Neonatal Endotracheal Intubation Research Articles

Laryngeal mask ventilation with chest compression during neonatal resuscitation: randomized, non-inferiority trial in lambs.

Background:Effective positive pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC).Methods:Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 minutes of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till return of spontaneous circulation (ROSC) or 20 minutes.Results:Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min – 9.1 min) in the LMA group and 7.50 min (5.33 min – 18 min) in the ETT group (p = 0.65).Conclusion:LMA ventilation during CC is feasible and non-inferior to ETT in this model.

Indications and outcomes of neonatal intubation: A single-center, prospective study in a middle-income country

This study assessed the success rate and associated complications of hospital-wide neonatal endotracheal intubations by pediatric residents and neonatal fellows using direct laryngoscopy. Secondary objectives were to identify characteristics and indications for the procedure in a tertiary-care center. A cross-sectional observational study was conducted. We prospectively collected performance and infant outcome data after neonatal intubation between March 1, 2019 and February 29, 2020. 171 intubations were observed in 105 infants. The median infant gestational age was 31.0 weeks (interquartile range [IQR]: 27.5-36.0 weeks). Fifty infants (48%) were very low birth weight (VLBW, <1500g; median 1640g [IQR: 870-2420g]). The most common indication for intubation was respiratory failure (65%). Pediatric residents and neonatal fellows had overall success rates of 66% and 98%, respectively. The success rate for the first intubation attempt was higher with more advanced pediatric residency training (P<0.001). The median attempts for each intubation were 1 (IQR: 1-2) for both VLBW and non-VLBW infants (P=0.48). The adverse outcome rates were 5% and 3% for VLBW and non-VLBW infants, respectively (P=0.53). More than 2 intubation attempts was the only significant independent risk factor for adverse outcomes (adjusted odds ratio 6.7; 95% CI 1.3-33.6; P=0.02). The success rate of pediatric residents for neonatal intubation was similar for VLBW and non-VLBW infants. The main indication was respiratory failure, and nearly half were infants with VLBW. To minimize adverse sequelae, written guidelines limiting the number of intubation attempts by junior trainees are warranted.

The SHINE trial (a multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation): statistical analysis plan

The SHINE trial (a multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation): statistical analysis plan

In Newborn Infants a New Intubation Method May Reduce the Number of Intubation Attempts: A Randomized Pilot Study.

Severe desaturation or bradycardia often occur during neonatal endotracheal intubation. Using continuous gas flow through the endotracheal tube might reduce the incidence of these events. We hypothesized that continuous gas flow through the endotracheal tube during nasotracheal intubation compared to standard nasotracheal intubation will reduce the number of intubation attempts in newborn infants. In a randomized controlled pilot study, neonates were either intubated with continuous gas flow through the endotracheal tube during intubation (intervention group) or no gas flow during intubation (control group). Recruitment was stopped early due to financial and organizational issues. A total of 16 infants and 39 intubation attempts were analyzed. The median (interquartile range) number of intubation attempts and number of abandoned intubations due to desaturation and/or bradycardia were 1 (1–2) and 4 (2–5), (p = 0.056) and n = 3 versus n = 20, (p = 0.060) in the intervention group and control group, respectively. Continuous gas flow through the endotracheal tube during intubation seems to be favorable and there are no major unexpected adverse consequences of attempting this methodology.

Simulation for Neonatal Endotracheal Intubation Training: How Different Is It From Clinical Practice?

Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity. A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach. Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design. Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.

Different Effects of Two Protocols for Pre-Procedural Analgosedation on Vital Signs in Neonates during and after Endotracheal Intubation.

