Intubation In Newborns Research Articles

The Impact of the COVID-19 Pandemic on Respiratory Syncytial Virus Infection in the Neonatal Period.

Respiratory syncytial virus (RSV) is the most common viral respiratory infection in infants. This study aimed to establish the potential changes in the clinical course of RSV in the neonatal period with the onset of the coronavirus disease 2019(COVID-19) pandemic. During the observational study period, newborns diagnosed with community-acquired RSV infection and admitted to the neonatal intensive care unit (NICU) were evaluated. RSV-infected neonates before the COVID-19 pandemic were classified as Group 1, those during the strict isolation period as Group 2, and RSV-infected newborns after the removal of restrictions were classified as Group 3. A total of 208 community-acquired RSV-infected neonates were analyzed. The median age at admission to the NICU was 26 days, and the mean gestational week was 37.2 ± 2.7. The ratio of hospitalized babies with RSV infection to all hospitalized newborns rose after the pandemic significantly (1.9, 1.6, and 5.2%; p < 0.001). Following the pandemic, there was an increase in full-term, early-term, and late-preterm cases. Nevertheless, no change was observed in the number of preterm cases (p > 0.05). There was also a statistically significant increase in the need for intubation, noninvasive ventilation (NIV), supplemental oxygen, inhaled bronchodilator drugs, and length of hospital stay in Group 3 after the pandemic (p < 0.001). All these parameters related to more severe RSV infection when the precautions were removed, while there was a milder disease with restrictions during the pandemic in Group 2 (p < 0.001). However, none died due to RSV infection during the study because of timely supportive care. Following the COVID-19 pandemic, the frequency and severity of RSV infection in newborns have increased, and it can result in a serious clinical picture even in full-term babies with no comorbidities. Attention to strict contact precautions, particularly in newborns, who are a more vulnerable population after the pandemic, may play an important role in any future outbreak. · The course of neonatal RSV infection has changed after the pandemic.. · A statistically significant increase was observed in the need of intubation in newborns with RSV.. · The strict precautions during the pandemic also helped to prevent the transmission of RSV..

Value of the Hyomental Distance Measured With Ultrasound in Forecasting Difficult Laryngoscopy in Newborns

PurposePreoperative evaluations of difficult airways are imperative, especially in newborns. The hyomental distance is a reliable index for predicting difficult airways in adults. However, few studies have evaluated the value of the hyomental distance for predicting difficult airways in newborns. It is unclear whether the hyomental distance forecasts a restricted or difficult view when using direct laryngoscopy. We intended to develop an effective system for predicting difficult tracheal intubation in newborns. DesignA prospective observational clinical study. MethodsNewborns aged 0 to 28 days undergoing oral endotracheal intubation with direct laryngoscopy for elective surgery under general anesthesia were enrolled. The hyomental distance and hyoid level tissue thickness were assessed by ultrasound. Other parameters, such as the mandibular length and sternomental distance, were also evaluated before anesthesia. The glottic structure view under laryngoscopy was graded according to the Cormack-Lehane classification. The patients with Grade 1 and 2 laryngeal views were assigned to Group E. Those with Grade 3 and 4 views were assigned to Group D. FindingsA total of 123 newborns were recruited for our study. The incidence of poor visualization of the larynx during laryngoscopy in our study was 10.6%. The multifactor logistic regression results showed that the hyomental distance was a powerful predictor of difficult laryngoscopy (OR = 0.16, 95% CI 0.03-0.74, P = .019). The curve with the highest sensitivity and specificity and the maximum area under the curve (AUC) was the hyomental distance. The receiver operating characteristic (ROC) curve for the hyomental distance suggested that the best cut-off value was less than equal to 2.74 cm, with an AUC of 0.80 (95% CI 0.64-0.95). ConclusionsIt is noninvasive and feasible to accurately measure the hyomental distance with ultrasound in newborns, and the results are reliable. We believe that the hyomental distance measured with ultrasound could be used as a marker for predicting difficult laryngoscopy in newborns.

Anatomical investigations on the upper airway in premature and newborn babies.

