCLUSION

A TBIT improves success rate of ETIs in ELBW infants but decreases educational exposure of residents. Educational strategies may help maintain resident procedural competency without impacting on quality of care.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine

Background

Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees.

Methods

This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods.

Results

There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods.

Conclusions

The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

OBJECTIVE

In adult patients with acute respiratory failure, nasal high-flow (NHF) therapy at the time of intubation can decrease the duration of hypoxia. The objective of this pilot study was to calculate duration of peripheral oxygen saturation below 75% during single and multiple intubation attempts in order to inform development of a larger definitive trial.

DESIGN AND SETTING

This double-blinded randomised controlled pilot trial was conducted at a single, tertiary neonatal centre from October 2020 to October 2021.

PARTICIPANTS

Infants undergoing oral intubation in neonatal intensive care were included. Infants with upper airway anomalies were excluded.

INTERVENTIONS

Infants were randomly assigned (1:1) to have NHF 6 L/min, FiO₂ 1.0 or NHF 0 L/min (control) applied during intubation, stratified by gestational age (<34 weeks vs ≥34 weeks).

MAIN OUTCOME MEASURES

The primary outcome was duration of hypoxaemia of <75% up to the time of successful intubation, RESULTS: 43 infants were enrolled (26 <34 weeks and 17 ≥34 weeks) with 50 intubation episodes. In infants <34 weeks' gestation, median duration of SpO₂ of <75% was 29 s (0-126 s) vs 43 s (0-132 s) (p=0.78, intervention vs control). Median duration of SpO_{2 of} <75% in babies ≥34 weeks' gestation was 0 (0-32 s) vs 0 (0-20 s) (p=0.9, intervention vs control).

CONCLUSION

This pilot study showed that it is feasible to provide NHF during intubation attempts. No significant differences were noted in duration of oxygen saturation of <75% between groups; however, this trial was not powered to detect a difference. A larger, higher-powered blinded study is warranted.

Effect of training using high-versus low-fidelity simulator mannequins on neonatal intubation skills of pediatric residents: a randomized controlled trial

BACKGROUND

Mounting evidence supports the effective acquisition of skills through simulation-based training including intubation skills of neonates. Our aim is to compare the effect of using high- versus low-fidelity mannequin simulation-based training on the acquisition and retention of neonatal intubation skills by junior pediatric residents.

METHODS

Randomized controlled trial involving first- and second-year pediatric residents from two centers in Jeddah, Saudi Arabia.

RESULTS

Twenty-eight junior pediatric residents (12 low- and 16 high-fidelity mannequins) completed the study. A significantly greater number of residents achieved and retained the required skills after completing the training course in both arms. There was no significant difference in the achieved skills between residents trained on high- versus low-fidelity mannequins at the baseline, immediately after training, and at 6-9 months after training.

CONCLUSION

Simulation-based training resulted in improving pediatric residents' intubation skills regardless of the level of fidelity.

Nasal High-Flow Therapy during Neonatal Endotracheal Intubation

BACKGROUND

Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt.

METHODS

We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant.

RESULTS

The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3).

CONCLUSIONS

Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).

Appropriate Management of the Nonvigorous Meconium-Stained Newborn Meconium

Before 2015, major changes in Neonatal Resuscitation Program (NRP) recommendations not supporting previously endorsed antepartum, intrapartum and postpartum interventions to prevent meconium aspiration syndrome were based on adequately powered multicenter randomized controlled trials. The 2015 and 2020 American Heart Association guidelines and 7th and 8th edition of NRP suggest not performing routine intubation and tracheal suctioning of nonvigorous meconium-stained newborns. However, this was given as a weak recommendation with low-certainty evidence. The purpose of this review is to summarize the evidence and explore the question of appropriate delivery room management for nonvigorous meconium-stained newborns.

Indications and outcomes of neonatal intubation: A single-center, prospective study in a middle-income country

BACKGROUND

This study assessed the success rate and associated complications of hospital-wide neonatal endotracheal intubations by pediatric residents and neonatal fellows using direct laryngoscopy. Secondary objectives were to identify characteristics and indications for the procedure in a tertiary-care center.

METHODS

A cross-sectional observational study was conducted. We prospectively collected performance and infant outcome data after neonatal intubation between March 1, 2019 and February 29, 2020.

