Endotracheal intubation in a neonatal population remains associated with a high risk of adverse events

Development of a New Dry Powder Aerosol Synthetic Lung Surfactant Product for Neonatal Respiratory Distress Syndrome (RDS) - Part I: In Vitro Testing and Characterization

PURPOSE

Improving the deep lung delivery of aerosol surfactant therapy (AST) with a dry powder formulation may enable significant reductions in dose while providing improved efficacy. The objective of Part I of this two-part study was to present the development of a new dry powder aerosol synthetic lung surfactant (SLS) product and to characterize performance based on aerosol formation and realistic in vitro airway testing leading to aerosol delivery recommendations for subsequent in vivo animal model experiments.

METHODS

A new micrometer-sized SLS excipient enhanced growth (EEG) dry powder formulation was produced via spray drying and aerosolized using a positive-pressure air-jet dry powder inhaler (DPI) intended for aerosol delivery directly to intubated infants with respiratory distress syndrome (RDS) or infant-size test animals.

RESULTS

The best-case design (D2) of the air-jet DPI was capable of high emitted dose (> 80% of loaded) and formed a < 2 µm mass median aerodynamic diameter (MMAD) aerosol, but was limited to ≤ 20 mg mass loadings. Testing with a realistic in vitro rabbit model indicated that over half of the loaded dose could penetrate into the lower lung regions. Using the characterization data, a dose delivery protocol was designed in which a 60 mg total loaded dose would be administered and deliver an approximate lung dose of 14.7-17.7 mg phospholipids/kg with a total aerosol delivery period < 5 min.

CONCLUSIONS

A high-efficiency aerosol SLS product was designed and tested that may enable an order of magnitude reduction in administered phospholipid dose, and provide rapid aerosol administration to infants with RDS.

Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants: Follow-Up of the OPTIMIST-A Randomized Clinical Trial

Importance

The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified.

Objective

To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age.

Design, Setting, and Participants

Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022.

Interventions

Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment.

Main Outcomes and Measures

The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years.

Results

Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]).

Conclusions and Relevance

In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life.

Trial Registration

anzctr.org.au Identifier: ACTRN12611000916943.

Comparison of mortality and short-term outcomes between classic, intubation-surfactant-extubation, and less invasive surfactant administration methods of surfactant replacement therapy

Background

Intubation-Surfactant-Extubation (InSurE) and less invasive surfactant administration (LISA) are alternative surfactant replacement therapy methods for reducing the complications associated with invasive mechanical ventilation. This study aimed to compare the Classic, InSurE, and LISA methods in Very-Low-Birth-Weight infants (VLBWIs) in South Korea.

Methods

The Korean Neonatal Network (KNN) enrolled VLBWIs born between January 1, 2019 and December 31, 2020. They were analyzed retrospectively to compare the duration of respiratory support, length of hospitalization, mortality, and short-term outcomes of the three groups.

Results

The duration of invasive ventilator support was shorter in the following order: InSurE (3.99 ± 11.93 days), LISA (8.78 ± 29.32 days), and the Classic group (22.36 ± 29.94 days) (p = 0.014, p < 0.01) and InSurE had the shortest hospitalization (64.91 ± 24.07 days, p < 0.05) although the results couldn't adjust for confounding factor because of irregular distribution. InSurE had the lower risk of intraventricular hemorrhage (IVH) grade II-IV [odds ratio (OR) 0.524 [95% confidence interval (CI): 0.287-0.956], p = 0.035] than in the Classic group. Mortality was lower in the InSurE [OR 0.377 (95% CI: 0.146-0.978), p = 0.045] and LISA [OR 0.296 (95% CI: 0.102-0.862), p = 0.026] groups than in the Classic group. There was a reduced risk of moderate to severe bronchopulmonary dysplasia (BPD) [OR 0.691 (95% CI: 0.479-0.998, p = 0.049), OR 0.544 (95% CI: 0.355-0.831, p = 0.005), respectively], pulmonary hypertension [OR 0.350 (95% CI: 0.150-0.817, p = 0.015), OR 0.276 (95% CI: 0.107-0.713, p = 0.008), respectively], periventricular leukomalacia (PVL) [OR 0.382 (95% CI: 0.187-0.780, p = 0.008), OR 0.246 (95% CI: 0.096-0.627, p = 0.003), respectively], and patent ductus arteriosus (PDA) with treatment [OR 0.628 (95% CI: 0.454-0.868, p = 0.005), OR 0.467 (95% CI: 0.313-0.696, p < 0.001) respectively] in the InSurE and LISA groups compared to the Classic group.

Conclusion

InSurE showed the lowest duration of invasive ventilator support, length of hospitalization. InSurE and LISA exhibited reduced mortality and decreased risks of moderate to severe BPD, pulmonary hypertension, PVL, and PDA with treatment compared to the Classic group.

Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel

Background: Optimal neonatal resuscitation requires knowledge and experience on the part of healthcare personnel. This study aims to assess the readiness of hospital healthcare personnel to perform neonatal resuscitation. Methods: This was an observational study conducted in May 2021 by distributing questionnaires to nurses, midwives, doctors, and residents to determine the level of knowledge and experience of performing neonatal resuscitation. Questionnaires were adapted from prior validated questionnaires by Jukkala AM and Henly SJ. We conducted the research in four types of hospitals A, B, C, and D, which are defined by the Regulation of the Minister of Health of the Republic of Indonesia. Type A hospitals have the most complete medical services, while type D hospitals have the least medical services. The comparative analysis between participants' characteristics and the knowledge or experience score was conducted. Results: A total of 123 and 70 participants were included in the knowledge and experience questionnaire analysis, respectively. There was a significant difference (p = 0.013) in knowledge of healthcare personnel between the type A hospital (median 15.00; Interquartile Range [IQR] 15.00-16.00) and type C hospital (median 14.50; IQR 12.25-15.75). In terms of experience, the healthcare personnel of type A (median 85.00; IQR 70.00-101.00) and type B (median 92.00; IQR 81.00-98.00) hospitals had significantly (p =0,026) higher experience scores than the type D (median 42.00; IQR 29.00-75.00) hospital, but we did not find a significant difference between other type of hospitals. Conclusions: In this study, we found that the healthcare personnel from type A and type B hospitals are more experienced than those from type D hospitals in performing neonatal resuscitation. We suggest that a type D hospital should refer the neonate to a type A or type B hospital if there is sufficient time in cases of risk at need for resuscitation.

