Provider visual attention on a respiratory function monitor during neonatal resuscitation

Positive Pressure Ventilation in Preterm Infants in the Delivery Room: A Review of Current Practices, Challenges, and Emerging Technologies

BACKGROUND

A major proportion of preterm neonates require positive pressure ventilation (PPV) immediately after delivery. PPV may be administered through a face mask (FM) or nasal prongs. Current literature indicates that either of these are associated with similar outcomes.

SUMMARY

Nonetheless, FM remains the most utilized and the best choice. However, most available FM sizes are too large for extremely preterm infants, which leads to mask leak and ineffective PPV. Challenges to providing effective PPV include poor respiratory drive, complaint chest wall, weak thoracic muscle, delayed liquid clearance, and surfactant deficiency in preterm infants. Mask leak, airway obstruction, poor technique, and inappropriate size are correctable causes of ineffective PPV. Visual assessment of chest rise is often used to assess the efficacy of PPV. However, its accuracy is debatable. Though end tidal CO2 may adjudge the effectiveness of PPV, clinical studies are limited. The compliance of a preterm lung is highly dynamic. The inflating pressure set on T-piece is constant throughout the resuscitation, but the lung volume and dynamics changes with every breath. This leads to huge fluctuations of tidal volume delivery and can trigger inflammatory cascade in preterm infants leading to brain and lung injury. Respiratory function monitoring in the delivery room has potential for guiding and optimizing delivery room resuscitation. This is, however, limited by high costs, complex information that is difficult to interpret during resuscitation, and absence of clinical trials.

KEY MESSAGES

This review summarizes the existing literature on PPV in preterm infants, the various aspects related to it such as the pathophysiology, interfaces, devices utilized to deliver it, appropriate technique, emerging technologies, and future directions.

Quantifying Workload and Stress in Intensive Care Unit Nurses: Preliminary Evaluation Using Continuous Eye-Tracking

OBJECTIVE

(1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU.

BACKGROUND

Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data.

METHODS

Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes.

RESULTS

While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter.

CONCLUSION

Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Exploring eye-tracking data as an indicator of situational awareness in nursing students during a cardiorespiratory arrest simulation

AIM

To examine the components of visual attention that maintain situational awareness during simulation training in undergraduate nursing students with different instruction levels.

BACKGROUND

Eye-tracking can provide deep insight into the nurses' attention during simulated practice. Knowing which gaze patterns promote situational awareness can significantly improve nurse instruction.

DESIGN

A comparative observational study investigated the role of visual attention on the performance quality, psychophysiological parameters (vital signs, anxiety and stress) and socioemotional competencies (cognitive workload, motivation and self-efficacy) of nursing students with various experience levels.

METHODS

Thirty nursing students divided into two groups according to their academic level: first cycle (n=14) and second-cycle (n=16) faced a clinical simulation scenario to resolve a cardiorespiratory arrest event. Eye tracking-based analysis required the selection of six areas of interest. The monitorization of vital signs included measuring blood pressure, heart rate, respiratory rate and oxygen saturation before and after the simulation practice. Participants completed the socioemotional questionnaire (NASA-TLX). They answered the state subscale of the State-Trait Anxiety Inventory (STAI), the Visual Analogue Scale (VAS) of stress, the Situational Motivation Scale (SIMS) and the Baessler and Schwarzer General Self-Efficacy Scale.

RESULTS

The first-cycle group displayed higher vital sign scores than the second cycle, apart from the post-simulation respiratory rate. All physiological parameters increased in mean value after the clinical simulation, except oxygen saturation. Anxiety was the only parameter in the socioemotional domain to present a statistically significant difference between the groups. First-year nursing students showed greater anxiety, stress, mental workload, identified regulation and intrinsic motivation, while second-year students showed higher levels of amotivation, external regulation and perceived self-efficacy. Eye-tracking data (revisits, gaze and duration of fixations) exhibited statistically significant differences depending on the area of interest in both groups (p =. 05). The performance outcomes showed a negative and moderate association with gaze the total number of gazes in the second-cycle group (rho = -0.640, p = 0.010).