RESULTS

171 intubations were observed in 105 infants. The median infant gestational age was 31.0 weeks (interquartile range [IQR]: 27.5-36.0 weeks). Fifty infants (48%) were very low birth weight (VLBW, <1500 g; median 1640 g [IQR: 870-2420 g]). The most common indication for intubation was respiratory failure (65%). Pediatric residents and neonatal fellows had overall success rates of 66% and 98%, respectively. The success rate for the first intubation attempt was higher with more advanced pediatric residency training (P < 0.001). The median attempts for each intubation were 1 (IQR: 1-2) for both VLBW and non-VLBW infants (P = 0.48). The adverse outcome rates were 5% and 3% for VLBW and non-VLBW infants, respectively (P = 0.53). More than 2 intubation attempts was the only significant independent risk factor for adverse outcomes (adjusted odds ratio 6.7; 95% CI 1.3-33.6; P = 0.02).

CONCLUSIONS

The success rate of pediatric residents for neonatal intubation was similar for VLBW and non-VLBW infants. The main indication was respiratory failure, and nearly half were infants with VLBW. To minimize adverse sequelae, written guidelines limiting the number of intubation attempts by junior trainees are warranted.

Simulation for Neonatal Endotracheal Intubation Training: How Different Is It From Clinical Practice?

INTRODUCTION

Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity.

METHODS

A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach.

RESULTS

Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design.

CONCLUSIONS

Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.

Improving Intubation Success in Pediatric and Neonatal Transport Using Simulation

BACKGROUND

Pediatric and neonatal first-pass intubation rates are higher in adult trained retrieval services than in neonatal or pediatric trained services. Some authors have attributed this to more frequent opportunities to practice the skill in the adult population.

OBJECTIVE

The aim of this study was to increase the first-pass intubation rate without adverse events by introducing daily intubation simulation at our mixed neonatal and pediatric retrieval service.

METHODS

This prospective cohort study performed from July to December 2018 in our mixed neonatal and pediatric retrieval service involved 16 medical staff performing simulated intubation at commencement of their retrieval shift with a retrieval nurse. Checklists for neonatal and pediatric intubation were introduced to the retrieval service for the intervention cohort. Participants were asked to complete questionnaires about intubation performed on retrieval to gather data not routinely collected by the service.

RESULTS

Seven hundred and sixty-eight patients were retrieved by the service and 70 patients required intubation by the retrieval team during the intervention period. First-pass intubation rates were higher during the intervention period compared with a historical cohort, despite less intubations being performed overall. First-pass intubation rates improved from 59% to 78% in neonatal patients (P = 0.032), 58% to 65% in pediatric patients (P = 0.68) and from 58% to 74% overall (P = 0.043). There were no severe adverse events detected during the intervention period. Minor adverse events were associated with multiple attempts at intubation (P < 0.001). Overall compliance with simulation protocol was 43.5%, and on average, each doctor completed simulation once per month.

CONCLUSIONS

Simulation is a useful adjunct to support neonatal and pediatric intubation training in the current environment of reducing intubation frequency.

Validation of an Instrument for Real-Time Assessment of Neonatal Intubation Skills: A Randomized Controlled Simulation Study

OBJECTIVE

This study aimed to evaluate the construct validity and reliability of real-time assessment of a previously developed neonatal intubation scoring instrument (NISI).

STUDY DESIGN

We performed a randomized controlled simulation study at a simulation-based research and training facility. Twenty-four clinicians experienced in neonatal intubation ("experts") and 11 medical students ("novices") performed two identical elective intubations on a neonatal patient simulator. Subjects were randomly assigned to either the intervention group, receiving predefined feedback between the two intubations, or the control group, receiving no feedback. Using the previously developed NISI, all intubations were assessed, both in real time and remotely on video. Construct validity was evaluated by (1) comparing the intubation performances, expressed as percentage scores, with and without feedback, and (2) correlating the intubation performances with the subjects' level of experience. The intrarater reliability, expressed as intraclass correlation coefficient (ICC), of real-time assessment compared with video-based assessment was determined.

