1
|
Shay R, Weikel BW, Mascorro M, Harding E, Beard L, Grover T, Barry JS. Continuous improvement of non-emergent neonatal intubations in a level IV NICU. J Perinatol 2024:10.1038/s41372-024-02062-7. [PMID: 39025954 DOI: 10.1038/s41372-024-02062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/05/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit. STUDY DESIGN A multidisciplinary team created guidelines for non-emergent neonatal intubations. In period 1, premedication practices were standardized. In period 2, paralytic use and video laryngoscope use were recommended. Premedication and video laryngoscopy practices were assessed along with number of intubation attempts and frequency of bradycardia and desaturation. RESULTS 636 intubations performed by neonatology fellows and neonatal advanced practice providers were reviewed over six academic years. Two academic years were included in each of the following study periods: baseline, period 1, and period 2. In our unit, compliance with recommended premedication practices and administration of paralytic medication has increased considerably, and video laryngoscopy is now utilized in most of our procedures. The frequency of intubation success on the first attempt has increased, and the frequency of both bradycardia and desaturation during intubation has decreased. In our analysis, paralytic use (AOR 2.41, 95 CI (1.53, 3.81)) and the combination of paralytic and video laryngoscopy (AOR 4.07, 95 CI (2.09, 7.92)) are associated with increased odds of intubating successfully on the first attempt. CONCLUSIONS This initiative increased the use of standardized premedication, paralytic medication and video laryngoscopy for non-emergent neonatal intubations with temporally associated improvement in patient outcomes including fewer intubation attempts and reduction in physiologic instability.
Collapse
Affiliation(s)
- Rebecca Shay
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA.
| | - Blair W Weikel
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Melanie Mascorro
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Emma Harding
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Lauren Beard
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Theresa Grover
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - James S Barry
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| |
Collapse
|
2
|
Corder W, Nelin T, Ades AM, Flibotte J, Laverriere E, Daly Guris R, Soorikian L, Foglia EE. Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326992. [PMID: 38951016 DOI: 10.1136/archdischild-2024-326992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/18/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL). DESIGN Prospective single-centre observational study. SETTING Quaternary neonatal intensive care unit. PATIENTS Infants requiring NTI at the Children's Hospital of Philadelphia. INTERVENTIONS VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location. MAIN OUTCOME MEASURE VL NTI attempt success. RESULTS A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009). CONCLUSION We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.
Collapse
Affiliation(s)
- William Corder
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Timothy Nelin
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne M Ades
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Laverriere
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rodrigo Daly Guris
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leane Soorikian
- Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Corder W, Nelin T, Ades AM, Flibotte J, Laverriere E, Daly Guris R, Soorikian L, Foglia EE. Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326992. [PMID: 38951017 DOI: 10.1136/fetalneonatal-2024-326992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/18/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL). DESIGN Prospective single-centre observational study. SETTING Quaternary neonatal intensive care unit. PATIENTS Infants requiring NTI at the Children's Hospital of Philadelphia. INTERVENTIONS VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location. MAIN OUTCOME MEASURE VL NTI attempt success. RESULTS A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009). CONCLUSION We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.
Collapse
Affiliation(s)
- William Corder
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Timothy Nelin
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne M Ades
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Laverriere
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rodrigo Daly Guris
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leane Soorikian
- Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Kaufmann J, Huber D, Engelhardt T, Kleine-Brueggeney M, Kranke P, Riva T, von Ungern-Sternberg BS, Fuchs A. [Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]. DIE ANAESTHESIOLOGIE 2024; 73:473-481. [PMID: 38958671 PMCID: PMC11222175 DOI: 10.1007/s00101-024-01424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.
Collapse
Affiliation(s)
- Jost Kaufmann
- Kinderkrankenhaus der Kliniken der Stadt Köln gGmbH, Amsterdamer Str. 59, 50735, Köln, Deutschland.
- Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland.
| | - Dennis Huber
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Thomas Engelhardt
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Kanada
| | - Maren Kleine-Brueggeney
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Thomas Riva
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australien
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australien
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australien
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australien
| | - Alexander Fuchs
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| |
Collapse
|
5
|
Edwards G, Van Der Heide P, O'Shea JE. Experience of endotracheal intubation and supraglottic airway insertion by consultant paediatricians in non-tertiary neonatal units: a Scotland-wide survey. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327257. [PMID: 38937075 DOI: 10.1136/archdischild-2024-327257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Gemma Edwards
- Neonatology, Royal Hospital for Children, Glasgow, UK
| | | | | |
Collapse
|
6
|
Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med 2024; 390:1885-1894. [PMID: 38709215 DOI: 10.1056/nejmoa2402785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain. METHODS In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection. RESULTS Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively. CONCLUSIONS Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).
Collapse
Affiliation(s)
- Lucy E Geraghty
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Emma A Dunne
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Caitríona M Ní Chathasaigh
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Akke Vellinga
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Niamh C Adams
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Eoin M O'Currain
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Lisa K McCarthy
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Colm P F O'Donnell
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| |
Collapse
|
7
|
Chen DY, Devsam B, Sett A, Perkins EJ, Johnson MD, Tingay DG. Factors that determine first intubation attempt success in high-risk neonates. Pediatr Res 2024; 95:729-735. [PMID: 37777605 PMCID: PMC10899101 DOI: 10.1038/s41390-023-02831-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/17/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Approximately 50% of all neonatal endotracheal intubation attempts are unsuccessful and associated with airway injury and cardiorespiratory instability. The aim of this study was to describe intubation practice at a high-risk Neonatal Intensive Care Unit (NICU) and identify factors associated with successful intubation at the first attempt. METHODS Retrospective cohort study of all infants requiring intubation within the Royal Children's Hospital NICU over three years. Data was collected from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Outcomes were number of attempts, level of operator training, equipment used, difficult airway grade, and clinical factors. Univariate and multivariate analysis were performed to determine factors independently associated with first attempt success. RESULTS Three hundred and sixty intubation courses, with 538 attempts, were identified. Two hundred and twenty-five (62.5%) were successful on first attempt, with similar rates at subsequent attempts. On multivariate analysis, increasing operator seniority increased the chance of first attempt success. Higher glottic airway grades were associated with lower chance of first attempt success, but neither a known difficult airway nor use of a stylet were associated with first attempt success. CONCLUSION In a NICU with a high rate of difficult airways, operator experience rather than equipment was the greatest determinant of intubation success. IMPACT Neonatal intubation is a high-risk lifesaving procedure, and this is the first report of intubation practices at a quaternary surgical NICU that provides regional referral services for complex medical and surgical admissions. Our results showed that increasing operator seniority and lower glottic airway grades were associated with increased first attempt intubation success rates, while factors such as gestational age, weight, stylet use, and known history of difficult airway were not. Operator factors rather than equipment factors were the greatest determinants of first attempt success, highlighting the importance of team selection for neonatal intubations in a high-risk cohort of infants.
