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Pinheiro JMB. Neonatal Airway Management. CHILDREN (BASEL, SWITZERLAND) 2024; 11:82. [PMID: 38255395 PMCID: PMC10814596 DOI: 10.3390/children11010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Abstract
The neonatal airway is often difficult to secure, whether the practitioner responsible for managing the airway is a neonatologist, pediatrician, anesthesiologist, another specialist or an advanced practice provider [...].
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Affiliation(s)
- Joaquim M B Pinheiro
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA
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Herrick HM, O'Reilly MA, Foglia EE. Success rates and adverse events during neonatal intubation: Lessons learned from an international registry. Semin Fetal Neonatal Med 2023; 28:101482. [PMID: 38000925 PMCID: PMC10842734 DOI: 10.1016/j.siny.2023.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
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.
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Affiliation(s)
- Heidi M Herrick
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Mackenzie A O'Reilly
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
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Glenn T, Fischer L, Markowski A, Carr CB, Malay S, Hibbs AM. Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants. Am J Perinatol 2023; 40:1245-1252. [PMID: 34500482 PMCID: PMC9239052 DOI: 10.1055/s-0041-1736130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH). STUDY DESIGN A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2. RESULTS A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048). CONCLUSION The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD. KEY POINTS · Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..
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Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Linnea Fischer
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Cara Beth Carr
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
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Cavallin F, Margarita T, Bua B, Beltrame F, Pasta E, Villani PE, Trevisanuto D. Rigid versus soft catheter for less invasive surfactant administration: A crossover randomized controlled manikin trial. Pediatr Pulmonol 2023. [PMID: 37154505 DOI: 10.1002/ppul.26458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/01/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND We compared surfactant administration with a rigid versus soft catheter in a manikin simulating an extremely preterm infant. METHODS Randomized controlled crossover (AB/BA) trial. Fifty tertiary hospital consultants and pediatric residents. The primary outcome was the time of device positioning. The secondary outcomes were the success of the first attempt, the number of attempts, and the participant's opinion. RESULTS Median time of device positioning was 19 s (interquartile range [IQR]: 15-25) with rigid catheter and 40 s (IQR: 28-66) with soft catheter (p < 0.0001). Success at first attempt was 92% with rigid catheter and 74% with soft catheter (p = 0.01). Median number of attempts was 1 (IQR: 1-1) with rigid catheter and 1 (IQR: 1-2) with soft catheter (p = 0.009). Participants found the rigid catheter easier to use (p < 0.0001). CONCLUSIONS In a preterm manikin model, using a rigid catheter for less invasive surfactant administration was quicker and easier to use than a soft catheter.
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Affiliation(s)
| | - Teresa Margarita
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Benedetta Bua
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Francesca Beltrame
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
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Pinheiro JMB, Munshi UK, Chowdhry R. Strategies to Improve Neonatal Intubation Safety by Preventing Endobronchial Placement of the Tracheal Tube-Literature Review and Experience at a Tertiary Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020361. [PMID: 36832490 PMCID: PMC9955846 DOI: 10.3390/children10020361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
Unintended endobronchial placement is a common complication of neonatal tracheal intubation and a threat to patient safety, but it has received little attention towards decreasing its incidence and mitigating associated harms. We report on the key aspects of a long-term project in which we applied principles of patient safety to design and implement safeguards and establish a safety culture, aiming to decrease the rate of deep intubation (beyond T3) in neonates to <10%. Results from 5745 consecutive intubations revealed a 47% incidence of deep tube placement at baseline, which decreased to 10-15% after initial interventions and remained in the 9-20% range for the past 15 years; concurrently, rates of deep intubation at referring institutions have remained high. Root cause analyses revealed multiple contributing factors, so countermeasures specifically aimed at improving intubation safety should be applied before, during, and immediately after tube insertion. Extensive literature review, concordant with our experience, suggests that pre-specifying the expected tube depth before intubation is the most effective and simple intervention, although further research is needed to establish accurate and accepted standards for estimating the expected depth. Presently, team training on intubation safety, plus possible technological advances, offer additional options for safer neonatal intubations.
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Foran J, Moore CM, Ni Chathasaigh CM, Moore S, Purna JR, Curley A. Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial. Arch Dis Child Fetal Neonatal Ed 2022; 108:244-249. [PMID: 36307187 PMCID: PMC10176365 DOI: 10.1136/archdischild-2022-324649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/04/2022] [Indexed: 11/03/2022]
Abstract
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 SpO2 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.
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Affiliation(s)
- Jason Foran
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Caitriona M Ni Chathasaigh
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Shirley Moore
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Jyothsna R Purna
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Anna Curley
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 2022; 42:1221-1227. [PMID: 35982243 DOI: 10.1038/s41372-022-01484-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between number of attempts and adverse events during neonatal intubation. STUDY DESIGN A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation). RESULTS Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt. CONCLUSION The risk of adverse safety events during intubation increases with the number of intubation attempts.
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