RESULTS

The intervention group contained 18 subjects, the control group 17. Background characteristics and baseline intubation scores were comparable in both groups. The median (IQR) change in percentage scores between the first and second intubation was significantly different between the intervention and control group (11.6% [4.7-22.8%] vs. 1.4% [0.0-5.7%], respectively; p = 0.013). The 95% CI for this 10.2% difference was 2.2 to 21.4%. The subjects' experience level correlated significantly with their percentage scores (Spearman's R = 0.70; p <0.01). ICC's were 0.95 (95% CI: 0.89-0.97) and 0.94 (95% CI: 0.89-0.97) for the first and second intubation, respectively.

CONCLUSION

Our NISI has construct validity and is reliable for real-time assessment.

KEY POINTS

· Our neonatal intubation scoring instrument has construct validity.. · Our instrument can be reliably employed to assess neonatal intubation skills directly in real time.. · It is suitable for formative assessment, i.e., providing direct feedback during procedural training..

Intubation Competence During Neonatal Fellowship Training

OBJECTIVES

To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training.

METHODS

Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success.

RESULTS

There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14).

CONCLUSIONS

The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.

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.

Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management

BACKGROUND

This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration.

METHODS

This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model.

RESULTS

Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopy are unique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community.

CONCLUSIONS

Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation (the SHINE trial): a study protocol

INTRODUCTION

Neonatal endotracheal intubation is an essential but potentially destabilising procedure. With an increased focus on avoiding mechanical ventilation, particularly in preterm infants, there are fewer opportunities for clinicians to gain proficiency in this important emergency skill. Rates of successful intubation at the first attempt are relatively low, and adverse event rates are high, when compared with intubations in paediatric and adult populations. Interventions to improve operator success and patient stability during neonatal endotracheal intubations are needed. Using nasal high flow therapy extends the safe apnoea time of adults undergoing upper airway surgery and during endotracheal intubation. This technique is untested in neonates.

METHODS AND ANALYSIS

The Stabilisation with nasal High flow during Intubation of NEonates (SHINE) trial is a multicentre, randomised controlled trial comparing the use of nasal high flow during neonatal intubation with standard care (no nasal high flow). Intubations are randomised individually, and stratified by site, use of premedications, and postmenstrual age (<28 weeks' gestation; ≥28 weeks' gestation). The primary outcome is the incidence of successful intubation on the first attempt without physiological instability of the infant. Physiological instability is defined as an absolute decrease in peripheral oxygen saturation >20% from preintubation baseline and/or bradycardia (<100 beats per minute).

ETHICS AND DISSEMINATION

The SHINE trial received ethical approval from the Human Research Ethics Committees of The Royal Women's Hospital, Melbourne, Australia and Monash Health, Melbourne, Australia. The trial is currently recruiting in these two sites. The findings of this study will be disseminated via peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618001498280.

Implementation of less invasive surfactant administration in clinical practice-Experience of a mid-sized country

Objective

There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level.

Methods

A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform.

Results

Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated “easy/very easy” vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with “RAM” cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes.

Conclusions

The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.

Current training in percutaneously inserted central catheter (PICC) placement and maintenance for neonatal-perinatal medicine fellows

OBJECTIVE

To describe the current educational status of percutaneously inserted central catheter (PICC) insertion/ maintenance training for neonatal-perinatal medicine (NPM) fellows in the United States.

STUDY DESIGN

A cross-sectional 34-question survey was electronically distributed to NPM fellowship training program directors (PDs) in the United States.

RESULTS

The response rate was 81.8% (81/99 PD). Most PDs (68.5%) reported that their neonatal intensive care unit has a PICC team. Fellows were PICC team members in 72%. Only 52% of programs offer formal training in PICC placement to fellows; 61.5% of these utilize a standardized curriculum. Dedicated PICC team existence was negatively associated with formal training for PICC insertion and maintenance for fellows (42.0% with PICC team vs. 73.91% without, p = 0.01).

CONCLUSIONS

Wide variation exists in fellow's exposure, education, and competency assessment in PICC-related activities nationally. Development of a standardized curriculum would be beneficial.

Normal and difficult airways in children: "What's New"-Current evidence

BACKGROUND

Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit.

METHODS

Expert review of the recent literature.

RESULTS

Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation-associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration.

CONCLUSION

Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.