Collapse
Affiliation(s)
- Donna Y Chen
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Bianca Devsam
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
- Department of Nursing, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Arun Sett
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
- Newborn Services, Joan Kirner Women's and Children's, Western Health, Melbourne, VIC, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Mitchell D Johnson
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
| |
Collapse
|
8
|
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Collapse
Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
9
|
Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Collapse
Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Kurepa D, Boyar V, Predtechenska O, Gupta V, Weinberger B, Pulju M, Zaytseva A, Galanti SG, Kasniya G, Perveen S. Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative. Arch Dis Child Fetal Neonatal Ed 2023; 108:588-593. [PMID: 37028921 DOI: 10.1136/archdischild-2023-325357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/25/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support. SETTING Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA). STUDY POPULATION Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration. RESULTS LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation. CONCLUSIONS Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.
Collapse
Affiliation(s)
- Dalibor Kurepa
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Vitaliya Boyar
- Pediatrics, Cohen Children's Medical Center Division of Neonatology, New Hyde Park, New York, USA
| | - Olena Predtechenska
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Venkata Gupta
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Barry Weinberger
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Margaret Pulju
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Alla Zaytseva
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Stephanie G Galanti
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Gangajal Kasniya
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Shahana Perveen
- Pediatrics, Cohen Children's Medical Center Division of Neonatology, New Hyde Park, New York, USA
| |
Collapse
|
11
|
Ming Y, Chu S, Yang K, Zhang Z, Wu Z. Network meta-analysis of comparative efficacy and safety of intubation devices in children. Sci Rep 2023; 13:18626. [PMID: 37903873 PMCID: PMC10616294 DOI: 10.1038/s41598-023-45173-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 10/17/2023] [Indexed: 11/01/2023] Open
Abstract
To evaluate the comparative efficacy and safety of different intubation devices on intubation outcomes in pediatric intubation. We identified relevant studies from previous meta-analyses and literature retrieval in PubMed, EMBASE, and Cochrane Library. The primary outcome was the first-pass success (FPS), and the secondary outcome included the time to intubation (TTI) and the risk of local complications (LC). Network meta-analysis was performed using STATA 14.0. Twenty-three randomized comparative trials (RCTs) including 12 devices were included. Compared with Macintosh, Airtraq (odds ratio [OR] = 13.05, 95% confidence interval [CI] = 4.68 to 36.38), Miller (OR = 4.77, 95%CI = 1.32 to 17.22), Glidescope (OR = 2.76, 95%CrI = 1.60 to 4.75) and McGrath (OR = 4.61, 95%CI = 1.18 to 17.99) obtained higher PFS. Meanwhile, Airtraq was superior to Glidescope (OR = 0.21, 95%CI = 0.07 to 0.65) for PFS. For TTI, Canada was superior to other intubation devices, as well as CMAC was superior to TruViewEVO2, Glidescope, and StorzDCI. Airtraq lowered the risk of LC compared with Macintosh and Pentax but there was no statistical difference between Airtraq and KingVision. Airtraq may be the optimal option for FPS, Canada for TTI, and KingVision for LC in pediatric intubation.
Collapse
Affiliation(s)
- Yu Ming
- College of Medicine and Health Science, Wuhan Polytechnic University, Wuhan, 430023, Hubei, China
| | - Shujuan Chu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kai Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Zhouyang Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| |
Collapse
|
12
|
Herrick HM, O'Reilly MA, Foglia EE. Success rates and adverse events during neonatal intubation: Lessons learned from an international registry. Semin Fetal Neonatal Med 2023; 28:101482. [PMID: 38000925 PMCID: PMC10842734 DOI: 10.1016/j.siny.2023.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Neonatal endotracheal intubation is a challenging procedure with suboptimal success and adverse event rates. Systematically tracking intubation outcomes is imperative to understand both universal and site-specific barriers to intubation success and safety. The National Emergency Airway Registry for Neonates (NEAR4NEOS) is an international registry designed to improve neonatal intubation practice and outcomes that includes over 17,000 intubations across 23 international sites as of 2023. Methods to improve intubation safety and success include appropriately matching the intubation provider and situation and increasing adoption of evidence-based practices such as muscle relaxant premedication and video laryngoscope, and potentially new interventions such as procedural oxygenation.
Collapse
Affiliation(s)
- Heidi M Herrick
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Mackenzie A O'Reilly
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
13
|
Gizicki E, Assaad MA, Massé É, Bélanger S, Olivier F, Moussa A. Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial. J Pediatr 2023; 261:113576. [PMID: 37353151 DOI: 10.1016/j.jpeds.2023.113576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/09/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI). STUDY DESIGN A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests. RESULTS Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P = .71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P = .035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P = .048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P = .02). There were more mucosal trauma events in the simulation-based JITT group (P = .02). Residents in both groups reported similar confidence level in performing ETI. CONCLUSIONS Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents. TRIAL REGISTRATION ClinicalTrials.gov: NCT02809924.
Collapse
Affiliation(s)
- Ewa Gizicki
- Division of Neonatology, Department of Pediatrics, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Michael-Andrew Assaad
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada; Centre for Applied Health Sciences Education (CPASS), Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Édith Massé
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sherbooke, Sherbrooke, QC, Canada
| | - Sylvie Bélanger
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Laval, Quebec, QC, Canada
| | - François Olivier
- Division of Neonatology, Department of Pediatrics, Centre Universitaire de santé McGill, Montreal, QC, Canada
| | - Ahmed Moussa
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada; Centre for Applied Health Sciences Education (CPASS), Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; Centre Hospitalier Universitaire Sainte-Justine Research Center, Montreal, QC, Canada.
| |
Collapse
|
14
|
Abstract
Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.
Collapse
Affiliation(s)
- Sandy Kirolos
- Neonatal unit, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
| | - Gemma Edwards
- Neonatal unit, Princess Royal Maternity Hospital, 16 Alexandra Parade, Glasgow, G31 2ER, UK.
| | - Joyce O'Shea
- Neonatal unit, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK. Joyce.O'
| |
Collapse
|
15
|
Breindahl N, Tolsgaard MG, Henriksen TB, Roehr CC, Szczapa T, Gagliardi L, Vento M, Støen R, Bohlin K, van Kaam AH, Klotz D, Durrmeyer X, Han T, Katheria AC, Dargaville PA, Aunsholt L. Curriculum and assessment tool for less invasive surfactant administration: an international Delphi consensus study. Pediatr Res 2023; 94:1216-1224. [PMID: 37142651 PMCID: PMC10444608 DOI: 10.1038/s41390-023-02621-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/20/2023] [Accepted: 04/01/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Training and assessment of operator competence for the less invasive surfactant administration (LISA) procedure vary. This study aimed to obtain international expert consensus on LISA training (LISA curriculum (LISA-CUR)) and assessment (LISA assessment tool (LISA-AT)). METHODS From February to July 2022, an international three-round Delphi process gathered opinions from LISA experts (researchers, curriculum developers, and clinical educators) on a list of items to be included in a LISA-CUR and LISA-AT (Round 1). The experts rated the importance of each item (Round 2). Items supported by more than 80% consensus were included. All experts were asked to approve or reject the final LISA-CUR and LISA-AT (Round 3). RESULTS A total of 153 experts from 14 countries participated in Round 1, and the response rate for Rounds 2 and 3 was >80%. Round 1 identified 44 items for LISA-CUR and 22 for LISA-AT. Round 2 excluded 15 items for the LISA-CUR and 7 items for the LISA-AT. Round 3 resulted in a strong consensus (99-100%) for the final 29 items for the LISA-CUR and 15 items for the LISA-AT. CONCLUSIONS This Delphi process established an international consensus on a training curriculum and content evidence for the assessment of LISA competence. IMPACT This international consensus-based expert statement provides content on a curriculum for the less invasive surfactant administration procedure (LISA-CUR) that may be partnered with existing evidence-based strategies to optimize and standardize LISA training in the future. This international consensus-based expert statement also provides content on an assessment tool for the LISA procedure (LISA-AT) that can help to evaluate competence in LISA operators. The proposed LISA-AT enables standardized, continuous feedback and assessment until achieving proficiency.