Safe intubation of newborns remains a challenge. This investigates the upper airway anatomy of (pre-)term infants was investigated to improve airway management and the development of airway devices. Angles and diameters of both oral and nasal intubation pathways of 22 cadavers of premature and term stillborn infants were measured, relative to their gestational age (GA) and tested for statistical significance. The systematic influence of sex on the distribution of values was examined. Cast models of the oral and nasal intubation pathway were (produced using a silicone dental impression material) 3D-scanned. No significant correlation with GA was seen in the angles studied. However, four distances around the hard and soft palate did show statistically significant positive correlations with GA. Regarding differences between the sexes, only the angle between the entrance of the trachea and the esophagus was greater for male cadavers. The angles of the ventilation pathway of (pre-)term infants do not depend systematically on GA. Anatomically, laryngeal masks might therefore also be well-suited ventilators for preterm infants. Alterations in the size but not the shape of laryngeal masks for small preterm infants is recommended. The data obtained may thus be used as a basis for the development of airway devices and airway simulators for medical education and clinical training.

Sonographic Evaluation of the Endotracheal Tube Position in the Neonatal Population: A Comprehensive Review and Meta-Analysis.

BackgroundEndotracheal intubation in neonates is challenging and requires a high level of precision, due to narrow and short airways, especially in preterm newborns. The current gold standard for endotracheal tube (ETT) verification is chest X-ray (CXR); however, this method presents some limitations, such as ionizing radiation exposure and delayed in obtaining the radiographic images, that point of care ultrasound (POCUS) could overcome.Primary ObjectiveTo evaluate ultrasound efficacy in determining ETT placement adequacy in preterm and term newborns.Secondary ObjectiveTo compare the time required for ultrasound confirmation vs. time needed for other standard of care methods.Search MethodsA search in Medline, PubMed, Google Scholar and in the Cochrane Central Register of Controlled Trials (CENTRAL) was performed. Our most recent search was conducted in September 2021 including the following keywords: “newborn”, “infant”, “neonate”, “endotracheal intubation”, “endotracheal tube”, “ultrasonography”, “ultrasound”.Selection CriteriaWe considered randomized and non-randomized controlled trials, prospective, retrospective and cross-sectional studies published after 2012, involving neonatal intensive care unit (NICU) patients needing intubation/intubated infants and evaluating POCUS efficacy and/or accuracy in detecting ETT position vs. a defined gold-standard method. Three review authors independently assessed the studies' quality and extracted data.Main ResultsWe identified 14 eligible studies including a total of 602 ETT evaluations in NICU or in the delivery room. In about 80% of cases the gold standard for ETT position verification was CXR. Ultrasound was able to identify the presence of ETT in 96.8% of the evaluations, with a pooled POCUS sensitivity of 93.44% (95% CI: 90.4–95.75%) in detecting an appropriately positioned ETT as assessed by CXR. Bedside ultrasound confirmation was also found to be significantly faster compared to obtaining a CXR.ConclusionPOCUS appears to be a fast and effective technique to identify correct endotracheal intubation in newborns. This review could add value and importance to the use of this promising technique.

Prospective follow-up of a cohort of preterm infants < 33 WG receiving ketamine for tracheal intubation in the delivery room: Neurological outcome at 1 and 2 years

ObjectiveAlthough ketamine analgesia is effective in reducing pain and facilitating the tracheal intubation of newborns in the delivery room, no data on the neurological effects of this treatment are available. This study compared the neurodevelopmental outcomes at 2 years of age in a cohort of preterm newborns having received ketamine prior to tracheal intubation at birth (the ketamine group) and in a control group. MethodsWe included newborns delivered at less than 33 weeks gestational age (WGA) having undergone tracheal intubation at birth. The Ages and Stages Questionnaire (ASQ) was completed at 1 and 2 years of age. The development quotient (DQ) was calculated from the revised Brunet-Lezine score assessed at a corrected age of 2 years. ResultsThere were no statistically significant differences between the ketamine group (n=54 at 1 year and n=51 at 2 years) and the control group (n=16 at 1 and 2 years) in terms of the mean±standard deviation DQ at the age of 2 (98±12 vs. 103±9, respectively; P=0.17) and the ASQ score at the age of 2 (221±44 vs. 230±39, respectively; P=0.55). DiscussionThis prospective cohort of 51 preterm newborns having received ketamine at birth did not reveal any differences in terms of neurological development at the age of 2 (relative to a control group and the literature data). These preliminary results must be confirmed in a randomized trial with longer follow-up.