Analgosedation is often used for endotracheal intubation in neonates, but no consensus exists on the optimal pre-procedural medication. To compare the time to intubation and vital signs during and after intubation in 2 NICUs using different premedication protocols. Prospective observational study in 2 tertiary NICUs, comparing fentanyl and optional vecuronium for elective neonatal endotracheal intubation (NICU-1) with atropine, morphine, midazolam and optional pancuronium (NICU-2). Primary endpoints were: time to intubate and number of intubation attempts; secondary endpoints were: deviations of heart rate, oxygen saturation and blood pressure from baseline until 20 min post intubation. 45 and 30 intubations were analyzed in NICU-1 and NICU-2. Time to intubation was longer in NICU-1 (7 min) than in NICU-2 (4 min; p=0.029), but the mean number of intubation attempts did not differ significantly. Bradycardias (34 vs. 1, p<0.001) and hypoxemias (136 vs. 48, p<0.001) were more frequent in NICU-1, and tachycardias (59 vs. 72, p<0.001) more frequent in NICU-2. Mean arterial blood pressure (MAP) increased in NICU-1 (+6.18 mmHg) and decreased in NICU-2 (-5.83 mmHg), whereas mean heart rates (HR) decreased in NICU-1 (-19.29 bpm) and increased in NICU-2 (+15.93 bpm). MAP and HR returned to baseline 6-10 min after intubation in NICU-1 and after 11-15 min and 16-20 min in NICU-2, respectively. The two protocols yielded significant differences in the time to intubation and in the extent and duration of physiologic changes during and post-intubation. Short acting drugs should be preferred and vital signs should be closely monitored at least 20 min post intubation. More studies are required to identify analgosedation protocols that minimize potentially harmful events during endotracheal intubation.

Preparing A University Hospital Neonatal Intensive Care Unit for Covid-19 Pandemic and Country Lockdown

Jordan is one of the earliest countries that took a very strict approach to contain COVID-19 pandemic by declaring a country lock down. Our neonatal intensive care unit is a level three 30 beds unit. The shortage of neonatal nurses, doctors, and of respiratory support devices are the major existing challenges. During COVID-19 pandemic, those two issues were magnified. This paper will shortly discuss the measures taken as a preparedness for COVID-19 Pandemic in our unit. Team development and work schedule: The medical knowledge about COVID-19 was foggy, however; teamwork is the only ev-ident thing. Our team included, the neonatologists, pediatric intensivist, pediatric pul-monologists, in addition to the infectious disease specialist. The team also included three of our senior residents, and the neonatal unit head nurse. To enhance communication, we created a WhatsApp group (Peds COVID -19). Among this group, unidentified Patients’ information, in addition to recent publications and sci-entific opinions, were shared. Meeting with the obstetric department was done to famil-iarize both teams with the measures taken on both sides. The neonatal care is provided by two neonatologists. The in-house care providers are the pediatric residents. Senior residents are well-trained on neonatal resuscitation, endotra-cheal intubation, and umbilical venous catheterization. During COVID-19 lock down, residents were split into separate teams. Neonatal team, the pediatric floor team, and the emergency room team, each team had their sleeping room and lounges. The consultants did rounds daily, the in-house team consisted of two senior residents, and a junior resident. they did a 24-hour shift every four days and are off duty for the next three days. Regarding the nursing staff schedule, their work schedule changed from an 8- hour shift to a 12- hour shifts schedule. The aim was to promote staff well-being, minimize the number of staff who could potentially be exposed to a COVID-19 case, and therefore will need to be quarantined. Visitation policy: Mothers could come at any time, but fathers could visit briefly. Parents were requested to wear gowns and face masks. We continued to encourage breast feeding, and we continued to receive expressed breast milk from mothers at home. Neonatal isolation area: A separate area was designated for isolating asymptomatic infants born to COVID-19 positive or suspected mothers, another area was designated for sick newborns, both areas were outside the current NICU. A separate nursing staff were assigned to take care of the isolated newborns. Infection control measures: The unit medical and nursing staff were instructed to stay home if feeling unwell, with fever or respiratory illness. They were also instructed to declare any contact with sick individuals. Wearing face mask and maintaining social distancing whenever possible, is a policy we adopted very early. When providing medical care to suspected cases, the staff were instructed to follow the hospital protocol. Management plan: After reviewing the available literature of COVID-19 infection a management flow chart was constructed to standardize the care. It contains the main steps and principles of management. It was circulated to all residents, the hospital administration, and to the hospital infection control unit (Table1). This chart is designed to help with the initiation of the care. The management process might vary according to the patient situation, in addition to the change of the current COVID-19 knowledge that will mandate a change in the implemented guidelines. Neonatal units should have an in-house policy that will guarantee standardization of care, better communication with different disciplines, and most importantly policies that could decrease the transmission risk of the corona virus among the staff and neonatal patients. Infection control measures, minimum staff on duty, and shorter contact time, are the most important items in such policies.