Collapse
Affiliation(s)
- Niklas Breindahl
- Department of Neonatal and Pediatric Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
- Prehospital Center Region Zealand, Næstved, Denmark.
| | - Martin G Tolsgaard
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tine B Henriksen
- Department of Paediatrics (Intensive Care Neonatology), Aarhus University Hospital, Aarhus, Denmark
- Perinatal Research Unit, Clinical Institute, Aarhus University, Aarhus, Denmark
| | - Charles C Roehr
- Newborn Services, Southmead Hospital, North Bristol NHS Trust Bristol, Bristol, UK
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Tomasz Szczapa
- 2nd Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Luigi Gagliardi
- Division of Neonatology and Pediatrics, Ospedale Versilia, Viareggio, Azienda USL Toscana Nord Ovest, Pisa, Italy
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe (HULAFE) and Health Research Institute (IISLAFE), Valencia, Spain
| | - Ragnhild Støen
- Department of Neonatology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kajsa Bohlin
- Department of Neonatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel Klotz
- Center for Pediatrics, Division of Neonatology and Pediatric Intensive Care Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Durrmeyer
- Department of Neonatal Intensive Care and Neonatology, Centre Hospitalier Intercommunal de Créteil, Université Paris Est Créteil, Créteil, France
- GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
| | - Tongyan Han
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, 92123, USA
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Lise Aunsholt
- Department of Neonatal and Pediatric Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
16
|
Irouschek A, Moritz A, Kremer S, Fuchte T, Danzl A, Schmidt J, Golditz T. An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists. PLoS One 2023; 18:e0288816. [PMID: 37535590 PMCID: PMC10399777 DOI: 10.1371/journal.pone.0288816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS. METHODS For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded. RESULTS A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating. CONCLUSIONS Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.
Collapse
Affiliation(s)
- Andrea Irouschek
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Moritz
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Kremer
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Fuchte
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Anja Danzl
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Joachim Schmidt
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Golditz
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
17
|
Giuliano J, Krishna A, Napolitano N, Panisello J, Shenoi A, Sanders RC, Rehder K, Al-Subu A, Brown C, Edwards L, Wright L, Pinto M, Harwayne-Gidansky I, Parsons S, Romer A, Laverriere E, Shults J, Yamada NK, Walsh CM, Nadkarni V, Nishisaki A. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936-947. [PMID: 37058348 DOI: 10.1097/ccm.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN Prospective multicenter interventional quality improvement study. SETTING Ten PICUs in North America. PATIENTS Patients undergoing tracheal intubation in the PICU. INTERVENTIONS VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.
Collapse
Affiliation(s)
- John Giuliano
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Ashwin Krishna
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UW Health American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Calvin Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lisa Wright
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Matthew Pinto
- Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ilana Harwayne-Gidansky
- Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Medical Center, Albany, NY
| | - Simon Parsons
- Division of Critical Care, Alberta Children's Hospital, Calgary, AB, Canada
| | - Amy Romer
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Laverriere
- Division of Critical Care Medicine and Division of General Anesthesiology at Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole K Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, ON, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
18
|
Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev 2023; 5:CD009975. [PMID: 37171122 PMCID: PMC10177149 DOI: 10.1002/14651858.cd009975.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018. OBJECTIVES To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age). SEARCH METHODS In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www. CLINICALTRIALS gov; www.controlled-trials.com), and reference lists of relevant studies. SELECTION CRITERIA Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy. DATA COLLECTION AND ANALYSIS Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence). For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies. AUTHORS' CONCLUSIONS Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.
Collapse
Affiliation(s)
- Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicole Neveln
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer L Arnold
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
19
|
Miller KA, Auerbach M, Bin SS, Donoghue A, Kerrey BT, Mittiga MR, D'Ambrosi G, Monuteaux MC, Marchese A, Nagler J. Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation. AEM EDUCATION AND TRAINING 2023; 7:e10846. [PMID: 36936084 PMCID: PMC10014969 DOI: 10.1002/aet2.10846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
Background Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.
Collapse
Affiliation(s)
- Kelsey A. Miller
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven S. Bin
- Departments of Pediatrics and Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Aaron Donoghue
- Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin T. Kerrey
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | - Ashley Marchese
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Joshua Nagler
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
20
|
Videolaryngoscopy in neonates: A narrative review exploring the current state of the art. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
|
21
|
Pinheiro JMB, Munshi UK, Chowdhry R. Strategies to Improve Neonatal Intubation Safety by Preventing Endobronchial Placement of the Tracheal Tube-Literature Review and Experience at a Tertiary Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020361. [PMID: 36832490 PMCID: PMC9955846 DOI: 10.3390/children10020361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
Unintended endobronchial placement is a common complication of neonatal tracheal intubation and a threat to patient safety, but it has received little attention towards decreasing its incidence and mitigating associated harms. We report on the key aspects of a long-term project in which we applied principles of patient safety to design and implement safeguards and establish a safety culture, aiming to decrease the rate of deep intubation (beyond T3) in neonates to <10%. Results from 5745 consecutive intubations revealed a 47% incidence of deep tube placement at baseline, which decreased to 10-15% after initial interventions and remained in the 9-20% range for the past 15 years; concurrently, rates of deep intubation at referring institutions have remained high. Root cause analyses revealed multiple contributing factors, so countermeasures specifically aimed at improving intubation safety should be applied before, during, and immediately after tube insertion. Extensive literature review, concordant with our experience, suggests that pre-specifying the expected tube depth before intubation is the most effective and simple intervention, although further research is needed to establish accurate and accepted standards for estimating the expected depth. Presently, team training on intubation safety, plus possible technological advances, offer additional options for safer neonatal intubations.
Collapse
|
22
|
Gariépy-Assal L, Janaillac M, Ethier G, Pennaforte T, Lachance C, Barrington KJ, Moussa A. A tiny baby intubation team improves endotracheal intubation success rate but decreases residents' training opportunities. J Perinatol 2023; 43:215-219. [PMID: 36309565 DOI: 10.1038/s41372-022-01546-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the educational and clinical impact of a tiny baby intubation team (TBIT). STUDY DESIGN Retrospective study comparing endotracheal intubation (ETI) performed: pre-implementation of a TBIT (T1), 6 months post-implementation (T2), and 4 years post-implementation (T3). RESULTS Post-implementation (T2), first-attempt success rate in tiny babies increased (44% T1; 59% T2, p = 0.04; 56% T3, p = NS) and the proportion of ETIs performed by residents decreased (53% T1; 37% T2, p = 0.001; 45% T3, p = NS). After an educational quality improvement intervention (prioritizing non-tiny baby ETIs to residents, systematic simulation training and ETI using videolaryngoscopy), in T3 residents' overall (67% T1; 60% T2, p = NS; 79% T3, p = 0.02) and non-tiny baby ETI success rate improved (72% T1; 60% T2, p = NS; 82% T3, p = 0.02). CONCLUSION A TBIT improves success rate of ETIs in ELBW infants but decreases educational exposure of residents. Educational strategies may help maintain resident procedural competency without impacting on quality of care.