Autonomic markers of extubation readiness in premature infants

BACKGROUND

In premature infants, extubation failure is common and difficult to predict. Heart rate variability (HRV) is a marker of autonomic tone. Our aim is to test the hypothesis that autonomic impairment is associated with extubation readiness.

METHODS

Retrospective study of 89 infants <28 weeks. HRV metrics 24 h prior to extubation were compared for those with and without extubation success within 72 h. Receiver-operating curve analysis was conducted to determine the predictive ability of each metric, and a predictive model was created.

RESULTS

Seventy-three percent were successfully extubated. The success group had significantly lower oxygen requirement, higher sympathetic HRV metrics, and a lower parasympathetic HRV metric. α₁ (measure of autocorrelation, related to sympathetic tone) was the best predictor of success-area under the curve (AUC) of .73 (p = 0.001), and incorporated into a predictive model had an AUC of 0.81 (p < 0.0001)-sensitivity of 81% and specificity of 78%.

CONCLUSIONS

Extubation success is associated with HRV. We show an autonomic imbalance with low sympathetic and elevated parasympathetic tone in those who failed. α₁, a marker of sympathetic tone, was noted to be the best predictor of extubation success especially when incorporated into a clinical model.

IMPACT

This article depicts autonomic markers predictive of extubation success. We depict an autonomic imbalance in those who fail extubation with heightened parasympathetic and blunted sympathetic signal. We describe a predictive model for extubation success with a sensitivity of 81% and specificity of 78%.

Surfactant therapy using a bronchofiberscope in respiratory distress syndrome

BACKGROUND

Avoiding endotracheal intubation and using nasal continuous positive airway pressure as the initial treatment is recommended in infants with respiratory distress syndrome (RDS), and modes of lesser invasive surfactant administration have recently been reported. We report a pilot study assessing the feasibility of surfactant therapy using a bronchofiberscope (STUB) in RDS.

METHODS

Surfactant was administered to 31 preterm infants (gestational age range of 28 weeks 0 days to 36 weeks 6 days) diagnosed with RDS, through the working channel of the bronchofiberscope or endotracheal tubes. Patient characteristics, outcomes, adverse events, and comorbidities were assessed in the two groups.

RESULTS

Twelve infants received STUB. Two of the 12 infants (17%) needed subsequent intubation and additional surfactant administration. Nineteen infants received surfactant through endotracheal tubes. Four of the 19 infants (21%) required additional surfactants. There was no significant difference in the number of infants that needed additional surfactant (p = 1.00). Gestational age, birthweight, length of hospitalization, adverse events, such as desaturations and bradycardias, and comorbidities were similar between the two groups. Days of invasive ventilation were significantly shorter in the STUB group (p = 0.0002).

CONCLUSION

STUB was feasible in this small cohort and reduced the need for intubation to 17%, leading to fewer days of invasive ventilation, without increasing comorbidities and adverse events. To the best of our knowledge, this is the first study to administer surfactants using bronchofiberscopes.

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

OBJECTIVE

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

RESULTS

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

CONCLUSIONS

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

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.

Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants

BACKGROUND

Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants.

METHODS

When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure.

RESULTS

Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6-30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5-4.2) versus 3.5 (2.1-5.3) µV; p < 0.001]. In the whole cohort, postmenstrual age (PMA) was the strongest predictor for extubation failure (area under the curve (AUC) 0.77). In infants of gestational age <29 weeks, the percentage change of the EMG predicted extubation failure with an AUC of 0.74 while PMA was not associated with the outcome of extubation.

CONCLUSIONS

In all preterm infants, PMA was the strongest predictor of extubation failure; in those born <29 weeks of gestation, diaphragmatic electromyography during an SBT was the best predictor of extubation failure.

IMPACT

Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.

Premedication with intravenous midazolam for neonatal endotracheal intubation: A double blind randomized controlled trial

Background

Pain during the neonatal period has been associated with immediate and long-term adverse effects. One of the most frequent painful procedures that neonates face in neonatal intensive care unit is the endotracheal intubation. Midazolam has been a candidate for premedication before neonatal intubation. Our aim was to evaluate the effects of midazolam as the premedication on endotracheal intubation of premature infants during surfactant administration.

Materials and Methods

In a double-blind clinical trial, 80 preterm infants were undertaken for tracheal intubation following the use of atropine associated to either midazolam or placebo. Patient's vital signs and general conditions were constantly monitored, and pain was assessed using premature infant pain profile (PIPP) score.

Results

The mean ± standard deviation for postnatal age was 95.38 ± 50.04 and 111.63 ± 49.4 min in control and midazolam groups, respectively. The patients in the midazolam group had significantly better outcomes across several intubation outcome measures such as duration of endotracheal intubation (23.5 ± 6.7 vs. 18.8 ± 4.8 s, P = 0.001), oxygen saturation level (88.05% ±13.7 vs. 95.1 ± 1.8%, P = 0.002), intubation failure (34.2% vs. 2.5%, P = 0.0001), awake and resistance during intubation (95% vs. 20%, P = 0.0001), and excellent patient condition during intubation (0% vs. 82.5%, P = 0.0001). In addition, PIPP score was significantly lower in the midazolam group (5.2 ± 2.06 vs. 12.9 ± 2.9, P = 0.0001).

Conclusion

Premedication with midazolam in newborns before intubation, can hold promising effects that manifests as better overall outcomes, less complications, better vital signs, more comfortable situation, and lesser pain for these patients.

Relationship Between the Respiratory Severity Score and Extubation Failure in Very-Low-Birth-Weight Premature Infants

Objective:

The objective of the study is to investigate the utility of the respiratory severity score (RSS), an easy-to-use, non-invasive respiratory failure assessment tool that does not require arterial blood sampling, for predicting extubation failure in very-low-birth-weight premature infants.

Methods:

Demographic characteristics, clinical course, and neonatal morbidities were retrospectively analyzed. Data were obtained from the files of infants who were admitted to our unit between February 2016 and September 2020, were born before 30 weeks’ gestation, and had a birth weight <1250 g. Extubation success was defined as no need for reintubation for 72 h after extubation. RSS and RSS/kg values before each patient’s first planned extubation were calculated. RSS values before extubation and risk factors for extubation failure were compared between infants in the successful and failed extubation groups.