The most common patient safety issues resulting in legal action against neonatologists

Common patient safety issues may result in injuries to babies in the newborn period. A medical malpractice lawsuit is one way in which an injured patient can obtain compensation for the injuries they sustained as the result of an error. There are a number of common areas of malpractice risk for neonatologists including the delivery room, jaundice, hypoglycemia, and late preterm infants. A better understanding of the medical malpractice system and common patient safety issues in neonatology can lead to protective strategies to reduce risk for untoward events and subsequent litigation. Strategies including maintaining competency, following national guidelines, and proper communication and documentation can improve the care and treatment of neonatal patients and their families resulting in less malpractice exposure.

A review of the use of supraglottic airways in neonates for use during interhospital transfer

A secure and patent airway is a prerequisite to safe interhospital transfer and this has traditionally been via endotracheal tubes. Neonatal intubation success rates are falling as there is declining opportunities amongst paediatric junior doctors and consultants, therefore being able to successfully intubate an infant before or during a transfer, especially if they have an airway anomaly, may be very challenging. The use of supraglottic airways is increasingly popular in neonatology as an alternative to facemask ventilation or endotracheal intubation. This review considers the role of supraglottic airway devices during the stabilisation and transfer of neonates.

Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates

OBJECTIVE

To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU).

DESIGN

Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates.

SETTING

Ten academic NICUs.

PATIENTS

Neonates intubated in the NICU at each of the sites between October 2014 and March 2017.

MAIN OUTCOME MEASURES

Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation.

RESULTS

Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53).

CONCLUSIONS

Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.

Endotracheal intubation skills of pediatricians versus anesthetists in neonates and children

This study compares the performance of pediatricians and anesthetists in neonatal and pediatric endotracheal intubations (ETI) during simulated settings. Participants completed a questionnaire and performed an ETI scenario on a neonatal and a child manikin. The procedures were recorded with head cameras and cameras attached to standard laryngoscope blades. The outcomes were successful intubation, time to successful intubation, number of attempts, complications, total performance score, end-assessment rating, and an assessment whether the participant was sufficiently able to perform an ETI. Fifty-two pediatricians and 52 anesthetists were included. For the neonatal ETI, the rate of successful intubation was in favor of anesthetists although not significant. Anesthetists performed significantly better in all other outcomes. Of the pediatricians, 65% was rated sufficiently adept to perform a neonatal ETI vs 100% of the anesthetists. Pediatricians (29%) overestimated while anesthetists (33%) underestimated their performance in neonatal ETI. For the pediatric ETI, all outcomes were significantly better for anesthetists. Only 15% of all pediatricians were considered sufficiently able to perform pediatric ETI vs 94% of the anesthetists.Conclusion: Anesthetists are far more adept in performing ETI in neonates and children compared with pediatricians in a simulated setting. Complications are expected to occur less frequently and less seriously when anesthetists perform ETI. What is Known: • Endotracheal intubation (ETI) performed by inexperienced care providers can lead to unsuccessful and/or prolonged intubation attempts. This can cause complications such as hypoxemia, trauma to the oropharynx and larynx, and prolonged interruption of resuscitation, which results in a high morbidity/mortality. • Fifty to 60 real-life ETI procedures are needed before ETI can be performed with a 90% success rate. Despite this, 18% of providers still require some assistance even after performing 80 intubations. Skill fade will occur if there is too little exposure. What is New: • This study shows that, on both neonatal and child manikins, anesthetists perform better in ETI compared with pediatricians. Besides this, complications are expected to occur less frequently and less seriously when anesthetists are performing the ETIs on neonates and children. • In those countries where there are no clear interprofessional agreements made in general hospitals on who will perform ETI on neonates and children in acute care settings, these agreements are urgently necessary.

Neonatal Intubation Practice and Outcomes: An International Registry Study

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What Do NICU Fellows Identify as Important for Achieving Competency in Neonatal Intubation?

BACKGROUND

Tracheal intubation (TI) is one of the most important interventions for the stabilization of critically ill neonates. Competency in airway management is essential for neonatal fellows. No studies have assessed which educational models, techniques, or instructions are perceived by neonatal fellows as the most beneficial for achieving competency in TI.