Collapse
Affiliation(s)
- L Gariépy-Assal
- Department of Pediatrics, Université de Montreal, Montréal, QC, Canada
| | - M Janaillac
- Service de néonatologie, Centre Hospitalier Annecy-Genevois, Annecy, France
| | - G Ethier
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montreal, Montréal, QC, Canada
| | - T Pennaforte
- Department of Pediatrics, Université de Montreal, Montréal, QC, Canada
| | - C Lachance
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montreal, Montréal, QC, Canada
| | - K J Barrington
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montreal, Montréal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada
| | - A Moussa
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montreal, Montréal, QC, Canada. .,CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada. .,Centre de pédagogie appliquée aux sciences de la santé, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.
| |
Collapse
|
23
|
The Association of Teamwork and Adverse Tracheal Intubation–Associated Events in Advanced Airway Management in the PICU. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1756715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractTracheal intubation (TI) in critically ill children is a life-saving but high-risk procedure that involves multiple team members with diverse clinical skills. We aim to examine the association between the provider-reported teamwork rating and the occurrence of adverse TI-associated events (TIAEs). A retrospective analysis of prospectively collected data from 45 pediatric intensive care units in the National Emergency Airway Registry for Children (NEAR4KIDS) database from January 2013 to March 2018 was performed. A composite teamwork score was generated using the average of each of five (7-point Likert scale) domains in the teamwork assessment tool. Poor teamwork was defined as an average score of 4 or lower. Team provider stress data were also recorded with each intubation. A total of 12,536 TIs were reported from 2013 to 2018. Approximately 4.1% (n = 520) rated a poor teamwork score. TIs indicated for shock were more commonly associated with a poor teamwork score, while those indicated for procedures and those utilizing neuromuscular blockade were less commonly associated with a poor teamwork score. TIs with poor teamwork were associated with a higher occurrence of adverse TIAE (24.4% vs 14.4%, p < 0.001), severe TIAE (13.7% vs 5.9%, p < 0.001), and peri-intubation hypoxemia < 80% (26.4% vs 17.9%, p < 0.001). After adjusting for indication, provider type, and neuromuscular blockade use, poor teamwork was associated with higher odds of adverse TIAEs (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.35–2.34), severe TIAEs (OR, 2.23; 95% CI, 1.47–3.37), and hypoxemia (OR, 1.63; 95% CI, 1.25–2.03). TIs with poor teamwork were independently associated with a higher occurrence of TIAEs, severe TIAEs, and hypoxemia.
Collapse
|
24
|
Bakshi SG, Singh P, Bhosale S. Role of video-based learning on competency level of direct laryngoscopic skills of novice anaesthesiologists - A randomised clinical trial. Indian J Anaesth 2022; 66:712-718. [PMID: 36437980 PMCID: PMC9698288 DOI: 10.4103/ija.ija_668_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND AIMS Video laryngoscopes are often used for education and training of intubation skills. This study aimed to examine the influence of video-assisted guidance and video replay on intubation skills of novice anaesthesiologists. METHODS Adult patients of American Society of Anesthesiologists physical status grade I-II, with a normal airway and scheduled to undergo elective surgical procedures requiring general anaesthesia and orotracheal intubation were included in this randomised study. Ten trainee anaesthesiologists, with no prior experience of performing tracheal intubation were enroled and randomly divided into group STD (received traditional learning) and group VL (received video-based learning). After initial mannequin training, the first seven intubations in patients in both the groups were done under supervision. In group VL, in addition to traditional cues, posttracheal intubation, the trainee and instructor had a session of video replay to discuss the entire process of laryngoscopy and tracheal intubation with areas of improvement. For the subsequent 15 intubations in patients, the trainees intubated independently using a standard Macintosh blade. The primary objective was to compare time required to intubate (TTI) for both groups using Mann-Whitney U test. Secondary objectives included comparison of difficulty in intubation (using a 5-point Likert scale), self-confidence scores (1-10, 10 - most confident), and intubation-related trauma. RESULTS The mean TTI was significantly lower in group VL than in group STD - 40s [Interquartile range (IQR): 32-50] versus 52s [IQR: 39-76], P = 0.002. No difference was seen in self-assessed confidence levels, rating of difficulty in intubation, and airway trauma. CONCLUSION Video replay of the intubation process has a positive impact on direct laryngoscopy learning.
Collapse
Affiliation(s)
- Sumitra G Bakshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India,Address for correspondence: Dr. Sumitra G. Bakshi, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India. E-mail:
| | - Pankaj Singh
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shil Bhosale
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
25
|
Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 2022; 42:1221-1227. [PMID: 35982243 DOI: 10.1038/s41372-022-01484-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between number of attempts and adverse events during neonatal intubation. STUDY DESIGN A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation). RESULTS Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt. CONCLUSION The risk of adverse safety events during intubation increases with the number of intubation attempts.
Collapse
|
26
|
Laverriere E, Fiadjoe JE, McGowan N, Bruins BB, Napolitano N, Watanabe I, Yamada NK, Walsh CM, Berg RA, Nadkarni VM, Nishisaki A. A prospective observational study of video laryngoscopy-guided coaching in the pediatric intensive care unit. Paediatr Anaesth 2022; 32:1015-1023. [PMID: 35656910 PMCID: PMC9357165 DOI: 10.1111/pan.14505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/05/2022] [Accepted: 05/30/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. AIM Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation-associated events. METHODS This is a pre-post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single-center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation-associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured. RESULTS Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation-associated events between the two phases (pre- 9% vs. post- 5%, absolute difference -3%, CI95 : -8% to 1%, p = .11), oxygen desaturations <80% (pre- 13% vs. post- 13%, absolute difference 1%, CI95 : -6% to 5%, p = .75), or first attempt success (pre- 73% vs. post- 76%, absolute difference 4%, CI95 : -3% to 11%, p = .29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95 : 23% to 51%, p < .001). CONCLUSIONS Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation-associated events and oxygen desaturation.