Results:

Our study enrolled 142 infants who met the inclusion criteria. The extubation failure rate was 30.2% (43/142). Early gestation, low birth weight, male sex, high RSS, grade ≥3 intraventricular hemorrhage, late-onset sepsis, low weight at the time of extubation, and postmenstrual age at the time of extubation were identified as risk factors for extubation failure. In the logistic regression analysis including these risk factors, RSS/kg remained a significant risk factor, along with late-onset sepsis (OR 25.7 [95% CI: 5.70–115.76]; p<0.001). In the receiver operating characteristic analysis of RSS values, at a cutoff value of 2.13 (area under the curve: 82.5%), RSS/kg had 77% sensitivity and 78% specificity (p<0.001). The duration of mechanical ventilation and hospital stay were prolonged in infants with extubation failure. The incidence rates of stage ≥3 retinopathy of prematurity and stage ≥2 necrotizing enterocolitis were also higher.

Conclusions:

High RSS and RSS/kg values were closely associated with extubation failure and can be used as a non-invasive assessment tool to support clinical decision-making, and thus reduce the rate of extubation failure.

Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle

BACKGROUND

Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months.

METHODS

A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts.

RESULTS

Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once.

CONCLUSIONS

We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.

Respiratory setback associated with extubation failure in extremely preterm infants

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of Adherence to Surfactant Best Practice Uses With Clinical Outcomes Among Neonates in Sweden

IMPORTANCE

While surfactant therapy for respiratory distress syndrome (RDS) in preterm infants has been evaluated in clinical trials, less is known about how surfactant is used outside such a framework.

OBJECTIVE

To evaluate registered use, off-label use, and omissions of surfactant treatment by gestational age (GA) and associations with outcomes, mainly among very preterm infants (GA <32 weeks).

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used registry data for 97 377 infants born in Sweden between 2009 and 2018. Infants did not have malformations and were admitted for neonatal care. Data analysis was conducted from June 2019 to June 2020.

EXPOSURES

Timing and number of surfactant administrations, off-label use, and omission of use. Registered use was defined by drug label (1-3 administrations for RDS). Omissions were defined as surfactant not administered despite mechanical ventilation for RDS.

MAIN OUTCOME AND MEASURES

In-hospital survival, pneumothorax, intraventricular hemorrhage grade 3 to 4, duration of mechanical ventilation, use of postnatal systemic corticosteroids for lung disease, treatment with supplemental oxygen at 28 days' postnatal age and at 36 weeks' postmenstrual age. Odds ratios (ORs) were calculated and adjusted for any prenatal corticosteroid treatment, cesarean delivery, GA, infant sex, Apgar score at 10 minutes, and birth weight z score of less than -2.

RESULTS

In total, 7980 surfactant administrations were given to 5209 infants (2233 [42.9%] girls; 2976 [57.1%] boys): 629 (12.1%) born at full term, 691 (13.3%) at 32 to 36 weeks' GA, 1544 (29.6%) at 28 to 31 weeks' GA, and 2345 (45.0%) at less than 28 weeks' GA. Overall, 977 infants (18.8%) received off-label use. In 1364 of 3508 infants (38.9%) with GA of 22 to 31 weeks, the first administration of surfactant was given more than 2 hours after birth, and this was associated with higher odds of pneumothorax (adjusted OR [aOR], 2.59; 95% CI, 1.76-3.83), intraventricular hemorrhage grades 3 to 4 (aOR, 1.71; 95% CI, 1.23-2.39), receipt of postnatal corticosteroids (aOR, 1.57; 95% CI, 1.22-2.03), and longer duration of assisted ventilation (aOR, 1.34; 95% CI, 1.04-1.72) but also higher survival (aOR, 1.45; 95% CI, 1.10-1.91) than among infants treated within 2 hours of birth. In 146 infants (2.8%), the recommended maximum of 3 surfactant administrations was exceeded but without associated improvements in outcome. Omission of surfactant treatment occurred in 203 of 3551 infants (5.7%) who were receiving mechanical ventilation and was associated with lower survival (aOR, 0.49; 95% CI, 0.30-0.82). In full-term infants, 336 (53.4%) of those receiving surfactant had a diagnosis of meconium aspiration syndrome. Surfactant for meconium aspiration was not associated with improved neonatal outcomes.

CONCLUSIONS AND RELEVANCE

In this study, adherence to best practices and labels for surfactant use in newborn infants varied, with important clinical implications for neonatal outcomes.

Management of the Unexpected Difficult Airway in Neonatal Resuscitation

A "difficult airway situation" arises whenever face mask ventilation, laryngoscopy, endotracheal intubation, or use of supraglottic device fail to secure ventilation. As bradycardia and cardiac arrest in the neonate are usually of respiratory origin, neonatal airway management remains a critical factor. Despite this, a well-defined in-house approach to the neonatal difficult airway is often lacking. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Infant (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the delivery room (DR) and neonatal intensive care unit (NICU). Experience from anesthesiology is that a "difficult airway algorithm," advance planning and routine practicing, prepares the resuscitation team to respond adequately to the technical and non-technical stress of a difficult airway situation. We learned from observing current approaches to advanced airway management in DR resuscitations in a university hospital and make recommendations on how the neonatal difficult airway may be managed through technical and non-technical approaches. Our recommendations mainly pertain to DR resuscitations but may be transferred to the NICU environment.

Predicting extubation outcomes using the Heart Rate Characteristics index in preterm infants: a cohort study

A strategy of early extubation to noninvasive respiratory support in preterm infants could be boosted by the availability of a decision support tool for clinicians. Using the Heart Rate Characteristics index (HRCi) with clinical parameters, we derived and validated predictive models for extubation readiness and success.Peri-extubation demographic, clinical and HRCi data for up to 96 h were collected from mechanically ventilated infants in the control arm of a randomised trial involving eight neonatal centres, where clinicians were blinded to the HRCi scores. The data were used to produce a multivariable regression model for the probability of subsequent re-intubation. Additionally, a survival model was produced to estimate the probability of re-intubation in the period after extubation.Of the 577 eligible infants, data from 397 infants (69%) were used to derive the pre-extubation model and 180 infants (31%) for validation. The model was also fitted and validated using all combinations of training (five centres) and test (three centres) centres. The estimated probability for the validation episodes showed discrimination with high statistical significance, with an area under the curve of 0.72 (95% CI 0.71-0.74; p<0.001). Data from all infants were used to derive models of the predictive instantaneous hazard of re-intubation adjusted for clinical parameters.Predictive models of extubation readiness and success in real-time can be derived using physiological and clinical variables. The models from our analyses can be accessed using an online tool available at www.heroscore.com/extubation, and have the potential to inform and supplement the confidence of the clinician considering extubation in preterm infants.