The Initiation of Positive Pressure Ventilation is Delayed During Elective Newborn Intubation

The Initiation of Positive Pressure Ventilation is Delayed During Elective Newborn Intubation

Efficacy of Laryngeal Mask Airway in Neonatal Resuscitation

Aim: This study aimed at evaluating the use of LMA for resuscitation in the delivery room among newborn infants whom positive pressure ventilation (PPV) by bag and mask had failed. Materials and methods: This is a single center, prospective, unblinded, randomized clinical trial of LMA ventilation versus ETT on neonates during resuscitation upon delivery at Ain Shams Maternity Hospital during the period between January 2012 and January 2015. The Study included 80 newborns delivered in the Maternity hospital, Ain Shams University with gestational age of 34 weeks or more who needed neonatal resuscitation in the delivery room which was performed according to the current guidelines for neonatal resuscitation by the American Academy of Pediatrics. Results: In Our Study, there was significant correlation between the LMA and the ETT as both of them succeeded to achieve adequate ventilation of the resuscitated infants. Both groups showed statistical significant improvement between their Oxygen saturation at 1 minute & at 5 minutes. The ETT showed more improvement as the mean difference between 1 & 5 minutes was -27.4±3.07 compared to -26.5±3.4 among the LMA, but with insignificant difference between both groups. Comparison between Apgar score at 1 & 5 minutes in both groups is apparent, which showed statistical significant improvement in the 2 groups. However, the ETT group showed more improvement (although non-significant) as the mean difference between 1 & 5 minutes was -5.02±0.9 compared to -4.6±0.7 among the LMA group. Conclusion: The Laryngeal Mask Airway can be used as an efficient and successful alternative to endotracheal intubation in newborns > 2000 Gms who require neonatal resuscitation.

Assessment of sedation level prior to neonatal intubation: Asystematic review.

Adequate premedication before neonatal endotracheal intubation reduces pain, stress, and adverse physiological responses, diminishes duration and number of attempts at intubation, and prevents traumatic airway injury. Therefore, intubation should not be started until an adequate level of sedation is reached. It is not clear how this should be measured in the clinical situation. The aim of this study is to provide a systematic review of the usability and validity of scoring systems or other objective parameters to evaluate the level of sedation before intubation in neonates. Secondary aims were to describe parameters that are used to determine the level of sedation and criteria on which the decision to proceed with intubation is based. Literature was searched (January 2017) in the following electronic databases: Embase, Medline, Web of Science, Cochrane Central Registrar of Controlled Trials, Pubmed Publisher, and Google Scholar. From 1653 hits, 20 studies were finally included in the systematic review. In 7 studies, intubation was started after a predefined time period; in 1 study, preoxygenation was the criterion to start with intubation; and in 12 studies, intubation was started in case of adequate sedation and/or relaxation. Only 4 studies described the use of 3 different objective scoring system, all in the neonatal intensive care unit, which are not validated. No validated scoring systems to assess the level of sedation prior to intubation in newborns are available in the literature. Three objective sedation assessment tools seem promising but need further validation before they can be implemented in research and clinical settings.

Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants

To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events. We conducted a prospective, observational study in a 100-bed, academic, level IV neonatal intensive care unit from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as nonsevere or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent, or emergent). We used logistic regression models to estimate the association of these variables with adverse events. During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with nonsevere and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (OR 2.1, 95% CI, 1.6-2.6) and emergent intubations (OR 4.7, 95% CI, 1.7-13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%). Adverse events are common in the neonatal intensive care unit, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety.

Feasibility of monitoring stress using skin conduction measurements during intubation of newborns.