Premedication for Nonemergent Intubation in the NICU: A Call for Standardized Practice.

This paper discusses neonatal endotracheal intubation and the need for standardization in practice regarding the use of premedication. Intubation is common in the NICU because of resuscitation, surfactant administration, congenital anomalies, apnea, and sedation for procedures or surgery. Intubation is both painful and stressful. Unmedicated intubation is associated with several adverse outcomes including repeat and prolonged attempts, airway trauma, bradycardia, severe desaturation, and need for resuscitation. Most providers believe intubation is painful and that premedication should be provided; however, there is still resistance to provide premedication and inconsistency in doing so. Reasons for not providing premedication include concerns about medication side effects such as chest wall rigidity or prolonged respiratory depression inhibiting immediate extubation after surfactant administration. Premedication should include an opioid analgesic for pain, a benzodiazepine for an adjuvant sedation, a vagolytic to decrease bradycardia, and the optional use of a muscle relaxant for paralysis.

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

Background:Pain during the neonatal period has been associated with immediate and long-term adverse effects. One of the most frequent painful procedures that neonates face in neonatal intensive care unit is the endotracheal intubation. Midazolam has been a candidate for premedication before neonatal intubation. Our aim was to evaluate the effects of midazolam as the premedication on endotracheal intubation of premature infants during surfactant administration.Materials and Methods:In a double-blind clinical trial, 80 preterm infants were undertaken for tracheal intubation following the use of atropine associated to either midazolam or placebo. Patient's vital signs and general conditions were constantly monitored, and pain was assessed using premature infant pain profile (PIPP) score.Results:The mean ± standard deviation for postnatal age was 95.38 ± 50.04 and 111.63 ± 49.4 min in control and midazolam groups, respectively. The patients in the midazolam group had significantly better outcomes across several intubation outcome measures such as duration of endotracheal intubation (23.5 ± 6.7 vs. 18.8 ± 4.8 s, P = 0.001), oxygen saturation level (88.05% ±13.7 vs. 95.1 ± 1.8%, P = 0.002), intubation failure (34.2% vs. 2.5%, P = 0.0001), awake and resistance during intubation (95% vs. 20%, P = 0.0001), and excellent patient condition during intubation (0% vs. 82.5%, P = 0.0001). In addition, PIPP score was significantly lower in the midazolam group (5.2 ± 2.06 vs. 12.9 ± 2.9, P = 0.0001).Conclusion:Premedication with midazolam in newborns before intubation, can hold promising effects that manifests as better overall outcomes, less complications, better vital signs, more comfortable situation, and lesser pain for these patients.

An Intelligent Augmented Reality Training Framework for Neonatal Endotracheal Intubation.

Neonatal Endotracheal Intubation (ETI) is a critical resuscitation skill that requires tremendous practice of trainees before clinical exposure. However, current manikin-based training regimen is ineffective in providing satisfactory real-time procedural guidance for accurate assessment due to the lack of see-through visualization within the manikin. The training efficiency is further reduced by the limited availability of expert instructors, which inevitably results in a long learning curve for trainees. To this end, we propose an intelligent Augmented Reality (AR) training framework that provides trainees with a complete visualization of the ETI procedure for real-time guidance and assessment. Specifically, the proposed framework is capable of capturing the motions of the laryngoscope and the manikin and offer 3D see-through visualization rendered to the head-mounted display (HMD). Furthermore, an attention-based Convolutional Neural Network (CNN) model is developed to automatically assess the ETI performance from the captured motions as well as identify regions of motions that significantly contribute to the performance evaluation. Lastly, augmented user-friendly feedback is delivered with interpretable results with the ETI scoring rubric through the color-coded motion trajectory that classifies highlighted regions that need more practice. The classification accuracy of our machine learning model is 84.6%.

A multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation (the SHINE trial): a study protocol

IntroductionNeonatal endotracheal intubation is an essential but potentially destabilising procedure. With an increased focus on avoiding mechanical ventilation, particularly in preterm infants, there are fewer opportunities for clinicians to gain...