Haemodynamic effects of premedication for neonatal intubation: an observational study

OBJECTIVE

To examine changes in blood pressure (BP), cardiac output (CO) and cerebral regional oxygen saturation (rScO2) with administration of premedication for neonatal intubation.

DESIGN

Pilot, prospective, observational study. Oxygen saturation, heart rate, CO, rScO2 and BP data were collected. Monitoring began 5 min prior to premedication and continued until spontaneous movement.

SETTING

Single-centre, level 3 neonatal intensive care unit PATIENTS: 35 infants, all gestational ages. 81 eligible infants: 66 consented, 15 refused.

INTERVENTIONS

Intravenous atropine, fentanyl or morphine, ±cisatracurium MAIN OUTCOME MEASURES: BP, CO, rScO2 RESULTS: n=37 intubations. Mean gestational age and median birth weight were 31 4/7 weeks and 1511 g. After premedication, 10 episodes resulted in a BP increase from baseline and 27 in a BP decrease. Of those whose BP decreased, 17 had <20% decrease and 10 had ≥20% decrease. Those with <20% BP decrease took an average of 2.5 min to return to baseline while those with a ≥20% BP decline took an average of 15.2 min. Three did not return to baseline by 35 min. Following intubation, further declines in BP (21%-51%) were observed in eight additional cases. One infant required a bolus for persistently low BPs. CO and rScO2 changes were statistically similar between the two groups.

CONCLUSION

About 30% of infants dropped their BP by ≥20% after premedication for elective intubation. These BP changes were not associated with any significant change in rScO2 or CO. More data are needed to better characterise the immediate haemodynamic changes and clinical outcomes associated with premedication.

Comparison of Neonatal Intubation Practice and Outcomes between the Neonatal Intensive Care Unit and Delivery Room

BACKGROUND

Characteristics of neonatal tracheal intubations (TI) may vary between the neonatal intensive care unit (NICU) and delivery room (DR). The impact of the setting on TI outcomes is not well characterized.

OBJECTIVE

The aim of this study was to define variation in neonatal TI practice between settings, and identify the association between setting and TI success and safety outcomes.

DESIGN

This was a retrospective cohort study of TIs in the National Emergency Airway Registry for Neonates from October 2014 to September 2017. The setting (NICU vs. DR) was the exposure of interest. The outcomes were first attempt success, course success, success within 4 attempts, adverse TI-associated events, severe desaturation, and bradycardia. We compared TI characteristics and outcomes between settings in univariable analysis. Factors significant in univariable analysis (p < 0.1) were included in a logistic regression model, with adjustment for clustering by center, to identify the independent impact of the setting on TI outcomes.

RESULTS

There were 3,145 TI encounters (2279 NICU, 866 DR) in 9 centers. Almost all baseline characteristics significantly varied between settings. First attempt success rates were 48% (NICU) and 46% (DR). In multivariable analysis, the setting was not associated with first attempt success. DR was associated with a higher adjusted OR (aOR) of success within 4 attempts (1.48, 95% CI 1.06-2.08) and a lower aOR for bradycardia (0.43, 95% CI 0.26-0.71).

CONCLUSION

Significant differences in patient, provider, and practice characteristics exist between NICU and DR TIs. There is substantial room for improvement in first attempt success rates. These results suggest interventions to improve safety and success need to be targeted to the distinct setting.

Surfactant therapy in premature babies: SurE or InSurE

BACKGROUND

Preterm infants with respiratory distress syndrome (RDS) requiring surfactant therapy have been traditionally receiving surfactant by intubation surfactant and extubation technique (InSurE), which comprises of tracheal intubation, surfactant administration, and extubation. However, more recently noninvasive methods like least invasive surfactant therapy or minimally invasive surfactant therapy have been reported to be successful. These methods, avoid intubation thus minimize airway trauma and avoid barotrauma. The primary aim of this randomized trial was to compare the need for mechanical ventilation (MV) between the administration of surfactant via a thin catheter during spontaneous breathing and the InSurE technique.

METHODS

Preterm infant's ≤34 weeks with RDS requiring continuous positive airway pressure (CPAP) within 6 hours of life were prospectively randomized to receive early surfactant either by SurE (surfactant without endotracheal tube intubation) or InSurE technique. The need for MV within the first 72 hours and other related outcomes were analyzed between the two groups.

RESULTS

One hundred seventy-five infants in each group were analyzed. The need for MV in the first 72 hours of life was significantly lower in the SurE group compared to the InSurE group (19% vs 40%, P < .01). Similarly, duration of oxygen therapy and hospital stay were significantly shorter in the SurE group. Furthermore, bronchopulmonary dysplasia (BPD) rate was significantly lower among the infants administered surfactant by the SurE technique.

CONCLUSION

In preterm neonates with RDS who are stabilized on CPAP, the SurE technique for surfactant delivery results in the reduced need for MV and also may decrease the rate of BPD in some vulnerable subpopulations.

Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events

OBJECTIVE

To determine the impact of premedication for tracheal intubation (TI) on adverse TI associated events, severe oxygen desaturations, and first attempt success STUDY DESIGN: Retrospective cohort study in neonatal intensive care units (NICU) participating in the National Emergency Airway Registry for Neonates from 10/2014 to 6/2017. Premedication for TI was categorized as sedation with neuromuscular blockade, sedation only, or no medication.

RESULTS

2260 TIs were reported from 11 NICUs. Adverse TI associated events occurred less often in sedation with neuromuscular blockade group (10%) as compared to sedation only (29%), or no medication group (23%), p < 0.001. The adjusted odds ratio (aOR) for adverse TI associated events were: sedation with neuromuscular blockade aOR 0.48 (95%CI 0.34-0.65, p < 0.001) compared to no medication.

CONCLUSION

Use of sedation with neuromuscular blockade was associated with favorable TI outcomes. This study supports the recommendation for the standard use of sedation with neuromuscular blockade in non-emergency TIs.