CONCLUSION

Eye-tracking-based analysis can help to predict performance quality while maintaining situational awareness during nursing instruction.

Newborn face mask ventilation training using a standardised intervention and respiratory function monitor: a before and after manikin study

OBJECTIVE

The International Liaison Committee on Resuscitation has recommended improvements in training for neonatal resuscitation, highlighting the potential role of respiratory function monitors (RFMs). Our objective was to determine whether a manikin-based, standardised face mask ventilation training intervention using an RFM with a simple visual display reduced face mask leak.

DESIGN

Multicentre, before and after study. Participants and instructors were blinded to the RFM display during both assessment periods.

PARTICIPANTS

Healthcare professionals working or training in a hospital providing maternity and neonatal services.

INTERVENTION

All participants underwent a training intervention on positive pressure ventilation using a modified, leak-free manikin and RFM. The intervention consisted of a demonstration of optimal face mask ventilation technique, training in RFM interpretation with corrective strategies for common scenarios and a period of deliberate practice. Each participant performed 30 s of positive pressure ventilation blinded to the RFM display before and after training.

MAIN OUTCOME MEASURES

The primary outcome was face mask leak (%) measured after training. Secondary outcome measures included expired tidal volume, inflating pressures and ventilation rate. Adjustments made to technique during training were an important qualitative outcome.

RESULTS

Four hundred and fourteen participants were recruited over a 13-month period from April 2022, and 412 underwent analysis. Median (IQR) face mask leak before training was 31% (10-69%) compared with 10% (6-18%) after training (p<0.0001). Improvements were noted across all other ventilation parameters.

CONCLUSION

Standardised face mask ventilation training using an RFM with simple visual feedback led to a significant reduction in leak.

Comparison of positive pressure ventilation devices during compliance changes in a neonatal ovine model

BACKGROUND

To compare tidal volume (VT) delivery with compliance at 0.5 and 1.5 mL/cmH2O using four different ventilation (PPV) devices (i.e., self-inflating bag (SIB), T-Piece resuscitator, Next Step (a novel Neonatal Resuscitator), and Fabian ventilator (conventional neonatal ventilator) using a neonatal piglet model.

DESIGN/METHODS

Randomized experimental animal study using 10 mixed-breed neonatal piglets (1-3 days; 1.8-2.4 kg). Piglets were anesthetized, intubated, instrumented, and randomized to receive positive pressure ventilation (PPV) for one minute with a SIB with or without a respiratory function monitor (RFM), T-Piece resuscitator with or without an RFM, Next Step, and Fabian Ventilator with both compliance levels. Compliance changes were achieved by placing a wrap around the piglets' chest and tightened it. Our primary outcome was targeted VT delivery of 5 mL/kg at 0.5 and 1.5 mL/cmH2O lung compliance.

RESULTS

At 0.5 mL/cmH2O compliance, the mean(SD) expired VT with the Next Step was 5.1(0.2) mL/kg compared to the Fabian 4.8(0.5) mL/kg, SIB 8.9(3.6) mL/kg, SIB + RFM 4.5(1.8) mL/kg, T-Piece 7.4(4.3) mL/kg, and T-Piece+RFM 6.4(3.1) mL/kg. At 1.5 mL/cmH2O compliance, the mean(SD) expired VT with the Next Step was 5.2(0.6) mL/kg compared to the Fabian 4.4(0.7) mL/kg, SIB 12.1(5.3) mL/kg, SIB + RFM 9.4(3.9) mL/kg, T-Piece 8.6(1.5) mL/kg, and T-Piece+RFM 6.5 (1.6) mL/kg.

CONCLUSION

The Next Step provides consistent VT during PPV, which is comparable to a mechanical ventilator.

IMPACT

Current guidelines recommend fixed peak inflation pressure in resuscitation, linked to lung and brain injury. The Next Step Neonatal Resuscitator, a cost-effective device, offers volume-targeted positive pressure ventilation with consistent tidal volumes. With two different compliances, the Next Step Neonatal Resuscitator delivered a consistent tidal volume which was similar to a mechanical ventilator. The Next Step Neonatal Resuscitator outperformed self-inflating bags and T-Pieces in delivering targeted tidal volumes. The Next Step Neonatal Resuscitator could be an alternative ventilation device for neonatal resuscitation.

