Time needed to intubate and suction a manikin prior to instituting positive pressure ventilation: a simulation trial

Nicoletta Doglioni,Chiara Monfredini,Daniele Trevisanuto,Paolo Ernesto Villani,Giulia Res,Francesco Cavallin,Gary Weiner

doi:10.1007/s00431-020-03759-5

Abstract

Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid (MSAF) is supposed to delay initiation of positive pressure ventilation (PPV), but the magnitude of such delay is unknown. To compare the time of PPV initiation when performing immediate laryngoscopy with intubation and suctioning vs. performing immediate PPV without intubation in a manikin model. Randomized controlled crossover (AB/BA) trial comparing PPV initiation with or without endotracheal suctioning in a manikin model of non-vigorous neonates born through MSAF. Participants were 20 neonatologists and 20 pediatric residents trained in advanced airway management. Timing of PPV initiation was longer with vs. without endotracheal suctioning in both pediatric residents (mean difference 13 s, 95% confidence interval 8 to 18 s; p < 0.0001) and neonatologists (mean difference 12 s, 95% confidence interval 8 to 16 s; p < 0.0001). The difference in timing of PPV initiation was similar between pediatric residents and neonatologists (mean difference − 1 s, 95% confidence interval − 7 to 6 s; p = 0.85).Conclusions: Performing immediate laryngoscopy with intubation and suctioning was associated with longer—but not clinically relevant—time of initiation of PPV compared with immediate PPV without intubation in a manikin model. While suggesting negligible delay in starting PPV, further studies in a clinical setting are warranted.Registration: clinicaltrial.gov NCT04076189.What is Known:• Management of the non-vigorous newborn delivered through meconium-stained amniotic fluid remains still controversial.• Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid is supposed to delay initiation of positive pressure ventilation, but the magnitude of such delay is unknown.What is New:• Performing immediate ventilation without intubation was associated with shorter—but not clinically relevant—time of initiation of ventilation compared to immediate laryngoscopy with intubation and suctioning in a manikin model.• Further studies in a clinical setting are warranted.

Highlights

3–14% of deliveries are complicated by meconium-stained amniotic fluid (MSAF), which can cause meconium aspiration syndrome (MAS) in 5–10% of these newborns [1,2,3].MAS has a multifactorial pathophysiology secondary to intrauterine asphyxia leading to chemical irritation, inflammatory response, surfactant inactivation, and airway obstruction [4,5,6]
Performing immediate laryngoscopy with intubation and suctioning was associated with longer—but not clinically relevant—time of initiation of positive pressure ventilation (PPV) compared with immediate PPV without intubation in a manikin model
Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid is supposed to delay initiation of positive pressure ventilation, but the magnitude of such delay is unknown

Summary

Introduction

3–14% of deliveries are complicated by meconium-stained amniotic fluid (MSAF), which can cause meconium aspiration syndrome (MAS) in 5–10% of these newborns [1,2,3].MAS has a multifactorial pathophysiology secondary to intrauterine asphyxia leading to chemical irritation, inflammatory response, surfactant inactivation, and airway obstruction [4,5,6]. 3–14% of deliveries are complicated by meconium-stained amniotic fluid (MSAF), which can cause meconium aspiration syndrome (MAS) in 5–10% of these newborns [1,2,3]. Endotracheal suctioning can be used to clear a blocked airway, the International Liaison Committee on Resuscitation (ILCOR) suggests against routine tracheal intubation and suctioning for nonvigorous newborns delivered through MSAF [8]. Routine tracheal suctioning of such infants is likely to delay the initiation of positive pressure ventilation (PPV), especially when performed by inexperienced healthcare providers, possibly increasing the severity of hypoxic-ischemic encephalopathy [8]. There is no evidence that routine tracheal suctioning provides clinical benefits when performed by experienced healthcare providers [8]

Results

Discussion

Conclusion