OBJECTIVES

This study identifies which factors are considered most helpful in achieving intubation competency.

METHOD

This was a mixed-method study. Semi-structured phone interviews addressed training experience for neonatal intubation. Through qualitative analysis, common themes were identified. RedCap electronic surveys and procedure logs were used to assess procedural experience.

RESULTS

Forty-two fellows from 5 programs completed phone interviews. Fellows recalled 6-10 intubation attempts before fellowship. Independent statements related to achieving intubation competency were analyzed and coded into 5 main themes (Procedure, Practice, Perceptual Environment, Personnel, and Preparation). A large proportion of the statements focused on the use of video laryngoscopy.

CONCLUSIONS

The themes identified by neonatal-perinatal medicine (NPM) fellows as being the most beneficial in achieving proficiency in neonatal TI are categorized as "The 5 Ps." Careful review of these themes may be utilized to develop validated curriculums that enhance the teaching of TI and optimize the achievement of TI competency among NPM fellows.

A Randomized Controlled Trial of a Video-Enhanced Advanced Airway Curriculum for Pediatric Residents

PURPOSE

Pediatric advanced airway management is a low-frequency but critical procedure, making it challenging for trainees to learn. This study examined the impact of a curriculum integrating prerecorded videos of patient endotracheal intubations on performance related to simulated pediatric intubation.

METHOD

The authors conducted a randomized controlled educational trial for pediatric residents between January 2015 and June 2016 at Boston Children's Hospital. Investigators collecting data were blinded to the intervention. The control group received a standard didactic curriculum including still images, followed by simulation on airway trainers. The intervention group received a video-enhanced didactic curriculum including deidentified intubation clips recorded using a videolaryngoscope, followed by simulation. The study assessed intubation skills on simulated infant and pediatric airway scenarios of varying difficulty immediately after instruction and at three months.

RESULTS

Forty-nine trainees completed the curriculum: 23 received the video-enhanced curriculum and 26 received the standard curriculum. Median time to successful intubation was 18.5 and 22 seconds in the video-enhanced and standard groups, respectively. Controlling for mannequin age and difficulty, residents receiving the video-enhanced curriculum successfully intubated faster (hazard ratio [95% confidence interval]: 1.65 [1.25, 2.19]). Video-enhanced curriculum participants also demonstrated decreased odds of requiring multiple attempts and of esophageal intubation. At three-month follow-up, residents who received the video-enhanced curriculum remained faster at intubation (hazard ratio [95% confidence interval]: 1.93 [1.23, 3.02]).

CONCLUSIONS

Integrating videos of patient intubations into an airway management curriculum improved participating pediatric residents' intubation performance on airway trainers with sustained improvement at three months.

Analysis of unsuccessful intubations in neonates using videolaryngoscopy recordings

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Trainees success rates with intubation to suction meconium at birth

OBJECTIVES

To assess the success rate and main reasons for failure of intubation performed by medical trainees to suction meconium below the vocal cords in non-vigorous infants delivered at ≥36 week gestation.

DESIGN

We conducted a prospective cohort study involving 54 residents and nine neonatology fellows in a Canadian level 3 neonatal intensive care unit. Endotracheal intubation to suction meconium was performed using a videolaryngoscope, the video screen being covered during the procedure. All videos were reviewed by two experts blinded to the procedure and to the identity of the trainee.

RESULTS

Sixteen videos were available to review between July 2014 and March 2016. Intubation success rate assessed by the reviewers was 6%, compared with 21% as assessed by the trainees. The most common reasons for intubation failure were an improper view of the glottis (87%) and meconium or secretions obscuring the view (67%). 36 % of the time, the trainees identified different reasons for intubation failure than the reviewers.

CONCLUSION

Success rate of neonatal intubation to suction meconium was much lower than the success rate reported on infants without meconium. Teaching should be geared towards the most common reasons for intubation failure, possibly using video-based teaching.

A randomized controlled trial: does coaching using video during direct laryngoscopy improve residents' success in neonatal intubations?

OBJECTIVE

To evaluate the intubation success rates of residents who receive coaching from supervisors concurrently viewing infants' airways via video during direct laryngoscopy (VDL), as compared with coaching during traditional direct laryngoscopy without video (TDL).