32. RESIDENT COMFORT WITH CORE PROCEDURAL REQUIREMENTS

Background ACGME requires graduating pediatric residents to perform essential procedures such as bag-mask ventilation (BMV), neonatal endotracheal intubation, lumbar puncture (LP), incision & drainage (I&D) of abscess, and fracture splinting. Recently there has been an increase in the number of providers who perform these procedures, with more residents and advanced practice providers (APPs), and increased utilization of interventional radiology. Additionally, there has been a dramatic decrease in the number of neonatal intubations performed since 2017 when the NRP recommended against intubation and suctioning for meconium aspiration syndrome. We hypothesize that pediatric residents have become less comfortable performing core procedures. Methods The number of categorical pediatric trainees from 2011-2017 was obtained from the ABP. The National ACGME Pediatric Resident Survey Data from 2013-2019 were reviewed, including Likert scale resident responses on how well prepared they felt to perform procedures (BMV, neonatal endotracheal intubation, LP, I&D of abscess, and fracture splinting) without supervision. Results From 2011-2017, there was a 6% increase in the number of categorical pediatric residents, from 8,774 to 9,396. Resident comfort with performing procedures declined from 2013-2019 for all five procedures. Residents felt more comfortable performing LPs and BMV. There was a 17% decline in comfort with neonatal intubations, with the steepest drop off after 2017. Conclusions Pediatric residents are less comfortable performing core procedures. This correlates with an increase in the number of trainees and APPs. Residents felt more comfortable performing higher-acuity procedures, such as LPs and BMV, compared to I&Ds and splinting. The most substantial decline was observed for neonatal intubations, specifically after the change in NRP guidelines, suggesting that resident comfort also decreased due to less procedures being performed. Our data suggests a need to alter procedural requirements for pediatric residents or devote more time to practice procedures, through procedure-focused rotations, guided workshops, or simulation.

Setting and techniques for monitoring blood pressure during pregnancy.

Setting and techniques for monitoring blood pressure during pregnancy.

Automated Assessment System for Neonatal Endotracheal Intubation Using Dilated Convolutional Neural Network.

Neonatal endotracheal intubation (ETI) is an important, complex resuscitation skill, which requires a significant amount of practice to master. Current ETI practice is conducted on the physical manikin and relies on the expert instructors' assessment. Since the training opportunities are limited by the availability of expert instructors, an automatic assessment model is highly desirable. However, automating ETI assessment is challenging due to the complexity of identifying crucial features, providing accurate evaluations and offering valuable feedback to trainees. In this paper, we propose a dilated Convolutional Neural Network (CNN) based ETI assessment model, which can automatically provide an overall score and performance feedback to pediatric trainees. The proposed assessment model takes the captured kinematic multivariate time-series (MTS) data from the manikin-based augmented ETI system that we developed, automatically extracts the crucial features of captured data, and eventually provides an overall score as output. Furthermore, the visualization based on the class activation mapping (CAM) can automatically identify the motions that have significant impact on the overall score, thus providing useful feedback to trainees. Our model can achieve 92.2% average classification accuracy using the Leave-One-Out-Cross-Validation (LOOCV).

Automated Assessment of Neonatal Endotracheal Intubation Measured by a Virtual Reality Simulation System.

Manual assessment from experts in neonatal endotracheal intubation (ETI) training is a time-consuming and tedious process. Such subjective, highly variable, and resource-intensive assessment method may not only introduce inter-rater/intra-rater variability, but also represent a serious limitation in many large-scale training programs. Moreover, poor visualization during the procedure prevents instructors from observing the events occurring within the manikin or the patient, which introduces an additional source of error into the assessment. In this paper, we propose a physics-based virtual reality (VR) ETI simulation system that captures the entire motions of the laryngoscope and the endotracheal tube (ETT) in relation to the internal anatomy of the virtual patient. Our system provides a complete visualization of the procedure, offering instructors with comprehensive information for accurate assessment. More importantly, an interpretable machine learning algorithm was developed to automatically assess the ETI performance by training on the performance parameters extracted from the motions and the scores rated by experts. Our results show that the leave-one-out-cross-validation (LOOCV) classification accuracy of the automated assessment algorithm is 80%, which indicates that our system can reliably conduct a consistent and standardized assessment for ETI training.