Mask ventilation using volume-targeted neonatal ventilator for neonatal resuscitation: a randomised cross-over simulation study

OBJECTIVE

To use simulations to compare a novel mask ventilation method using a neonatal ventilator, with mask ventilation using a T-piece resuscitator, to study human factors prior to clinical testing.

DESIGN

Prospective randomised cross-over simulation study. Participants were briefly trained to use a neonatal ventilator for mask ventilation. Each participant was fitted with eye-tracking glasses to record visual attention (VA) and performed two simulated preterm neonatal resuscitations in a randomised sequence.

SETTING

In situ in a neonatal resuscitation room within a Level 3 neonatal intensive care unit.

PARTICIPANTS

Healthcare professionals (HCPs) trained in neonatal resuscitation with experience as team leaders.

INTERVENTIONS

Semiautomated, ventilator-based, volume-targeted positive pressure mask ventilation (VTV-PPV) versus manual mask ventilation via T-piece device (T-piece PPV).

MAIN OUTCOME MEASURES

Subjective workload (Surgical Task Load Index, SURG-TLX), VA, quantitative and qualitative postsimulation survey responses.

RESULTS

Thirty HCPs participated. HCPs reported higher total SURG-TLX scores (43.5/120 vs 33.8/120) and higher scores in mental demand (8.2/20 vs 5.6/20), physical demand (6.6/20 vs 5.1/20), task complexity (8.2/20 vs 6/20) and situational stress (8.3/20 vs 5.9/20) for VTV-PPV. Temporal demand and distraction scores were similar. While participants took longer to complete VTV-PPV simulations, participants dedicated similar a %VA to the mannikin and T-piece gauges or ventilator screen. More participants increased the rate of ventilation during VTV-PPV; other corrective steps were similar. Overall, participants rated VTV-PPV positively. Participants identified potential challenges with physical ergonomics, cognition and teamwork.

CONCLUSION

Using a neonatal ventilator to perform volume-targeted PPV is feasible, but human factors need to be considered.

Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation

AIM

The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation.

METHODS

The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019.

RESULTS

The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial.

CONCLUSION

Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.

Respiratory function monitoring to improve the outcomes following neonatal resuscitation: a systematic review and meta-analysis

IMPORTANCE

Animal and observational human studies report that delivery of excessive tidal volume (V_T) at birth is associated with lung and brain injury. Using a respiratory function monitor (RFM) to guide V_T delivery might reduce injury and improve outcomes.

OBJECTIVE

To determine whether use of an RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room reduces in-hospital mortality and morbidity of infants <37 weeks' gestation.

STUDY SELECTION

Randomised controlled trials (RCTs) comparing RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room of infants born <37 weeks' gestation.

DATA ANALYSIS

Risk of bias was assessed using Covidence Collaboration tool and pooled into a meta-analysis using a random-effects model. The primary outcome was death prior to discharge.

MAIN OUTCOME

Death before hospital discharge.

RESULTS

Three RCTs enrolling 443 infants were combined in a meta-analysis. The pooled analysis showed no difference in rates of death before discharge with an RFM versus no RFM, relative risk (RR) 95% (CI) 0.98 (0.64 to 1.48). The pooled analysis suggested a significant reduction for brain injury (a combination of intraventricular haemorrhage and periventricular leucomalacia) (RR 0.65 (0.48 to 0.89), p=0.006) and for intraventricular haemorrhage (RR 0.69 (0.50 to 0.96), p=0.03) in infants receiving positive pressure ventilation with an RFM versus no RFM.

CONCLUSION

In infants <37 weeks, an RFM in addition to clinical assessment compared with clinical assessment during mask ventilation resulted in similar in-hospital mortality, significant reduction for any brain injury and intraventricular haemorrhage. Further trials are required to determine whether RFMs should be routinely available for neonatal resuscitation.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study

BACKGROUND

The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation.

METHODS

This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants.

RESULTS

Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant's chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants' subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively.

CONCLUSIONS

The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively.

IMPACT

Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.