STUDY DESIGN

In a randomized controlled trial, 48 first and second-year residents performed neonatal intubations using VDL or TDL. The primary outcome was intubation success rates. Data were analyzed using the Pearson X² and Student's t-test.

RESULTS

The overall intubation success rate was greater in the VDL vs. TDL group (57% vs. 33%, P < 0.05). First-year residents and residents intubating their first patient had higher intubation success rates in the VDL vs. TDL group (58% vs. 23% and 50% vs. 17%, respectively, P < 0.05).

CONCLUSIONS

Resident coaching using VDL improved neonatal intubation success rates. Incorporating VDL as a coaching tool can optimize the quality of training during limited opportunities to achieve procedural competency and improve intubation-related patient outcomes.

Improving neonatal intubation safety: A journey of a thousand miles

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.

Development and Testing of a Neonatal Intubation Checklist for an Air Medical Transport Team

OBJECTIVE

We developed a Neonatal Intubation Checklist for Airlift Northwest. Our goal was to improve the preparation, technical proficiency, and safety of neonatal intubation without increasing the time required to perform the procedure.

METHODS

The Neonatal Intubation Checklist, a "call and response" checklist for neonatal intubation, was developed. Its effectiveness was evaluated during a baseline assessment and 2 practice sessions after a checklist orientation. Intubation proficiency was evaluated using a validated assessment tool that included a proficiency score, a global rating scale (GRS) score, and time to perform the procedure.

RESULTS

Significant improvements in intubation proficiency and time to intubation were noted when teams used the intubation checklist (proficiency score: 29 [7] at baseline vs. 57 [1] with checklist, P < .001; GRS 2 [2, 2.5] at baseline vs. 5 [3, 5] with checklist, P < .001; baseline intubation time 626 [93] seconds vs. 479 (44) seconds with checklist, P < .001). These changes were associated with a large effect on proficiency (ƞ2 = 0.89), GRS (ƞ2 = 0.6), and time to successful intubation (ƞ2 = 0.52).

CONCLUSION

The use of the Neonatal Intubation Checklist improved transport team performance during simulated neonatal intubations and decreased the time required to successfully perform the procedure.

Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? a randomized controlled study

BACKGROUND

To study the impact of videolaryngoscopy (VL) on intubation success among pediatric trainees compared with direct laryngoscopy (DL).

METHODS

One hundred pediatric residents were enrolled in a randomized, crossover, simulation study comparing VL to DL. Following a didactic session on neonatal intubation, residents intubated a standard neonatal mannequin. Three Neonatal Resuscitation Program (NRP) scenarios were then conducted, followed by a mannequin intubation with the alternate device. Number of attempts and time to intubation were recorded for all intubations.

RESULTS

Proportion of successful intubations on first attempt was greater with VL compared with DL (88% versus 63%; P=0.008). The DL group increased success after crossover with VL (63% versus 89%; P=0.008). Exposure to VL also reduced intubation time after device crossover (median intubation time: 31 versus 17 s; P=0.048).

CONCLUSIONS

VL increased the success of endotracheal intubation by pediatric residents in simulation, with skills transferrable to DL.

Preparedness of pediatric residents for fellowship: a survey of US neonatal-perinatal fellowship program directors

OBJECTIVE

To evaluate the preparedness of pediatric residents entering accredited neonatal-perinatal medicine (NPM) fellowships in the United States.

STUDY DESIGN

A multi-domain, validated survey was distributed to Program Directors (PDs) of US NPM fellowship programs. The 47-item survey explored 5 domains: professionalism, independent practice, psychomotor ability, clinical evaluation, and academia. A systematic, qualitative analysis on free-text comments was also performed.

RESULTS

Sixty-one PDs completed the survey, for a response rate of 62% (61/98). For entering fellows, PDs assessed performance in professionalism positively, including 76% as communicating effectively with parents and 90% treating residents/house-staff with respect. In contrast, most PDs rated performance in psychomotor abilities negatively, including 59% and 79% as deficient in bag-and-mask ventilation and neonatal endotracheal intubation, respectively. Although 62% of PDs assessed entering fellows positively for genuine interest in academic projects, fewer than 10% responded positively that entering fellows understood research protocol design, basic statistics, or were capable of writing a cohesive manuscript well. Thematic clustering of qualitative data revealed deficits in psychomotor ability and academia/scholarship.

