Neonatal Intubation Research Articles

Outcomes, safety and health economics of introduction of video laryngoscopy-assisted less invasive surfactant administration.

Less invasive surfactant administration (LISA) is associated with better outcomes than InSurE (Intubation-Surfactant administration-Extubation). Video-laryngoscopy (VL) facilitates intubation in neonates, however safety and cost-effectiveness of VL-assisted LISA have not been evaluated. We compared the outcomes of infants receiving VL-assisted LISA (n = 67) with a historical cohort of infants who received InSurE (n = 52). Secondary aims were to evaluate safety and cost-effectiveness. VL-assisted LISA was associated with reduced duration of non-invasive ventilation (NIV), reduced duration of oxygen therapy, reduced composite days on NIV and mechanical ventilation (MV), and shorter NICU stay with lower hospital costs for infants ≥29 weeks GA, compared to InSurE. In the VL-assisted LISA group, 66% of the tracheal catheters were placed on the first attempt and 16% of infants displayed desaturation during placement. In infants ≥29 weeks GA, VL-assisted LISA reduced exposure to NIV, oxygen, NIV and MV combined, length of stay, and cost of care compared to InSurE.

Glottic opening detection using deep learning for neonatal intubation with video laryngoscopy.

This study aimed to develop an artificial intelligence (AI) method to augment video laryngoscopy (VL) by automating the detection of the glottic opening in neonates, as a step toward future studies on improving intubation outcomes. A deep learning model, YOLOv8, was trained on 1623 video frames from 84 neonatal intubations to detect the glottic opening and evaluated using 14-fold cross-validation on metrics like precision and recall. Additionally, it was compared with 25 medical providers of varied intubation experience to assess its relative performance. The model demonstrated a precision of 80.8% and a recall of 75.3% in identifying the glottic opening, detecting it 0.31 s faster than the average medical provider. It performed comparably or better than novice and intermediate providers, and slightly slower than experts. AI-powered tools can aid VL by providing real-time guidance, potentially enhancing neonatal intubation safety and efficiency for less experienced users.

Prospective evaluation of extended reality for neonatal intubation education

Purpose360° immersive videos may be useful in procedure-based healthcare settings. We hypothesized that extended reality (XR) neonatal intubation education is a feasible alternative to live demonstration in skill and knowledge transfer.MethodsThis was a prospective single center evaluation of an educational XR intubation video using Premature Anne™ (Laerdal Medical, Stavanger, Norway) comparing to a live demonstration. Participants were randomly allocated to either live demonstration or XR group. Each group received 20 min of teaching from the pediatric respiratory care education specialist, either in person or in video format. Intubation success, knowledge and skill acquisition were measured using a questionnaire and checklist.ResultsWe had a total of 23 participants, XR (n = 11) and live demonstration (n = 12). The groups were heterogeneous in experience level.The XR group was successful at intubating 73% of the time (n = 8), which was not significantly different to the live demonstration group 58% (n = 7) (p = 0.667). For patients who achieved intubation, there was no difference between groups in the mean time to successful intubation; 98 s (SD 73) for the XR group and 65 s (SD 22) for the live demonstration group (p = 0.685).When comparing scores between groups there were no statistically significant differences regarding knowledge scores (p = 0.514), skill scores (p = 0.826) and total scores (p = 0.926).ConclusionThese preliminary findings indicated no significant differences between the XR and live demonstration groups in terms of intubation success, knowledge acquisition, skill performance, total scores or time to successful intubation.

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

ObjectiveTo determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.DesignRetrospective analysis of prospectively collected data on...

Pregnancy Outcome of SARS-Cov-2 Infection on Newborns and Infants – A Systematic Review and Meta-Analysis

Abstract Background The impact of coronavirus disease (COVID -19) on maternal and newborn health is unclear so there is a great need to understand the effects of maternal COVID-19 infection on birth outcomes. Aim of the Work This study aimed to provide evidence using a systematic review and meta-analysis on the impact COVID-19 during pregnancy on neonates and infants. Patients and Methods The study included published case-control studies, case report studies, and retrospective case follow-up evaluating the COVID-19 infection in pregnancy and its effect on newborns and infants. A total of 429 studies were evaluated and only 61 met the eligibility criteria for data extraction and data analysis. Of these, 30 studies were used in meta-analysis and underwent quality assessment and bias evaluation. Results Fourteen studies were included detecting preterm labor event among cases with and without COVID-19 and showed significantly higher preterm labour among pregnant women with COVID-19 than without with p-value at < 0.0001. Eleven studies were included detecting NICU admission event among cases with and without COVID-19 which showed significantly higher NICU admission among pregnant women with COVID-19 than without with p-value at < 0.0001 while 4 studies were included detecting stillbirth admission event among cases with and without COVID-19 which showed insignificant differences of still births between the two groups with p-value at 0.6786, and 8 studies were included detecting Intrauterine growth retardation (IUGR)\ low birth weight admission event among cases with and without COVID-19 that showed insignificant differences of IUGR/ low birth weight between the two groups at p-value 0.1822. Conclusion COVID-19 infection in pregnant women has an impact on several neonatal outcomes, such as, preterm delivery, oxygen therapy, intubation, and NICU admission, but it does not significantly affect low birth weight, neonatal mortality, IUFD and stillbirth.