The objective of this study was to assess the feasibility of monitoring stress responses in newborns during naso-tracheal intubation after two different premedication regimens, using skin conductance measurements (SCM). Twenty-two newborns were randomised and premedicated with morphine + vecuronium or propofol. SCM (peaks/s) were collected prior to, during and after the procedure. Threshold for interpreting responses as stressful was 0.21 peaks/s. Intubation conditions and physiological parameters were registered. Intubation conditions were good in all newborns. Administration of morphine (range 1.4–10.3 min) before administration of vecuronium did not affect SCM when a stressful stimulus was applied. Within 1.6 min (range 0.8–3 min) after administration of vecuronium, SCM disappeared in 10 of 11 newborns. Propofol reduced SCM in 10 of 11 newborns at the first attempt. Further attempts were associated with increasing SCM, mostly above a threshold of 0.21 peaks/s. There were no significant changes in physiological parameters during the procedure for either premedication regimen.Conclusion: The variation in SCM between individual newborns limits the usefulness of SCM as stress monitor during intubation. The use of neuromuscular blockers for premedication precludes monitoring of SCM completely in newborns. What is Known: • Skin conductance measurements have been used successfully to monitor pain in awake newborn infants. What is New: • Premedicated newborns display significant interindividual variation in skin conductance measurements during an intubation procedure. • Neuromuscular blockade causes skin conductance measurements to disappear completely.

Impact d’un protocole de sédation avant intubation trachéale en salle de naissance. Pratiques dans deux centres de niveau III

Tracheal intubation in neonates is a painful procedure performed daily in the delivery room despite the widespread development of noninvasive ventilation. Specific analgesia is not commonly performed. The objective of this observational study was to compare practices between two level-III centers: one with a specific protocol for premedication before tracheal intubation of newborns in the delivery room, the other without.One hundred and fifteen neonates were intubated in the delivery room and included over a 4-month period: 25% of them received specific premedication before intubation, exclusively in the center with the protocol. None of the extreme premature neonates (age≤28 gestational weeks) received analgosedation before the procedure. Nalbuphine, midazolam, and sufentanil were mainly used, via the intravenous or intrarectal route. Infants receiving a premedication were significantly heavier and had a greater gestational age than the others (1500 g [range, 1180-2260 g] vs. 1170 [range, 860-1680 g] P=0.003, and 31 GW [range, 29-34 GW] vs. 29 [range, 27-32 GW] P=0.014, respectively). Most pediatricians (85-100%) favored a specific protocol for sedation before tracheal intubation. Implementation of a specific protocol allows specific analgesia to be implemented for newborns undergoing tracheal intubation. Further studies should be conducted to determine the best strategies for pain management during tracheal intubation of neonates, especially in the delivery room.

Education for practitioners and patients

Education for practitioners and patients

Smartphone technology enhances newborn intubation knowledge and performance amongst paediatric trainees

ObjectiveSmartphones are widely used by physicians, but their effectiveness in improving teaching of clinical skills is not known. The aim of this study was to determine if pre procedural use of a smartphone neonatal intubation instructional application (NeoTube) improves trainee knowledge and enhances procedural skills performance in newborn intubation. DesignNeonatal Resuscitation Program certified trainees in paediatrics and neonatology completed a knowledge based questionnaire on neonatal intubation, and were recorded intubating a term newborn manikin model. They then used the NeoTube iPhone application for 15min, before completing the questionnaire and intubation again. Video recordings were later reviewed by two independent assessors, blinded to whether it was pre or post NeoTube use. Results20 paediatric trainees (12 fellows and 8 residents) participated in this study. Comparing pre and post-viewing of the application, Questionnaire Scores (median (range)) increased from 18.5 (8–28) to 31 (24–35) (P<0.001), with calculation scores increasing from 6 (0–11) to 11 (6–12) (P<0.001), Skill Scores increased from 11 (9–15) to 12.5 (9–16) (P=0.016), and the duration of intubation attempt decreased from 39 to 31s (P=0.044) following utilisation of the application. There was a significant positive correlation with duration of specialist training for procedure performance post viewing, but not pre viewing of the application. ConclusionsBedside use of smartphones can enhance both knowledge of newborn intubation and improves procedural performance, including reducing the time to successfully intubate. Smartphones may have a useful role in bringing procedural skills training closer to the bedside.