Collapse
Affiliation(s)
- Elizabeth Laverriere
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - John E. Fiadjoe
- Division of General Anesthesiology, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Nancy McGowan
- Department of Respiratory Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Benjamin B. Bruins
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Natalie Napolitano
- Department of Respiratory Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ichiro Watanabe
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Nicole K. Yamada
- Division of Neonatal and Perinatal Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Catharine M. Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Robert A. Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Vinay M. Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
27
|
Kirolos S, O'Shea J. Neonatal videolaryngoscopy: a new scope offering improved direct airway views. Arch Dis Child Fetal Neonatal Ed 2022; 107:453-454. [PMID: 34172508 DOI: 10.1136/archdischild-2021-322502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Sandy Kirolos
- Neonatal Intensive Care Unit, Royal Hospital for Children, Glasgow, UK joyce.o'
| | - Joyce O'Shea
- Neonatal Intensive Care Unit, Royal Hospital for Children, Glasgow, UK joyce.o'
| |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Quick and precise facemask ventilation and tracheal intubation are critical clinical skills in neonatal airway management. In addition, this vulnerable population requires a thorough understanding of developmental airway anatomy and respiratory physiology to manage and anticipate potential airway mishaps. Neonates have greater oxygen consumption, increased minute ventilation relative to functional residual capacity, and increased closing volumes compared to older children and adults. After a missed airway attempt, this combination can quickly lead to dire consequences, such as cardiac arrest. Keeping neonates safe throughout the first attempt of airway management is key. RECENT FINDINGS Several techniques and practices have evolved to improve neonatal airway management, including improvement in neonatal airway equipment, provision of passive oxygenation, and closer attention to the management of anesthetic depth. The role of nontechnical skills during airway management is receiving more recognition. SUMMARY Every neonatal intubation should be considered a critical event. Below we discuss some of the challenges in neonatal airway management, including anatomical and physiological principles which must be understood to approach the airway. We then follow with a description of current evidence for best practices and training.
Collapse
|
29
|
Davis KF, Rosenblatt S, Buffman H, Polikoff L, Napolitano N, Giuliano JS, Sanders RC, Edwards LR, Krishna AS, Parsons SJ, Al-Subu A, Krawiec C, Harwayne-Gidansky I, Vanderford P, Salfity N, Lane-Fall M, Nadkarni V, Nishisaki A. Facilitators and Barriers to Implementing Two Quality Improvement Interventions Across 10 Pediatric Intensive Care Units: Video Laryngoscopy-Assisted Coaching and Apneic Oxygenation. Am J Med Qual 2022; 37:255-265. [PMID: 34935683 DOI: 10.1097/jmq.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To better understand facilitators and barriers to implementation of quality improvement (QI) efforts, this study examined 2 evidence-based interventions, video laryngoscopy (VL)-assisted coaching, and apneic oxygenation (AO). One focus group with frontline clinicians was held at each of the 10 participating pediatric intensive care units. Qualitative analysis identified common and unique themes. Intervention fidelity was monitored with a priori defined success as >50% VL-assisted coaching or >80% AO use for 3 consecutive months. Eighty percent of intensive care units with VL-assisted coaching and 20% with AO met this criteria during the study period. Common facilitator themes were adequate device accessibility, having a QI culture, and strong leadership. Common barrier themes included poor device accessibility and perception of delay in care. A consistently identified theme in the successful sites was strong QI leadership, while unsuccessful sites consistently identified insufficient education. These facilitators and barriers should be proactively addressed during dissemination of these interventions.
Collapse
Affiliation(s)
- Katherine Finn Davis
- School of Nursing and Dental Hygiene, University of Hawai'i at Mānoa, Honolulu, HI
| | - Samuel Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hayley Buffman
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lee Polikoff
- Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John S Giuliano
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lauren R Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Ashwin S Krishna
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KT
| | - Simon J Parsons
- Department of Pediatrics, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Conrad Krawiec
- Division of Pediatrics Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA
| | | | - Paula Vanderford
- Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR
| | - Nina Salfity
- Division of Critical Care, Phoenix Children's Hospital, Phoenix, AZ
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
30
|
O'Shea JE, Scrivens A, Edwards G, Roehr CC. Safe emergency neonatal airway management: current challenges and potential approaches. Arch Dis Child Fetal Neonatal Ed 2022; 107:236-241. [PMID: 33883207 DOI: 10.1136/archdischild-2020-319398] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/21/2021] [Accepted: 03/30/2021] [Indexed: 11/03/2022]
Abstract
This review examines the airway adjuncts currently used to acutely manage the neonatal airway. It describes the challenges encountered with facemask ventilation and intubation. Evidence is presented on how to optimise intubation safety and success rates with the use of videolaryngoscopy and attention to the intubation environment. The supraglottic airway (laryngeal mask airway) is emerging as a promising neonatal airway adjunct. It can be used effectively with little training to provide a viable alternative to facemask ventilation and intubation in neonatal resuscitation and be used as an alternative conduit for the administration of surfactant.
Collapse
Affiliation(s)
- Joyce E O'Shea
- Neonatology, Royal Hospital for Children, Glasgow, UK joyce.o'.,Neonatal Transport, Scotstar, Glasgow, UK
| | - Alexandra Scrivens
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gemma Edwards
- Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford, UK.,Department of Population Health, National Perinatal Epidemiology Unit Clinical Trials Unit, Oxford, UK
| |
Collapse
|
31
|
Hodgson KA, Owen LS, Kamlin COF, Roberts CT, Newman SE, Francis KL, Donath SM, Davis PG, Manley BJ. Nasal High-Flow Therapy during Neonatal Endotracheal Intubation. N Engl J Med 2022; 386:1627-1637. [PMID: 35476651 DOI: 10.1056/nejmoa2116735] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt. METHODS We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant. RESULTS The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3). CONCLUSIONS Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).
Collapse
Affiliation(s)
- Kate A Hodgson
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Louise S Owen
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - C Omar F Kamlin
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Calum T Roberts
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Sophie E Newman
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Kate L Francis
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Susan M Donath
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Peter G Davis
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Brett J Manley
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| |
Collapse
|
32
|
Weiner GM, Zaichkin J. Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines. Neoreviews 2022; 23:e238-e249. [PMID: 35362042 DOI: 10.1542/neo.23-4-e238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.
Collapse
Affiliation(s)
- Gary M Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | | |
Collapse
|
33
|
To View or Not To View? Standard Geometry Video Laryngoscopes and Screen Visualization. Ann Emerg Med 2022; 79:344-347. [PMID: 35337471 DOI: 10.1016/j.annemergmed.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 12/31/2022]
|
34
|
Batey N, Henry C, Garg S, Wagner M, Malhotra A, Valstar M, Smith T, Sharkey D. The newborn delivery room of tomorrow: emerging and future technologies. Pediatr Res 2022:10.1038/s41390-022-01988-y. [PMID: 35241791 DOI: 10.1038/s41390-022-01988-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 02/01/2022] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- Natalie Batey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Caroline Henry
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalabh Garg
- Department of Neonatal Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Michel Valstar
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Thomas Smith
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK.
| |
Collapse
|
35
|
Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
Collapse
Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| |
Collapse
|
36
|
V Salis-Soglio N, Hummler H, Schwarz S, Mendler MR. Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting. Front Pediatr 2022; 10:1031847. [PMID: 36507131 PMCID: PMC9731376 DOI: 10.3389/fped.2022.1031847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Endotracheal intubation of very low birth weight infants (VLBWI) is an essential procedure in NICUs, but intubation experience is often limited. Video laryngoscopy (VL) has been described as a tool to improve intubation skills, but studies in high-risk neonatal populations are limited. OBJECTIVE The aim of this study was to investigate whether VL is a useful tool to support airway management in high-risk premature infants with inexperienced operators. METHODS In this crossover study predominantly inexperienced participants were exposed in random sequence to VL and conventional direct laryngoscopy (DL) for endotracheal intubation of a VLBWI simulation manikin to measure total time, number of attempts, success rate on first attempt, view of the vocal cords and perceived subjective safety until successful intubation. RESULTS In our study group of 94 participants there was no significant difference in the total time (mean VL: 34 s (±24 s); DL: 37 s (±28 s), p = 0.246), while the number of intubation attempts using VL was significantly lower (mean VL: 1.22 (±0.53); DL: 1.37 (±0.60), p = 0.023). Success rate of VL during the first attempt was significantly higher (VL: 84%; DL 69%, p = 0.016), view of the vocal cords was significantly better and perceived subjective safety was increased using VL. CONCLUSIONS Our study results suggest that with rather inexperienced operators, VL can be a useful tool to increase rate of successful endotracheal intubation of VLBWI and to improve their perceived safety during the procedure, which may have an impact on mortality and/or morbidity.