Practical Way to Use Supraglottic Airway Device.

We read a review of case reports published on Current Pediatric Reviews 2024 about the use of I-gel® in neonatal complicated intubation, and we decided to write a commentary on the benefits and limitations of using supraglottic airways in neonatal age, with a specific focus on Igel [1]. The use of supraglottic airway devices in neonatal ages is limited to particular conditions, but further research is showing the utility of these devices as the first choice in neonatal resuscitation or airway stabilization. Our commentary highlights the broader practical applications of I-gel and reinforces its role as a valuable tool in neonatal resuscitation.

Continuous improvement of non-emergent neonatal intubations in a level IV NICU.

We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit. 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. 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. 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.

Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial

ObjectiveNeonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow...

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study

ObjectiveTo identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL).DesignProspective single-centre observational study.SettingQuaternary neonatal intensive care unit.PatientsInfants requiring NTI at the Children’s Hospital...

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study

ObjectiveTo identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL).DesignProspective single-centre observational study.SettingQuaternary neonatal intensive care unit.PatientsInfants requiring NTI at the Children’s Hospital...

Neonatal Endotracheal Intubation: Comparison of Existing Formulae for Accuracy

Background There are several formulae proposed to calculate the ideal depth of insertion of the endotracheal tube (ETT) in neonates, none of which are universally accurate. Our objective is to identify the most accurate of these formulae and to determine the most suitable formula for babies weighing less than 1 kg. Methods This is a retro-prospective observational study conducted in a tertiary neonatal intensive care unit. All intubated babies, irrespective of their gestational age, were included in this study. Those with congenital airway anomalies or syndromes with involvement of the upper airway and those who required short-term ventilation restricted to the theatre complex were excluded. The ideal insertion depth was determined via a chest X-ray (CXR) with the ETT projecting between thoracic vertebrae 2 and 3. Predictions from eight formulae investigated in the Indian population were analysed using paired Wilcoxon tests and Bland–Altman plots. Results The sample size was 83, of which 16 weighed less than 1 kg. Neither weight-based nor naso-tragal length (NTL)-based formulae were universally accurate in the prediction of the ideal depth of insertion, and using either of the formulae resulted in a high rate of malpositioning. Amongst the NTL-based formulae, Tatwavedi and Singh’s adjustments worked better than the original. Conclusion The currently available formulae remain inaccurate in the prediction of the ideal length of insertion of ETT, more so in babies less than 1 kg in our study population.

Development of capability lists for neonatal critical care at three levels in China: a modified Delphi study

BackgroundThe standardised management of neonatal critical care centres can help improve health outcomes of vulnerable newborns. Guidance is required to update evidence related to construction and management of neonatal critical...

Global cross-sectional survey on neonatal pharmacologic sedation and analgesia practices and pain assessment tools: impact of the sociodemographic index (SDI).

There is variability in the use of sedatives and analgesics in neonatal intensive care units (NICUs). We aimed to investigate the use of analgesics and sedatives and the management of neonatal pain and distress. This was a global, prospective, cross-sectional study. A survey was distributed May-November 2022. The primary outcome of this research was to compare results between countries depending on their socio-sanitary level using the sociodemographic index (SDI). We organized results based on geographical location. The survey collected 1304 responses, but we analyzed 924 responses after database cleaning. Responses from 98 different countries were analyzed. More than 60% of NICUs reported having an analgosedation guideline, and one-third of respondents used neonatal pain scales in more than 80% of neonates. We found differences in the management of sedation and analgesia between NICUs on different continents, but especially between countries with different SDIs. Countries with a higher SDI had greater availability of and adherence to analgosedation guidelines, as well as higher rates of analgosedation for painful or distressing procedures. Countries with different SDIs reported differences in analgosedation for neonatal intubation, invasive ventilation, and therapeutic hypothermia, among others. Socio-economic status of countries impacts on neonatal analgosedation management. There is significant variability in the pain management practices in neonates. There is a lack of knowledge related to how neonatal pain management practices differ between regions. Sociodemographic index is a key factor associated with differences in neonatal pain management practices across global regions.

Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service.

To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service. We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians. Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively. On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.

Neonatal intubation: what are we doing?

How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope. Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure.What is Known:• Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions.• Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown.What is New:• Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease.• The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.

Parental perceptions of informed consent in a study of tracheal intubations in neonatal intensive care.