Cerebral oxygenation associated with INSURE versus LISA procedures in surfactant-deficient newborn piglet RDS model

BACKGROUND

Nasal continuous-positive airway pressure (nCPAP) with the INSURE (INtubation-SURfactant-Extubation) or LISA (Less-Invasive Surfactant Administration) procedures are increasingly being chosen as the initial treatment for neonates with surfactant deficiency. Our objective was to compare the effects on cerebral oxygenation of different methods for surfactant administration: INSURE and LISA, using a nasogastric tube (NT) or a LISAcath® catheter, in spontaneously breathing SF-deficient newborn piglets.

METHODS

Eighteen newborn piglets with SF-deficient lung injury produced by repetitive bronchoalveolar lavages were randomly assigned to INSURE, LISA-NT, or LISAcath® groups. We assessed pulmonary (gas exchange, lung mechanics, lung histology) and hemodynamic (mean arterial blood pressure, heart rate) changes, cerebral oxygenation (cTOI) and cerebral fractional tissue extraction (cFTOE), with near-infrared spectroscopy, carotid blood flow and brain histology.

RESULTS

SF-deficient piglets developed respiratory distress (F_iO2  = 1, pH <7.2, P_aCO2 >70 mmHg, P_aO2 <70 mmHg, C_dyn <0.5 mL/cmH₂ O/kg). Rapid improvements in pulmonary status were observed in all surfactant-treated groups without hemodynamic alterations. In the INSURE group, a transient decrease in cTOI occurred during and immediately after surfactant administration, while cTOI only decreased during surfactant administration in the LISA-NT group and did not change significantly in the LISAcath® group. Brain injury scores were low in all surfactant-treated groups.

CONCLUSION

In spontaneously breathing SF-deficient newborn piglets, short-lasting decreases in cerebral oxygenation are associated with surfactant administration by the INSURE method or LISA using an NT, while no cerebral oxygenation changes occurred with LISA using a LISAcath®. Notably, none of treatments studied seems to have a negative impact on the neonatal brain.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Premedication for Endotracheal Intubation in the Neonate

Endotracheal intubation, a common procedure in neonatal intensive care, results in distress and disturbs physiologic homeostasis in the newborn. Analgesics, sedatives, vagolytics, and/or muscle relaxants have the potential to blunt these adverse effects, reduce the duration of the procedure, and minimize the number of attempts necessary to intubate the neonate. The medical care team must understand efficacy, safety, and pharmacokinetic data for individual medications to select the optimal cocktail for each clinical situation. Although many units utilize morphine for analgesia, remifentanil has a superior pharmacokinetic profile and efficacy data. Because of hypotensive effects in preterm neonates, sedation with midazolam should be restricted to near-term and term neonates. A vagolytic, generally atropine, blunts bradycardia induced by vagal stimulation. A muscle relaxant improves procedural success when utilized by experienced practitioners; succinylcholine has an optimal pharmacokinetic profile, but potentially concerning adverse effects; rocuronium may be the agent of choice based on more robust safety data despite a relatively prolonged duration of action. In the absence of an absolute contraindication, neonates should receive analgesia with consideration of sedation, a vagolytic, and a muscle relaxant before endotracheal intubation. Neonatal units must develop protocols for premedication and optimize logistics to ensure safe and timely administration of appropriate agents.

Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates

Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil's safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks' gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Predicting Extubation Outcomes-A Model Incorporating Heart Rate Characteristics Index

OBJECTIVE

To test the hypothesis that in neonates on mechanical ventilation, heart rate characteristics index (HRCi) can be combined with a clinical model for predicting extubation outcomes in neonates.

STUDY DESIGN

HRCi and clinical data for all intended intubation-extubation events (episodes) were retrospectively analyzed between June 2014 and January 2015. Each episode started 6 hours pre-extubation or at the time of primary intubation if ventilation duration was shorter than 6 hours (baseline). The episodes ended at 72 hours postextubation for successful extubations or at reintubation for failed extubations. Mean of 6 hourly epoch HRCi-scores (baseline) or fold-changes (postextubation) were analyzed. Results are expressed as medians (IQR) for continuous data and proportions for categorical data. Multivariable logistic regression mixed model was used for statistical analysis.

RESULTS

Sixty-six infants contributed to 96 episodes (18 failed extubations, 78 successful extubations) in the study. Failed extubations had significantly longer duration of ventilation (65.3 hours, 19.94-158.2 vs 38.4, 16.5-71.3) and more culture positive sepsis (33.3% vs 3.8%) than successful extubations. Baseline HRCi scores (1.68, 1.29-2.45 vs 0.95, 0.54-1.86) and postextubation epoch-1 fold changes (1.25, 0.94-1.55 vs 0.94, 0.82-1.11) were higher in failed extubations compared with successful extubations. Multivariable linear mixed-effects regression was used to create prediction models for success of extubation, using relevant variables.

CONCLUSIONS

The baseline and postextubation HRCi were significantly higher in neonates with extubation failure compared with those who succeeded. Models using HRCi and clinical variables to predict extubation success may add to the confidence of clinicians considering extubation.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease-Are Cardiac ICUs Safer?

OBJECTIVES

Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease.

DESIGN

Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children).

SETTING

Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016.

PATIENTS

Children with medical or surgical cardiac disease who underwent intubation in an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002).

CONCLUSIONS

In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

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.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00233324.

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.

Prediction of Extubation readiness in extremely preterm infants by the automated analysis of cardiorespiratory behavior: study protocol

Background

Extremely preterm infants (≤ 28 weeks gestation) commonly require endotracheal intubation and mechanical ventilation (MV) to maintain adequate oxygenation and gas exchange. Given that MV is independently associated with important adverse outcomes, efforts should be made to limit its duration. However, current methods for determining extubation readiness are inaccurate and a significant number of infants fail extubation and require reintubation, an intervention that may be associated with increased morbidities. A variety of objective measures have been proposed to better define the optimal time for extubation, but none have proven clinically useful. In a pilot study, investigators from this group have shown promising results from sophisticated, automated analyses of cardiorespiratory signals as a predictor of extubation readiness. The aim of this study is to develop an automated predictor of extubation readiness using a combination of clinical tools along with novel and automated measures of cardiorespiratory behavior, to assist clinicians in determining when extremely preterm infants are ready for extubation.