Airway management for intubation in newborns with pierre robin sequence

To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population. Case series and retrospective chart review at a tertiary children's hospital. PRS newborns who underwent endotracheal intubation or other airway intervention before 3 months of age between January 2000 and July 2011 were identified from a pediatric otolaryngology practice database. Indications for airway intervention, anesthetic management, method of intubation, and comorbid conditions were collected. Thirty-three PRS newborns were identified. Twenty had isolated PRS, and 13 had PRS related to a coexisting syndrome. Thirteen of 35 (37%) endotracheal intubations performed in PRS newborns prior to mandibular distraction osteogenesis were accomplished with direct laryngoscopy. The remaining 22 of 35 (63%) who failed intubation with direct laryngoscopy were intubated over a flexible fiberoptic bronchoscope. No significant difference was observed between the isolated and syndromic PRS newborns with regard to technique utilized for intubation. No patient required rescue laryngeal mask airway or emergent tracheotomy, and no case resulted in death. This series demonstrates that endotracheal intubation is safe and effective in PRS newborns. In patients who failed intubation with direct laryngoscopy, intubation over a flexible fiberoptic bronchoscope provided a reliable alternative method. Although airway management in PRS newborns poses a significant challenge, experienced otolaryngologists and anesthesiologists can successfully manage these difficult airway cases.

Common Complications of Endotracheal Intubation in Newborns

Objective The purpose of this study was to assess the frequency of complications of endotracheal intubation (ETI) in neonates. Methods The newborns that were admitted and needed urgent or semi-urgent intubation were enrolled in this study over a 1 year period. Route for intubation in all cases were orotracheal. Cases were not routinely sedated or paralyzed. The patients were clinically and radiographically assessed. Results Of 233 newborn infants who were admitted to the neonatal intensive care unit (NICU) at the Children’s Medical Center, 60 infants were intubated. A total of 131 attempts were documented. Unsuccessful attempts with difficult intubation were 17(13%); successful intubation attempts were 114(87%). Complications were detected in 69 cases (61%). The most common complication was laryngeal injury (24%). Accidental extubation was the most frequent event (12%).Tube blockage 7% and endotracheal tube (ETT) malposition was 3%. The complications were less during placement of ETT (12%), but were high during maintenance (61%) and removal of the endotracheal tube (28%). 47% of patients required repeated intubation. There was a significant statistical difference between complications of medicated and unmedicated patients. There was no significant statistical difference relative to gestational age, route of delivery, sex, birth weight, and length of time the ETT remained in place. Conclusion Trauma to the larynx and vocal cords were the most common complications. Difficult and repeated intubation played a major role. Premedication for non-urgent or semi-urgent intubation was safer and more effective than awake intubation. We did not assess long-term outcomes associated with endotracheal tube intubation; this was a limitation of the present study. Operator skill and postoperative care are confounding variables that may influence the results.

Finger guided intubation in newborns and infants with difficult airways: a possible ignored technique

Finger guided intubation in newborns and infants with difficult airways: a possible ignored technique

The lightwand‐guided digital intubation in newborns and infants with difficult airways

The lightwand‐guided digital intubation in newborns and infants with difficult airways

The Risk of Congenital Malformations and Other Neonatal and Maternal Health Outcomes among Licensed Cosmetologists

This study sought to determine if cosmetologists in New York State (NYS) have a higher risk of complications of labor/delivery or congenital malformations and poor neonatal health indicators among their offspring compared with Realtors and the general population. This retrospective cohort study matched licensing records for cosmetologists and realtors to birth records and the NYS Congenital Malformations Registry from 1997 to 2003. A random sample of NYS birth certificates, frequency matched to cosmetologists on year of child's birth, mother's ethnicity, and education, was also formed. Outcomes include malformations of each major organ system, neonatal health indicators, and complications of labor/delivery. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), controlling for potential confounders. Compared with Realtors, cosmetologists had an increased risk of several maternal and neonatal health indicators, including postpartum hemorrhage (OR = 2.12; 95% CI 1.26, 3.58), failure to progress (OR = 1.31; 95% CI 1.12, 1.54), and newborn intubation (OR = 2.34; 95% CI 1.21, 4.51), among others. We did not observe an increased risk of congenital malformations among cosmetologists' offspring. Working as a cosmetologist was positively associated with several adverse maternal perinatal and neonatal health indicators but was not associated with congenital malformations in this study. These results are useful for hypothesis generating.

Premedication before intubation in UK neonatal units: a decade of change?

Aims:To ascertain the prevalence of premedication before intubation and the choice of drugs used in UK neonatal units in 2007 and assess changes in practice since 1998.Methods:A structured telephone survey...

Survey of current intubation practices in Polish neonatal and pediatric ICUs

Guidelines pertaining to the details of intubation practices in neonates and children are not well established. We sought to describe the current practices with regard to the intubation of newborns and children.