Collapse
Affiliation(s)
| | - Helmut Hummler
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany.,Divison of Neonatology, Department of Pediatrics, University of Tübingen, Tübingen, Germany
| | - Stephan Schwarz
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Marc R Mendler
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany
| |
Collapse
|
37
|
Moussa A, Sawyer T, Puia-Dumitrescu M, Foglia EE, Ades A, Napolitano N, Glass KM, Johnston L, Jung P, Singh N, Quek BH, Barry J, Zenge J, DeMeo S, Mehrem AA, Nadkarni V, Nishisaki A. Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS. J Perinatol 2022; 42:1210-1215. [PMID: 35922664 PMCID: PMC9362392 DOI: 10.1038/s41372-022-01472-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We hypothesized that videolaryngoscope use for tracheal intubations would differ across NICUs, be associated with higher first attempt success and lower adverse events. STUDY DESIGN Data from the National Emergency Airway Registry for Neonates (01/2015 to 12/2017) included intubation with direct laryngoscope or videolaryngoscope. Primary outcome was first attempt success. Secondary outcomes were adverse tracheal intubation associated events and severe desaturation. RESULTS Of 2730 encounters (13 NICUs), 626 (23%) utilized a videolaryngoscope (3% to 64% per site). Videolaryngoscope use was associated with higher first attempt success (p < 0.001), lower adverse tracheal intubation associated events (p < 0.001), but no difference in severe desaturation. After adjustment, videolaryngoscope use was not associated with higher first attempt success (OR:1.18, p = 0.136), but was associated with lower tracheal intubation associated events (OR:0.45, p < 0.001). CONCLUSION Videolaryngoscope use is variable, not independently associated with higher first attempt success but associated with fewer tracheal intubation associated events.
Collapse
Affiliation(s)
- Ahmed Moussa
- Department of Pediatrics, Division of Neonatology, Université de Montréal, Montreal, Canada.
| | - Taylor Sawyer
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, WA USA
| | - Mihai Puia-Dumitrescu
- grid.34477.330000000122986657Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, WA USA
| | - Elizabeth E. Foglia
- grid.239552.a0000 0001 0680 8770Department of Pediatrics, Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Anne Ades
- grid.239552.a0000 0001 0680 8770Department of Pediatrics, Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Natalie Napolitano
- grid.239552.a0000 0001 0680 8770Respiratory Therapy Department, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Kristen M. Glass
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State Children’s Hospital, Penn State College of Medicine, Hershey, PA USA
| | - Lindsay Johnston
- grid.47100.320000000419368710Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT USA
| | - Philipp Jung
- grid.412468.d0000 0004 0646 2097Universitätsklinikum Schleswig-Holstein, Campus Luebeck, Lübeck, Germany
| | - Neetu Singh
- grid.413480.a0000 0004 0440 749XDepartment of Pediatrics, Dartmouth-Hitchcock Health System, Lebanon, NH USA
| | - Bin Huey Quek
- grid.414963.d0000 0000 8958 3388KK Women’s and Children’s Hospital, Singapore, Singapore
| | - James Barry
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Jeanne Zenge
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Stephen DeMeo
- grid.417002.00000 0004 0506 9656Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC USA
| | - Ayman Abou Mehrem
- grid.22072.350000 0004 1936 7697Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Vinay Nadkarni
- grid.239552.a0000 0001 0680 8770Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Akira Nishisaki
- grid.239552.a0000 0001 0680 8770Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | | |
Collapse
|
38
|
Goel S, Choudhary R, Magoon R, Sharma R, Usha G, Kapoor PM, Bagga D. A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation. J Anaesthesiol Clin Pharmacol 2022; 38:464-468. [PMID: 36505196 PMCID: PMC9728438 DOI: 10.4103/joacp.joacp_422_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 02/14/2021] [Accepted: 04/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background and Aims An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation. Material and Methods 150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups. Results C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant. Conclusion Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.
Collapse
Affiliation(s)
- Sachin Goel
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Ripon Choudhary
- Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Ridhima Sharma
- Department of Paediatric Anaesthesia, Postgraduate Institute of Child Health, Noida, Uttar Pradesh, India,Address for correspondence: Dr. Ridhima Sharma, Department of Paediatric Anaesthesia, Assistant Professor, Post Graduate Institute of Child Health, Noida - 201 310, Uttar Pradesh, India. E-mail:
| | - G. Usha
- Department of Paediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Poonam M. Kapoor
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, NewDelhi, Ansari Nagar, New Delhi, India
| | - Deepak Bagga
- Department of Paediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, Baba Kharak Singh Marg, New Delhi, India
| |
Collapse
|
39
|
Lum E, Sommer-Candelario S, Choi SY, Delos Santos S, Aeby K, Lee-Jayaram J. Emergency Pediatric Intubations in an Urban Children’s Hospital Before and After Just-in-Time Training for Video Laryngoscopy. Cureus 2021; 13:e19892. [PMID: 34976504 PMCID: PMC8712208 DOI: 10.7759/cureus.19892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives: The use of video laryngoscopy (VL) may augment emergency pediatric intubations outside the operating room (OR). Our objective was to describe the proportion of use and complications with VL before and after implementation of a VL just-in-time training (JITT). Study design: This study was a retrospective chart review of pediatric intubations performed outside the OR at a single women and children’s hospital from January 2015 to March 2020. Data were collected on patient age, intubation method, operator characteristics, adverse events, number of attempts, condition leading to intubation, and hospital location. Data were separated into pre-JITT (January 1, 2015 to April 31, 2018) and post-JITT (May 1, 2018 to March 1, 2020) periods. Descriptive statistics were used comparing pre- and post-JITT periods for VL use, and the complications of intubations with multiple attempts (IMAs) and intubations with one or more adverse events (AEs). Results: A total of 231 pediatric patients were intubated during the study period; 154 intubations in the pre-JITT and 77 intubations in the post-JITT periods. Pre- and post-JITT VL use was 17 (11%) and 17 (22%), respectively. With pre-JITT VL, there were four (23%) IMAs and zero (0%) intubation with one or more AE. With post-JITT VL, there were eight (47%) IMAs and one (6%) intubation with one or more AE. Conclusion: The proportion of emergency pediatric intubations using VL increased after the institution of a JITT. There was no significant change in IMAs and AEs. The infrequency of pediatric intubations makes drawing conclusions regarding the impact on IMAs and AEs challenging. JITT may increase VL use for emergency pediatric intubations outside the OR and may be considered for refresher training, especially during the coronavirus disease 2019 (COVID-19) pandemic.