Methods

In this prospective, multicenter observational study, cardiorespiratory signals will be recorded from 250 eligible extremely preterm infants with birth weights ≤1250 g immediately prior to their first planned extubation. Automated signal analysis algorithms will compute a variety of metrics for each infant, and machine learning methods will then be used to find the optimal combination of these metrics together with clinical variables that provide the best overall prediction of extubation readiness. Using these results, investigators will develop an Automated system for Prediction of EXtubation (APEX) readiness that will integrate the software for data acquisition, signal analysis, and outcome prediction into a single application suitable for use by medical personnel in the neonatal intensive care unit. The performance of APEX will later be prospectively validated in 50 additional infants.

Discussion

The results of this research will provide the quantitative evidence needed to assist clinicians in determining when to extubate a preterm infant with the highest probability of success, and could produce significant improvements in extubation outcomes in this population.

Trial registration

Clinicaltrials.gov identifier: NCT01909947. Registered on July 17 2013.

Trial sponsor: Canadian Institutes of Health Research (CIHR).

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0911-z) contains supplementary material, which is available to authorized users.

A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates

OBJECTIVE

To compare the short-term efficacy of surfactant administration by laryngeal mask airway versus endotracheal tube.

METHODS

Preterm infants (28-35 weeks of gestational age), weighing 1kg or more, with respiratory distress syndrome, requiring nasal continuous positive airway pressure, with increased respiratory effort and/or fraction of inspired oxygen (FiO₂)≥0.40 to maintain oxygen saturation 91-95%, were randomized to receive surfactant by LMA following nCPAP or by ETT following mechanical ventilation (MV). The primary outcome was a clinical response defined as FiO₂≤0.30 three hours after surfactant. Secondary outcomes for LMA group were: need of surfactant retreatment during the first 24h, MV requirement, and presence of surfactant in gastric content.

RESULTS

Forty-eight patients were randomized; 26 in the LMA group and 22 in the ETT group. Six of 26 patients (23%) in the LMA group and five of 22 patients (22.7%) in the ETT group did not meet the primary outcome (p=0.977). Fourteen (53.8%) of the LMA patients were not intubated nor ventilated; 12 (46.1%) were ventilated: for surfactant failure (23%), for nCPAP failure (11.5%), and for late complications (11.5%). Groups were similar regarding prenatal status, birth conditions, and adverse events. No significant gastric content was found in 61.5% of the LMA patients. Oxygen and second dose surfactant requirements, arterial/alveolar ratio, and morbidities were similar among groups.

CONCLUSIONS

Surfactant administration by LMA showed short-term efficacy, with similar supplementary oxygen need compared to surfactant by ETT, and lower MV requirement. Further studies with larger sample size are necessary to confirm these results.

Early extubation failure in very low birth weight infants: Clinical outcomes and predictive factors

OBJECTIVE

To identify the clinical outcomes and the potential predictive factors of early extubation failure (EEF) in very low birth weight (VLBW) infants.

METHODS

A retrospective study of VLBW infants admitted to the neonatal intensive care unit (NICU) over fifteen years. Neonates were intubated and mechanically ventilated on the first day of life, and early extubated within the first 3 days. EEF was defined as the need for re-intubation within 3 days of the first extubation. A composite outcome of mortality or any major morbidity (grade 3-4 intraventricular hemorrhage or periventricular leukomalacia; stage 3-4 retinopathy of prematurity, moderate-severe bronchopulmonary dysplasia or stage 2-3 necrotizing enterocolitis) was assessed.

RESULTS

In total, 394 infants were extubated early. Of those, 347 (88%) had early extubation success (EES), whereas 47 (12%) had EEF. Incidence of the composite outcome was significantly higher in the EEF group than the EES group, even after adjusting for confounding factors. Logistic regression indicated that birth weight < 1000 g (p < 0.01), administration of≥2 doses of surfactant (p < 0.01) and administration of≥2 inotropic agents (p < 0.01) were all significantly associated with EEF. The area under the curve (AUC) for the combination of these three factors (AUC = 0.77) indicated significantly higher predictive value (p < 0.01) for EEF in VLBW infants, compared with individual factors (AUC = 0.59 for≥2 inotropic agents, AUC = 0.64 for birth weight≤1000 g and AUC = 0.66 for≥2 doses of surfactant).

CONCLUSION

EEF is associated with poor clinical outcomes in VLBW infants. The combination of birth weight and the requirement for surfactants and inotropic agents can predict EEF.

Neonatal Resuscitation Training: Implications of Course Construct and Discipline Compartmentalization on Role Confusion and Role Ambiguity

BACKGROUND

The Neonatal Resuscitation Program's (NRP's) Sixth Edition introduced simulation-based training (SBT) into neonatal life support training. SBT offers neonatal emergency response teams a safe, secure environment to rehearse coordinated neonatal resuscitations. Teamwork and communication training can reduce tension and anxiety during neonatal medical emergencies.

PURPOSE

To discuss the implications of variability in number and type of simulation scenario, number and type of learners who comprise a course, and their influence upon scope of practice, role confusion, and role ambiguity.

METHODS

Relevant articles from MEDLINE, CINAHL, EMBASE, Google Scholar, the World Health Organization, the American Heart Association, and NRP were included in this integrative review of the literature.

FINDINGS/RESULTS

Purposeful synergy of optimal SBT course construct with teamwork and communication can resist discipline compartmentalization, role confusion, and role ambiguity. Five key themes were identified and coined the "5 Rights" of NRP SBT. These "5 Rights" can guide healthcare institutions with planning, implementation, and evaluation of NRP SBT courses.

IMPLICATIONS FOR PRACTICE

NRP SBT can facilitate optimal team function and reduce errors when teams of learners and varied scenarios are woven into the course construct. The simulated environment must be realistic and fully equipped to encourage knowledge transfer and attainment of the NRP's key behavioral outcomes.

IMPLICATIONS FOR RESEARCH

Investigation of teamwork and communication training with NRP SBT, course construct, discipline compartmentalization, and behavioral and clinical outcomes is indicated. Investigation of outcomes of SBT using a team-teaching model, combining basic and advanced practice NRP instructors, is indicated.