Analysis of visual attention and team communications during neonatal endotracheal intubations using eye-tracking: An observational study

PurposeEye-tracking can be used to analyse visual attention (VA) of health care providers during clinical tasks. No study has examined eye-tracking during neonatal endotracheal intubation. We aimed to examine VA and team communications during endotracheal intubation using eye-tracking in the Neonatal Intensive Care Unit. MethodsTwenty-seven video-recordings were obtained using eye-tracking glasses worn by intubators during endotracheal intubation of stable neonates. Videos were analysed to obtain i) intubation duration and success, ii) areas of interest (AOIs), iii) duration spent on each AOI, iv) types and frequency of gaze-shifts between AOIs, and v) monitor looking behaviour, and vi) team communications of vital signs and verbal medication orders. ResultsTwenty-four videos were of acceptable quality and analysed. Median attempt duration was 44.7 s. Success rate was 79%. Overall, 50% of VA was directed at the infant, with 23% of VA directed at equipment. There were 415 gaze-shifts types and 0.55 gaze-shifts/sec. Intubators glanced at the monitor spontaneously and rarely reported vital signs afterwards. Language used to communicate vital signs and medication orders varied. ConclusionDuring neonatal intubations, 50% of VA was directed away from the infant. Team communications were non-standard. Eye-tracking can be used to analyse human performance during neonatal resuscitation.

Automated Assessment System with Cross Reality for Neonatal Endotracheal Intubation Training.

Neonatal endotracheal intubation (ETI) is a resuscitation skill and therefore, requires an effective training regimen with acceptable success rates. However, current training regimen faces some challenges, such as the lack of visualization inside the manikin and quantification of performance, resulting in inaccurate guidance and highly variable manual assessment. We present a Cross Reality (XR) ETI simulation system which registers ETI training tools to their virtual counterparts. Thus, our system can capture all aspects of motions and visualize the entire procedure, offering instructors with sufficient information for assessment. A machine learning approach was developed to automatically evaluate the ETI performance for standardizing assessment protocols by using the performance parameters extracted from the motions and the scores from an expert rater. The classification accuracy of the machine learning algorithm is 83.5%.

A Physics-based Virtual Reality Simulation Framework for Neonatal Endotracheal Intubation.

Neonatal endotracheal intubation (ETI) is a complex procedure. Low intubation success rates for pediatric residents indicate the current training regimen is inadequate for achieving positive patient out-comes. Computer-based training systems in this field have been limited due to the complex nature of simulating in real-time, the anatomical structures, soft tissue deformations and frequent tool interactions with large forces which occur during actual patient intubation. This paper addresses the issues of neonatal ETI training in an attempt to bridge the gap left by traditional training methods. We propose a fully interactive physics-based virtual reality (VR) simulation framework for neonatal ETI that converts the training of this medical procedure to a completely immersive virtual environment where both visual and physical realism were achieved. Our system embeds independent dynamics models and interaction devices in separate modules while allowing them to interact with each other within the same environment, which offers a flexible solution for multi-modal medical simulation scenarios. The virtual model was extracted from CT scans of a neonatal patient, which provides realistic anatomical structures and was parameterized to allow variations in a range of features that affect the level of difficulty. Moreover, with this manikin-free VR system, we can capture and visualize an even larger set of performance parameters in relation to the internal geometric change of the virtual model for real-time guidance and post-trial assessment. Lastly, validation study results from a group of neonatologists are presented demonstrating that VR is a promising platform to train medical professionals effectively for this procedure.

Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy for Tracheal Intubation in Neonates

(Anesth Analg. 2019;129(2):482–486) Endotracheal intubation is a common technique for securing the airway and providing ventilation in patients undergoing anesthesia. Today, 2 instruments are available to facilitate this intubation: the classic direct laryngoscope (DL), and the newer GlideScope video laryngoscope (GS). Compared with DL, the GS has been reported to provide a better view of the glottis and helps to decrease the time to intubation (TTI) and improve first attempt success rates compared with DL. While GS has been studied in adults and pediatric patients, no studies have assessed its use in neonates. The aim of this study was to compare the TTI using either DL or GS for endotracheal intubation in neonates.

Propofol for endotracheal intubation in neonates: a dose-finding trial

ObjectiveTo find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA).Design and settingProspective multicentere dose-finding study in 3 neonatal intensive...