Obtaining informed consent in neonatal emergency research is challenging. The aim of this study was to assess parental perceptions of informed consent following participation in a clinical trial in neonatal emergency care. This was a supplementary analysis of a randomised controlled trial comparing video and direct laryngoscopy for neonatal endotracheal intubation in the delivery room and neonatal intensive care unit. After obtaining informed consent for the clinical trial, parents were asked to answer a series of self-administered questions about their perceptions of clinical trial participation and the consent process. Informed consent had been given either before birth, after birth but before inclusion in the trial, or after inclusion in the trial. We received responses from 33 mothers and 27 fathers (n = 60) of the 63 preterm and term infants who participated in the study. Fifty-three (89.8%, n = 59) parents agreed that infants should participate in clinical trials, and 51 (85%, n = 60) parents agreed that parents should be asked for informed consent. Fifty-three (89.8%, n = 59) parents felt that their infant's participation in this particular trial would be beneficial. Fifty-two (86.7%, n = 60) parents felt that the informed consent process was satisfactory. One parent (100%, n = 1) approached before birth, 23 parents (82.1%, n = 28) approached after birth but before enrolment and 26 (83.9%, n = 31) parents approached after enrolment were satisfied with the timing of the consent process. Eight (13.3%, n = 60) parents felt some pressure to provide informed consent. Of these, two (25%) were approached before enrolment and six (75%) were approached after enrolment. Parents valued their infant's participation in an emergency neonatal clinical trial and considered it important to be asked for consent. In this study, it seemed less important whether consent was obtained before or after the intervention. Future studies may need to investigate which form of consent is most acceptable to parents for the individual study in question.

Possible Efficacy of Vaginal Progesterone on Asymptomatic Women with a Short Cervix after 24 Weeks of Gestation: A Historical Cohort Study in Japan.

Few studies have explored the preventive efficacy of vaginal progesterone (VD) treatment for preterm delivery (PTD) in Japanese clinical practice. In this study, the efficacy of the VD treatment in pregnant women with a short cervix (sCX) diagnosed after 24 weeks is evaluated, focusing on perinatal outcomes. A retrospective historical cohort study. Clinical data of 273 singleton women hospitalized for preventing PTD were extracted. Inclusion criteria are diagnosed sCX at 24-33 weeks. We excluded women with factors including treatment start before 24 weeks, medically induced PTD, PTD on admission day, and fetal demise. Consequently, logistic regression analyses were conducted on data from 79 women during Period 1 (November 2015 to March 2018, using prolonged intravenous ritodrine hydrochloride) and 82 women during Period 2 (August 2018 to August 2022, implementing VD treatment), adjusting maternal age, parity, body mass index, gestational age, cervical length, and histological chorioamnionitis. The primary outcomes involved PTD <37 and <34 weeks and neonatal intensive care unit admission. Secondary outcomes included the interval from the diagnosis of sCX to delivery <14 and <28 days, infant intubation, and surfactant administration. Since VD use is off-label in Japan, we obtained written informed consent prior to treatment. VD treatment (Period 2) significantly decreased the incidence of PTD (birth < 37 weeks) (adjusted odds ratios [ORs] 0.43, 95% confidence intervals [CIs] 0.19-0.96), impending delivery within 14 and 28 days after confirming sCX (adjusted OR 0.12, 95% CI 0.06-0.72; adjusted OR 0.25, 95% CI 0.09-0.74, respectively), and neonatal intubation rate (adjusted OR 0.17, 95% CI 0.04-0.75). The VD treatment can prevent PTD in asymptomatic women with sCX diagnosed after 24 weeks of gestation. Although further validation is warranted, these findings may contribute to expanding the use of VD treatment in Japanese clinical practice.

Spontaneous breathing in selected neonates with very mild congenital diaphragmatic hernia.

Current treatment guidelines recommend immediate postnatal intubation in all neonates with congenital diaphragmatic hernia (CDH). This study aimed to investigate the feasibility and outcomes of a spontaneous breathing approach (SBA) versus immediate intubation in neonates with prenatally diagnosed very mild CDH. A retrospective study was conducted comparing neonates with very mild CDH (left-sided, liver-down, observed-to-expected lung-to-head ratio ≥45%) undergoing SBA and matched controls receiving standard treatment. Data on early echocardiographic findings, respiratory support, length of hospital stay, and clinical outcomes were analyzed. Of 151 CDH neonates, eight underwent SBA, while 31 received standard treatment. SBA was successful in six of eight patients. SBA patients had shorter length of stay (14 vs. 30 days, p = .005), mechanical ventilation (3.5 vs. 8.7 days, p = .011), and oxygen supplementation (3.2 vs. 9.3 days, p = .013) compared to matched controls. Echocardiographic evidence of pulmonary hypertension and cardiac dysfunction were significantly lower in SBA neonates after admission but similar before surgical repair. The SBA group tolerated enteral feeding earlier (day of life 7 vs. 16, p = .019). SBA appears feasible and beneficial for prenatally diagnosed very mild CDH. It was associated with a shortened hospital stay supportive therapies. However, larger trials are needed to confirm these findings and determine optimal respiratory support.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

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).

How does videolaryngoscopy compare with conventional direct laryngoscopy for neonatal tracheal intubation?

How does videolaryngoscopy compare with conventional direct laryngoscopy for neonatal tracheal intubation?