CONCLUSIONS

On the basis of the perspective of front line educators, graduating pediatric residents are underprepared for subspecialty fellowship training in NPM. To provide the best preparation for pediatric graduates who pursue advanced training, changes to residency education to address deficiencies in these important competencies are warranted.

Procedural training and assessment of competency utilizing simulation

This review examines the current environment of neonatal procedural learning, describes an updated model of skills training, defines the role of simulation in assessing competency, and discusses potential future directions for simulation-based competency assessment. In order to maximize impact, simulation-based procedural training programs should follow a standardized and evidence-based approach to designing and evaluating educational activities. Simulation can be used to facilitate the evaluation of competency, but must incorporate validated assessment tools to ensure quality and consistency. True competency evaluation cannot be accomplished with simulation alone: competency assessment must also include evaluations of procedural skill during actual clinical care. Future work in this area is needed to measure and track clinically meaningful patient outcomes resulting from simulation-based training, examine the use of simulation to assist physicians undergoing re-entry to practice, and to examine the use of procedural skills simulation as part of a maintenance of competency and life-long learning.

NewB for newbies: a randomized control trial training housestaff to perform neonatal intubation with direct and videolaryngoscopy

BACKGROUND

Competency rates in neonatal intubation among pediatric residents are low and currently not meeting ACGME/AAP standards.

AIMS

The aim of this study was to compare standard bedside teaching of neonatal endotracheal intubation to a computer module, as well as introduce residents to the emerging technology of videolaryngoscopy.

METHODS

The study population consisted of The University of Texas Health Science Center at San Antonio Pediatric interns/residents and PGY-1 Anesthesia interns rotating through the NICU. Prior to participating in the study, the residents completed a survey addressing past experiences with intubation, comfort level, and prior use of direct and videolaryngoscopy. Participants then performed timed trials of both direct and videolaryngoscopy on the SimNewB(®). They had up to three attempts to successfully intubate, with up to 30 s on each attempt. After randomization, participants received one of the following teaching interventions: standard, computer module, or both. This was followed by a second intubation trial and survey completion.

RESULTS

Thirty residents were enrolled in the study. There was significant improvement in time to successful intubation in both methods after any teaching intervention (direct 22.0 ± 13.4 s vs 14.7 ± 5.9 s, P = 0.002 and videolaryngoscopy 42.2 ± 29.3 s vs 26.8 ± 18.6 s, P = 0.003). No differences were found between the types of teaching. Residents were faster at intubating with direct laryngoscopy compared to videolaryngoscopy before and after teaching. By the end of the study, only 33% of residents preferred using videolaryngoscopy over direct laryngoscopy, but 76% felt videolaryngoscopy was better to teach intubation.

CONCLUSIONS

Both standard teaching and computer module teaching of neonatal intubation on a mannequin model results in improved time to successful intubation and overall improved resident confidence with intubation equipment and technique. Although intubation times were lower with direct laryngoscopy compared to videolaryngoscopy, the participating residents felt that videolaryngoscopy is an important educational tool.

Neonatal airway simulators, how good are they? A comparative study of physical and functional fidelity

OBJECTIVE

Proficiency in airway management is critical for neonatal health-care professionals. Simulation is a proven method to improve airway management skills. Skills transfer from simulation to the real life requires simulators with appropriate physical and functional fidelity.

STUDY DESIGN

A cohort of neonatal health-care professionals evaluated eight different neonatal airway simulators for physical and functional fidelity.

RESULT

Twenty-seven subjects completed 151 simulator evaluations. Significant differences were found between the simulators evaluated (P<0.001). The manikins with the highest fidelity scores were the SimNewB, Newborn Anne and Premature Anne (Laerdal Medical). The task trainers with the highest fidelity scores were the Neonatal Intubation Trainer (Laerdal Medical) and the Newborn Airway Trainer (Syndaver Labs).

CONCLUSION

Simulator fidelity is an important aspect of simulation training, but is rarely evaluated. The results of this study can aid in choosing the best simulators for training and research, and provide feedback to the industry to guide future simulator development.

Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predicting neonatal intubation competency in trainees

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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