Collapse
|
40
|
Altamimi T, Read B, da Silva O, Bhattacharya S. Airway injury and pneumomediastinum associated with less invasive surfactant administration in a premature neonate: a case report. BMC Pediatr 2021; 21:500. [PMID: 34758781 PMCID: PMC8579620 DOI: 10.1186/s12887-021-02981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
Background The use of less invasive surfactant administration (LISA)/minimally invasive surfactant therapy (MIST) has increased due to its potential advantage over traditional surfactant delivery methods through an endotracheal tube. Known complications for this procedure include failure of the first attempt at insertion, desaturation, and bradycardia. To the best of our knowledge, this is the first reported case of pneumomediastinum and subcutaneous emphysema following LISA. Case presentation A preterm newborn born at 27 weeks of gestation presented with respiratory distress syndrome requiring surfactant replacement. LISA using the Hobart method was completed. There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath. The newborn was subsequently noted to have subcutaneous emphysema over the anterior aspect of the neck and substantial pneumomediastinum on radiological assessment. Associated complications included hypotension requiring inotropic support. The newborn was successfully managed conservatively, with complete resolution of the air leak. Conclusions Upper airway injury leading to air leak syndrome is a rare complication of the Hobart method for LISA. Awareness of such procedural complications is important as the use of the LISA method increases.
Collapse
Affiliation(s)
- Talal Altamimi
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada.
| | - Brooke Read
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Orlando da Silva
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Soume Bhattacharya
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| |
Collapse
|
41
|
Foz C, Staffa SJ, Park R, Huang S, Kovatsis P, Peyton J, Nathan M, DiNardo JA, Nasr VG. Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study. J Clin Anesth 2021; 76:110565. [PMID: 34743956 DOI: 10.1016/j.jclinane.2021.110565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/13/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation. DESIGN Retrospective cohort study. SETTING Tertiary Children's Hospital. PARTICIPANTS 6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed. EXCLUSION CRITERIA age > 18 years, endotracheal tube or tracheostomy in-situ. METHODS/INTERVENTIONS Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets. RESULTS Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without. CONCLUSION Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.
Collapse
Affiliation(s)
- Carine Foz
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Pain Medicine, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - ShengXiang Huang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pete Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
42
|
Herrick HM, Pouppirt N, Zedalis J, Cei B, Murphy S, Soorikian L, Matthews K, Nassar R, Napolitano N, Nishisaki A, Foglia EE, Ades A, Nawab U. Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle. Pediatrics 2021; 148:peds.2020-035899. [PMID: 34526350 PMCID: PMC8628255 DOI: 10.1542/peds.2020-035899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 01/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Heidi M. Herrick
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicole Pouppirt
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jacqueline Zedalis
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bridget Cei
- Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Murphy
- Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leane Soorikian
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelle Matthews
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rula Nassar
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Neonatology, Christiana Care Health System, Newark, Delaware
| | - Natalie Napolitano
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ursula Nawab
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
43
|
Haase B, Badinska AM, Maiwald CA, Poets CF, Springer L. Comparison of nostril sizes of newborn infants with outer diameter of endotracheal tubes. BMC Pediatr 2021; 21:417. [PMID: 34556062 PMCID: PMC8459504 DOI: 10.1186/s12887-021-02889-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recommendations for endotracheal tube (ETT) size usually refer to the inner diameter (ID). Outer diameters (OD), however, vary greatly between manufacturers, which in some brands might cause difficulties in passing the ETT through the nostrils if choosing the nasal route for intubation. Even though the nostrils are dilatable by an ETT, it might be difficult to pass an ETT through the posterior naris (narrowest point of the nasal passage), if the OD is bigger than the nostrils. Therefore, nostril size may provide some guidance for the appropriate ETT size preventing unsuccessful intubation attempts. This study therefore compares nostril sizes of newborn infants with ODs of ETTs from several manufacturers. METHODS This is a subgroup analysis of a prospective observational study, performed in a single tertiary perinatal centre in Germany. The diameter of the nostril of infants born between 34 and 41 weeks´ gestation was measured in 3D images using 3dMDvultus software and compared to the OD of ETT from five different manufacturers. RESULTS Comparisons of nostril sizes with ODs of different ETTs were made for 99 infants with a mean (SD) birthweight of 3058g (559) [range: 1850-4100g]. Mean (SD) nostril size was 5.3mm (0.6). The OD of the 3.5mm ETT of different manufacturers ranged from 4.8-5.3mm and was thus larger than the nostril size of 20-46% of late preterm or term infants. Some OD of a 3.0mm ETT were even bigger than the OD of a 3.5mm ETT (e.g. the 3.0mm ETT from Rüsch® has an OD of 5.0mm while the 3.5mm ETT from Portex® has an OD of 4.8mm). CONCLUSIONS Clinicians should be aware of the OD of ETTs to reduce unsuccessful intubation attempts caused by ETT sizes not fitting the nasal cavity. Generated data may help to adapt recommendations in future. TRIAL REGISTRATION Subgroup analysis of the "Fitting of Commonly Available Face Masks for Late Preterm and Term Infants (CAFF)"-study: NCT03369028, www.ClinicalTrials.gov , December 11, 2017.
Collapse
Affiliation(s)
- Bianca Haase
- Department of Neonatology, University Children’s Hospital of Tuebingen, Calwerstraße 7, 72076 Tuebingen, Germany
| | - Ana-Maria Badinska
- Department of Neonatology, University Children’s Hospital of Tuebingen, Calwerstraße 7, 72076 Tuebingen, Germany
| | - Christian A. Maiwald
- Department of Neonatology, University Children’s Hospital of Tuebingen, Calwerstraße 7, 72076 Tuebingen, Germany
| | - Christian F. Poets
- Department of Neonatology, University Children’s Hospital of Tuebingen, Calwerstraße 7, 72076 Tuebingen, Germany
| | - Laila Springer
- Department of Neonatology, University Children’s Hospital of Tuebingen, Calwerstraße 7, 72076 Tuebingen, Germany
| |
Collapse
|
44
|
O'Shea JE, Edwards G, Kirolos S, Godden C, Brunton A. Implementation of a Standardized Neonatal Intubation Training Package. J Pediatr 2021; 236:189-193.e2. [PMID: 33940014 DOI: 10.1016/j.jpeds.2021.04.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the first attempt neonatal intubation success rates of pediatric trainees following the implementation of an evidence-based training package. STUDY DESIGN Data collection was undertaken from February, 1 2017, to January 31, 2018, to ascertain baseline preimplementation intubation success rates. An intubation training package, which included the use of videolaryngoscopy, preprocedure pause, and standardized instruction during the procedure, was introduced. Data on all subsequent intubations were collected prospectively from May 1, 2018, to April 30, 2020. RESULTS Preimplementation baseline data over a 1-year period demonstrated overall first attempt intubation success rate of junior trainees to be 37% (33/89). After implementation of the training package, 290 intubations were analyzed over a 2-year period. The overall success rate was 67% (194/290); 61% (117/192) for junior trainees and 79% (77/98) for senior clinicians. Three or more attempts were required for 13% of intubations (38/290). During the study period, the overall number of intubations being carried out decreased. Intubations with the videolaryngoscope had higher success rates for all tiers of clinician, most marked in the junior tiers. CONCLUSIONS The introduction of a standardized intubation training package, along with videolaryngoscopy, improved trainee intubation success rates.