Neonatal endotracheal intubation: How to make it more baby friendly

Neonatal endotracheal intubation is commonly accompanied by significant disturbances in physiological parameters. The procedure is often poorly tolerated, and multiple attempts are commonly required before the airway is secured. Adverse physiological effects include hypoxemia, bradycardia, hypertension, elevation in intracranial pressure and possibly increase in pulmonary vascular resistance. Use of premedications to facilitate intubation has been shown to reduce but not eliminate these effects. Other important preventative factors include adequate training of the operators and guidelines to limit the duration of attempts. Pre-intubation stabilisation with optimal bag and mask ventilation should allow for better neonatal tolerance of the procedure. Recent research has described significant mask leak and airway obstruction compromising efficacy of neonatal mask ventilation. Further research should help in elucidating mask ventilation techniques which minimise mask leak and airway obstruction.

The therapeutic value of atropine for critical care intubation

Recent studies of atropine during critical care intubation (CCI) have revealed that neonates frequently experience bradycardia, are infrequently affected by ventricular arrhythmias and conduction disturbances and deaths have not been reported in a series of studies. The indiscriminate use of atropine is unlikely to alter the outcome during neonatal CCI other than reducing the frequency of sinus tachycardia. In contrast, older children experience a similar frequency of bradycardia to neonates and are more frequently affected by ventricular arrhythmias and conduction disturbances. Mortality during CCI is in the order of 0.5%. Atropine has a beneficial effect on arrhythmias and conduction disturbances and may reduce paediatric intensive care unit mortality. The use of atropine for children >1 month of age may positively influence outcomes beyond a reduction in the frequency of sinus bradycardia. There is indirect evidence that atropine should be used for intubation during sepsis. Atropine should be considered when using suxamethonium. The reliance on heart rate as the sole measure of haemodynamic function during CCI is no longer justifiable. Randomised trials of atropine for mortality during CCI in general intensive care unit populations are unlikely to happen. As such, future research should be focused on establishing of a gold standard for haemodynamic decompensation for CCI. Cardiac output or blood pressure are the most likely candidates. The 'lost beat score' requires development but has the potential to be developed to provide an estimation of risk of haemodynamic decompensation from ECG data in real time during CCI.

Correlation of clinical parameters with cardiorespiratory behavior in successfully extubated extremely preterm infants

Extremely preterm infants (gestational age ≤ 28 weeks) often require EndoTracheal Tube-Invasive Mechanical Ventilation (ETT-IMV) to survive. Clinicians wean infants off ETT-IMV as early as possible using their judgment and clinical information. However, assessment of extubation readiness is not accurate since 20 to 40% of preterm infants fail extubation. We extended our work in automated prediction of extubation readiness by examining correlations of automated cardiorespiratory features to clinical parameters in successfully extubated infants. Only a few features, mainly those related to variability of breathing synchrony, had any consistent correlation with clinical parameters, namely gestational age, day of life at extubation, and bicarbonate. We conclude that the automated cardiorespiratory features likely provide different information additional to clinical practice.

Application of Lidocaine Spray for Tracheal Intubation in Neonates - A Clinical Trial Study

Background:

Tracheal intubation is extremely distressing, painful, and may influence heart rate and blood pressure. Sedatives, analgesics, and muscle relaxants are not commonly used for intubation in neonates.

Objectives:

This study aimed to evaluate the effects of lidocaine spray as a non-intravenous drug before neonatal intubation on blood pressure, heart rate, oxygen saturation and time of intubation.

Patients and Methods:

In a randomized, controlled study each neonate was randomly assigned to one of the two study groups by staffs who were not involved in the infant's care. The allocation concealment was kept in an opaque sealed envelope, and the investigators, the patient care team, and the assessors were blinded to the treatment allocation. The selected setting was NICU unit of a teaching hospital in Ilam city, Iran and participants were 60 neonates with indication of tracheal intubation with gestational age > 30 weeks. Patients in the treatment group received lidocaine spray and the placebo group received spray of normal saline prior to intubation. Main outcome measurements were the mean rates of blood pressure, heart rate, oxygen saturation, intubation time and lidocaine side effects were measured before and after intubation.

Results:

Totally 60 newborns including 31 boys and 29 girls were entered into the study (drug group n = 30; placebo group n = 30). Boy/girl ratio in treatment and placebo groups were 1.3 and 0.88, respectively. Mean age ± SD of participants was 34.1 ± 24.8 hours (treatment: 35.3 ± 25.7; placebo: 32.9 ± 24.3; P < 0.0001). Mean weight ± SD of neonates was 2012.5 ± 969 g. Application of lidocaine spray caused a significant reduction of mean intubation time among treatment group compared with placebo group (treatment: 15.03 ± 2.2 seconds; placebo: 18.3 ± 2.3 seconds; P < 0.0001). Mean blood pressure, heart rate and oxygen saturation rate, among neonates in treatment group was reduced after intubation compared with their relevant figures before intubation; however, their differences were not statistically significant except for mean oxygen saturation rate that was reduced significantly in placebo group. No side effects were observed during study.

Conclusions:

Though the current study revealed some promising results in the application of lidocaine spray during neonatal intubation without any considerable side effects; however, the current investigation could only be considered as a pilot study for further attempts in different locations with higher sample sizes and in different situations.

Factors Associated with Adverse Events during Tracheal Intubation in the NICU

BACKGROUND

The incidence of adverse tracheal intubation-associated events (TIAEs) and associated patient, practice, and intubator characteristics in the neonatal intensive care unit (NICU) setting are unknown.

OBJECTIVES

To determine the incidence of adverse TIAEs and to identify factors associated with TIAEs in the NICU.

METHODS

Single-site prospective observational cohort study of infants who were intubated in a level 4 referral NICU between September 1, 2011 and November 30, 2013. A standardized pediatric airway registry was implemented to document patient, practice, and intubator characteristics and outcomes of intubation encounters. The primary outcome was adverse TIAEs.

RESULTS

Adverse TIAEs occurred in 153 of 701 (22%) tracheal intubation encounters. Factors that were independently associated with lower incidence of TIAEs in logistic regression included attending physician (vs. resident; odds ratio (OR) 0.4, 95% CI: 0.16, 0.98) and use of paralytic medication (OR 0.45, 95% CI: 0.25, 0.81). Severe oxygen desaturations (≥ 20% decrease in oxygen saturation) occurred in 51.1% of encounters and were more common in tracheal intubations performed by residents (62.8%), compared to fellows (43.2%) or attendings (47.5%; p = 0.008).