Provider Visual Attention Correlates With the Quality of Pediatric Resuscitation: An Observational Eye-Tracking Study

Background

Eye-tracking devices are an innovative tool to understand providers' attention during stressful medical tasks. The knowledge about what gaze behaviors improve (or harm) the quality of clinical care can substantially improve medical training. The aim of this study is to identify gaze behaviors that are related to the quality of pediatric resuscitation.

Methods

Forty students and healthcare providers performed a simulated pediatric life support scenario, consisting of a chest compression task and a ventilation task, while wearing eye-tracking glasses. Skill Reporter software measured chest compression (CC) quality and Neo Training software measured ventilation quality. Main eye-tracking parameters were ratio [the number of participants who attended a certain area of interest (AOI)], dwell time (total amount of time a participant attended an AOI), the number of revisits (how often a participant returned his gaze to an AOI), and the number of transitions between AOIs.

Results

The most salient AOIs were infant chest and ventilation mask (ratio = 100%). During CC task, 41% of participants also focused on ventilation bag and 59% on study nurse. During ventilation task, the ratio was 61% for ventilation bag and 36% for study nurse. Percentage of correct CC rate was positively correlated with dwell time on infant chest (p = 0.044), while the overall CC quality was negatively correlated with dwelling outside of pre-defined task-relevant AOIs (p = 0.018). Furthermore, more dwell time on infant chest predicted lower leakage (p = 0.042). The number of transitions between AOIs was unrelated to CC parameters, but correlated negatively with mask leak during ventilations (p = 0.014). Participants with high leakage shifted their gaze more often between ventilation bag, ventilation mask, and task-irrelevant environment.

Conclusion

Infant chest and ventilation mask are the most salient AOIs in pediatric basic life support. Especially the infant chest AOI gives beneficial information for the resuscitation provider. In contrast, attention to task-irrelevant environment and frequent gaze shifts seem to harm the quality of care.

The newborn delivery room of tomorrow: emerging and future technologies

Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.

A multi-centre randomised controlled trial of respiratory function monitoring during stabilisation of very preterm infants at birth

AIM

To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range.

METHODS

Unmasked, randomised clinical trial conducted October 2013 - May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes.

RESULTS

Among 288 infants randomised (median (IQR) gestational age 26⁺² (25⁺³-27⁺¹) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no differences in other respiratory function measurements, oxygen saturation, heart rate or FiO₂. There were no differences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028).

CONCLUSION

In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range.

TRIAL REGISTRATION

Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.

Using eye-tracking augmented cognitive task analysis to explore healthcare professionals' cognition during neonatal resuscitation

AIM

We aimed to describe the cognitive processes of healthcare providers participating as airway leads in delivery room neonatal resuscitations using eye-tracking assisted debriefing to facilitate recall and provide situational context.

METHODS

Delivery room neonatal resuscitations were recorded using eye-tracking glasses worn by participants who acted as airway leads. These glasses analyze eye-movements to produce an audio-visual recording approximating what was "seen" by the participant and marking their visual attention. Participants then reviewed and debriefed their recordings. Debriefing involved a retrospective think-aloud prompted by eye-tracked recordings and an integrated semi-structured interview. Debriefing sessions were transcribed and subjected to thematic analysis.

RESULTS

Eight healthcare providers participated in 10 interviews; two providers participated twice in two separate resuscitations. Most visual attention was directed at the infant (62%), with 16% directed to monitors/gauges, 3% to team members. Five major themes emerged including situation awareness, performance, working in teams, addressing threats to performance, and perception of eye-tracking. Information processing was complex and involved top-down and bottom-up processing of environmental stimuli, integration of knowledge/experience, and anticipation of patient response. Despite the focus on individual cognition, interpersonal interactions and teamwork emerged as key aspects of resuscitation performance. Potential threats to performance include equipment issues, mental stress, distractions, and parental presence. Eye-tracking recordings were well-received by the participants.

CONCLUSION

Retrospective think-aloud prompted by point-of-view eye-tracked recordings is a useful means of examining cognition of healthcare providers during neonatal resuscitation. Themes identified in this project aligned with existing models of clinical reasoning.