Collapse
Affiliation(s)
- Joyce E O'Shea
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Gemma Edwards
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom.
| | - Sandy Kirolos
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Cliodhna Godden
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Andrew Brunton
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| |
Collapse
|
45
|
Hodgson K, Manley B, Kamlin O, Owen L, Roberts C, Francis K, Davis P, Donath S. The SHINE trial (a multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation): statistical analysis plan. Trials 2021; 22:565. [PMID: 34429132 PMCID: PMC8383434 DOI: 10.1186/s13063-021-05390-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/21/2021] [Indexed: 01/09/2023] Open
Affiliation(s)
- Kate Hodgson
- Newborn Research Centre, Royal Women's Hospital, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.
| | - Brett Manley
- Newborn Research Centre, Royal Women's Hospital, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Omar Kamlin
- Newborn Research Centre, Royal Women's Hospital, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise Owen
- Newborn Research Centre, Royal Women's Hospital, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Calum Roberts
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - Kate Francis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Peter Davis
- Newborn Research Centre, Royal Women's Hospital, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| |
Collapse
|
46
|
Developing a Profile of Procedural Expertise: A Simulation Study of Tracheal Intubation Using 3-Dimensional Motion Capture. Simul Healthc 2021; 15:251-258. [PMID: 32168289 DOI: 10.1097/sih.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving the assessment and training of tracheal intubation is hindered by the lack of a sufficiently validated profile of expertise. Although several studies have examined biomechanics of tracheal intubation, there are significant gaps in the literature. We used 3-dimensional motion capture to study pediatric providers performing simulated tracheal intubation to identify candidate kinematic variables for inclusion in an expert movement profile. METHODS Pediatric anesthesiologists (experienced) and pediatric residents (novices) were recruited from a pediatric institution to perform tracheal intubation on airway mannequins in a motion capture laboratory. Subjects performed 21 trials of tracheal intubation, 3 each of 7 combinations of laryngoscopic visualization (direct or indirect), blade type (straight or curved), and mannequin size (adult or pediatric). We used repeated measures analysis of variance to determine whether various kinematic variables (3-trial average for each participant) were associated with experience. RESULTS Eleven experienced and 15 novice providers performed 567 successful tracheal intubation attempts (9 attempts unsuccessful). For laryngoscopy, experienced providers exhibited shorter path length (total distance traveled by laryngoscope handle; 77.6 ± 26.0 cm versus 113.9 ± 53.7 cm; P = 0.013) and greater angular variability at the left wrist (7.4 degrees versus 5.5 degrees, P = 0.013) and the left elbow (10.1 degrees versus 7.6 degrees, P = 0.03). For intubation, experienced providers exhibited shorter path length of the right hand (mean = 61.1 cm versus 99.9 cm, P < 0.001), lower maximum acceleration of the right hand (0.19 versus 0.14 m/s, P = 0.033), and smaller angular, variability at the right elbow (9.7 degrees versus 7.9 degrees, P = 0.03). CONCLUSIONS Our study and the available literature suggest specific kinematic variables for inclusion in an expert profile for tracheal intubation. Future studies should include a larger sample of practitioners, actual patients, and measures of the cognitive and affective components of expertise.
Collapse
|
47
|
Glenn T, Sudhakar S, Markowski A, Malay S, Hibbs AM. Patient characteristics associated with complications during neonatal intubations. Pediatr Pulmonol 2021; 56:2576-2582. [PMID: 33983688 PMCID: PMC8298275 DOI: 10.1002/ppul.25453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood. DESIGN/METHODS A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation. RESULTS A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO2 of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23). CONCLUSION Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.
Collapse
Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Shwetha Sudhakar
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
48
|
Chess PR. Assessing Intubation Competence During Neonatal Fellowship Training. Pediatrics 2021; 148:peds.2021-050765. [PMID: 34172557 DOI: 10.1542/peds.2021-050765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Patricia R Chess
- School of Medicine and Dentistry, University of Rochester and Department of Pediatrics, Golisano Children's Hospital, Rochester, New York
| |
Collapse
|
49
|
Johnston L, Sawyer T, Ades A, Moussa A, Zenge J, Jung P, DeMeo S, Glass K, Singh N, Howlett A, Shults J, Barry J, Brei B, Foglia E, Nishisaki A. Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS). Neonatology 2021; 118:434-442. [PMID: 34111869 PMCID: PMC8376802 DOI: 10.1159/000516372] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed. METHODS Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference). RESULTS Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11-0.30) for residents and 0.80 (95% CI: 0.51-1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation. CONCLUSION Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.
Collapse
Affiliation(s)
- Lindsay Johnston
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Taylor Sawyer
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Anne Ades
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ahmed Moussa
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Luebeck, Germany
| | - Stephen DeMeo
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Neetu Singh
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - James Barry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brianna Brei
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Foglia
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | |
Collapse
|
50
|
Roberts CT, Manley BJ, O'Shea JE, Stark M, Andersen C, Davis PG, Buckmaster A. Supraglottic airway devices for administration of surfactant to newborn infants with respiratory distress syndrome: a narrative review. Arch Dis Child Fetal Neonatal Ed 2021; 106:336-341. [PMID: 32989046 DOI: 10.1136/archdischild-2020-319804] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/03/2022]
Abstract
Surfactant is an effective treatment for respiratory distress syndrome, being particularly important for infants in whom continuous positive airway pressure (CPAP) provides insufficient support. Supraglottic airway devices present an attractive option for surfactant delivery, particularly as an alternative to methods dependent on direct laryngoscopy, a procedural skill that is both difficult to learn and in which to maintain competence. Published studies provide encouraging data that surfactant administration by supraglottic airway device can be performed with a high rate of success and may reduce the need for subsequent intubation compared with either continued CPAP or surfactant administration via endotracheal tube. However, existing randomised controlled trials (RCTs) are heterogeneous in design and include just over 350 infants in total. To date, all RCT evidence has been generated in tertiary units, whereas the greatest potential for benefit from the use of these devices is likely to be in non-tertiary settings. Future research should investigate choice and utility of device in addition to safety and effectiveness of procedure. Importantly, studies conducted in non-tertiary settings should evaluate feasibility, meaningful clinical outcomes and the impact that this approach might have on infants and their families. Supraglottic airway devices may represent a simple and effective mode of surfactant administration that can be widely used by a variety of clinicians. However, further well-designed RCTs are required to determine their role, safety and effectiveness in both tertiary and non-tertiary settings before introduction into routine clinical practice.
Collapse
Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia .,Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
| | - Michael Stark
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hsopital, Adelaide, South Australia, Australia
| | - Chad Andersen
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hsopital, Adelaide, South Australia, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Adam Buckmaster
- Women, Children and Families, Central Coast Local Health District, Gosford, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|