CONCLUSIONS

Adverse TIAEs and severe oxygen desaturation events are common in the NICU setting. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.

Minimally invasive surfactant therapy with a gastric tube is as effective as the intubation, surfactant, and extubation technique in preterm babies

AIM

Preterm infants requiring surfactant replacement have been treated using the INSURE technique, which requires sedation and comprises tracheal intubation, surfactant instillation and extubation. However, minimally invasive surfactant therapy (MIST) does not require sedation, minimises airway injury and avoids placing positive pressure ventilation on an immature lung. This study compared the feasibility of the two techniques and the outcomes in preterm babies with respiratory distress syndrome (RDS).

METHODS

Preterm infants with RDS prospectively received surfactant via a gastric tube placed in the trachea by direct laryngoscopy with no sedation. Technique-related complications and respiratory outcomes were analysed.

RESULTS

We compared 44 patients who received MIST with a historic cohort of 31 patients who received INSURE. This showed no differences in the rate of intubation and mechanical ventilation in the first 72 h, or secondary respiratory outcomes and relevant morbidities, between the babies who received INSURE and those who received MIST. More babies in the MIST group (35%) needed a second dose of surfactant than the INSURE group (6.5%) (p < 0.0001).

CONCLUSION

Surfactant administration using MIST, with no sedation, is feasible in preterm infants with RDS. No significant differences in secondary respiratory outcomes were found between the MIST and INSURE techniques.

Assessment of atropine-sufentanil-atracurium anaesthesia for endotracheal intubation: an observational study in very premature infants

Background

Premedication before neonatal intubation is heterogeneous and contentious. The combination of a short acting, rapid onset opioid with a muscle relaxant is considered suitable by many experts. The purpose of this study was to describe the tolerance and conditions of intubation following anaesthesia with atropine, sufentanil and atracurium in very premature infants.

Methods

Monocentric, prospective observational study in premature infants born before 32 weeks of gestational age, hospitalised in the NICU and requiring semi-urgent or elective intubation. Intubation conditions, heart rate, pulse oxymetry (SpO₂), arterial blood pressure and transcutaneous PCO₂ (TcPCO₂) were collected in real time during 30 minutes following the first drug injection. Repeated physiological measurements were analysed using mixed linear models.

Results

Thirty five intubations were performed in 24 infants with a median post conceptional age of 27.6 weeks and a median weight of 850 g at the time of intubation. The first attempt was successful in 74% and was similar for junior (75%) and senior (74%) operators. The operator rated conditions as “excellent” or “good” in 94% of intubations. A persistent increase in TcPCO₂ as compared to baseline was observed whereas other vital parameters showed no significant variations 5, 10, 15 and 30 minutes after the first drug injection. Eighteen (51%) desaturations (SpO2 less than or equal to 80% for more than 60 seconds) and 2 (6%) bradycardia (heart rate less than100 bpm for more than 60 seconds) were observed.

Conclusion

This drug combination offers satisfactory success rate for first attempt and intubation conditions for the operator without any significant change in heart rate and blood pressure for the patient. However it is associated with frequent desaturations and a possible persistent hypercapnia. SpO₂ and PCO₂ can be significantly modified during neonatal intubation and should be cautiously followed in this high-risk population.

Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: a noninferiority randomized trial

OBJECTIVE

To compare remifentanil and morphine-midazolam for use in nonurgent endotracheal intubation in neonates.

STUDY DESIGN

In this prospective noninferiority randomized trial, newborns of gestational age ≥28 weeks admitted in the neonatal intensive care unit requiring an elective or semielective endotracheal intubation were divided into 2 groups. One group (n = 36) received remifentanil (1 μg/kg), and the other group (n = 35) received morphine (100 μg/kg) and midazolam (50 μg/kg) at a predefined time before intubation (different in each group), to optimize the peak effect of each drug. Both groups also received atropine (20 μg/kg). The primary outcome was to compare the conditions of intubation, and the secondary outcome was to compare the duration of successful intubation, physiological variables, and pain scores between groups for first and second intubation attempts. Adverse events and neurologic test data were reported.

RESULTS

Intubation with remifentanil was not inferior to that with morphine-midazolam. At the first attempted intubation, intubation conditions were poor in 25% of the remifentanil group and in 28.6% of the morphine-midazolam group (P = .471). For the second attempt, conditions were poor in 28.6% of the remifentanil group, compared with 10% of the morphine-midazolam group (P = .360). The median time to successful intubation was 33 seconds (IQR, 24-45 seconds) for the remifentanil group versus 36 seconds (IQR, 25-59 seconds) for the morphine-medazolam group (P = .359) at the first attempt and 45 seconds (IQR, 35-64 seconds) versus 56 seconds (IQR, 44-68 seconds), respectively, for the second attempt (P = .302). No significant between-group difference was reported for hypotension, bradycardia, or adverse events.

CONCLUSION

In our cohort, remifentanil was at least as effective as the morphine-midazolam regimen for endotracheal intubation. Thus, premedication using this very-short-acting opioid can be considered in urgent intubations and is advantageous in rapid extubation.

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children

Purpose

Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication.

Methods

Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats.

Results

333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0–1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15–83]). During intubation the median number of lost beats was 8 [1]–[32] when atropine was not used compared to 0 [0–0] when atropine was used (p<0.001).

Conclusions

A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.

Sedation of newborn infants for the INSURE procedure, are we sure?

Background. Neonatal intubation is a stressful procedure that requires premedication to improve intubation conditions and reduce stress and adverse physiological responses. Premedication used during the INSURE (INtubation, SURfactant therapy, Extubation) procedure should have a very short duration of action with restoration of spontaneous breathing within a few minutes. Aims. To determine the best sedative for intubation during the INSURE procedure by systematic review of the literature. Methods. We reviewed all relevant studies reporting on premedication, distress, and time to restoration of spontaneous breathing during the INSURE procedure. Results. This review included 12 studies: two relatively small studies explicitly evaluated the effect of premedication (propofol and remifentanil) during the INSURE procedure, both showing good intubation conditions and an average extubation time of about 20 minutes. Ten studies reporting on fentanyl or morphine provided insufficient information about these items. Conclusions. Too little is known in the literature to draw a solid conclusion on which premedication could be best used during the INSURE procedure. Both remifentanil and propofol are suitable candidates but dose-finding studies to detect effective nontoxic doses in newborns with different gestational ages are necessary.