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.
Keywords: Neonate, Intubation, Safety
Introduction
Endotracheal Intubation is a life-saving intervention performed in up to 20% of critically ill neonatal intensive care unit (NICU) patients.1 The procedure is high-risk, and adverse safety events are frequent. Therefore, pertinent procedural outcomes include both success and adverse events. The National Emergency Airway Registry for Neonates (NEAR4NEOS) is an international registry designed to improve neonatal intubation practice and outcomes. This article will review the state of neonatal intubation regarding both success and safety and will highlight contributions from the NEAR4NEOS collaborative.
The National Emergency Airway Registry for Neonates
NEAR4NEOS evolved from the National Emergency Airway Registry (NEAR) family. The National Emergency Airway Registry (NEAR) initially reported on the process and outcomes of airway management performed across 31 emergency departments from 1997–2002.2 The NEAR infrastructure was adapted for pediatric airway management and piloted in a single center.3 In 2010, the National Emergency Airway Registry for Children (NEAR4KIDS) was launched in a multicenter setting with 15 founding sites.4
NEAR4NEOS was further adapted for relevance to the neonatal population but retains many of the same structural elements and operational definitions as the other NEAR registries.5 NEAR4NEOS was originally established in 2014 and has since expanded to include 23 international sites. Detailed patient, provider, practice, and outcome data are collected using standard operational definitions for all intubations in the NICU and delivery room (DR) setting (Table 1). As of 2023, over 17,000 intubation procedures have been captured in NEAR4NEOS.
Table 1:
Event | Patient | Provider | Practice | Process | Outcome |
---|---|---|---|---|---|
Time | Age (gestation, postnatal) | Discipline | ETT size, type Stylet | Family presence | Success |
Date | Weight | Training level | Laryngo-scope type | Change in approach | TIAEs |
Hospital | Diagnoses | Years of Experience | Equipment | Teamwork assessment | Oxygen saturation |
Location | Intubation indication | Supervision present | Medication (type and dose) | Glottic exposure grade (I-IV) | Heart rate |
Difficult airway features | Method (oral vs nasal) | Number of attempts | NICU respiratory outcomes |
ETT: endotracheal tube; TIAE: tracheal intubation associated event
Neonatal Intubation Success
Endotracheal intubation is technically challenging to perform in neonatal patients due to airway anatomic differences from older patients, including a large epiglottis and anterior larynx.6 In addition, compared with adults and larger children, infants have a smaller functional residual capacity and higher oxygen consumption,7 leading to more rapid oxygen desaturation during apnea.8 This results in a shorter duration of apnoeic time for providers to safely perform the intubation. Accordingly, overall first attempt success rates in NEAR4NEOS (49%) are lower than those reported for older children in NEAR4KIDS (60%)9 or adolescents and adults in NEAR (83%).10
Airway provider training level is consistently associated with improved procedural success; neonatal fellows and attendings demonstrate progressively higher success rates compared with residents.5,11,12 Historically, reported success rates for residents ranged between 20–40% for a given attempt.11,13 More contemporary data suggest lower success rates: Haubner et al. reported first attempt rates of 16% and overall success rates of 20% for residents.12 In the initial NEAR4NEOS analysis, residents were successful in 24% of intubation procedures on the first attempt and 56% of procedures within 2 attempts.5
The impact of changes in neonatal care
Changes in neonatal practice and reductions in trainee work hours have reduced intubation procedural learning opportunities for medical trainees.14–15 Thus, it is important to ensure that all learners who must acquire intubation skills have sufficient exposure to the procedure. Evans et al. recently employed cumulative sum (Cusum) methodology to determine the number of intubation procedures required for neonatal fellows to achieve competence, which was defined as an 80% success rate within 2 attempts.16 Among fellows who demonstrated procedural competence, a median of 18 procedures was required. Of note, the number of procedures required to demonstrate competence ranged from 8–46 across fellows, suggesting an individualized approach is warranted to promote trainees’ progression to procedural competence.
Optimising Neonatal Intubation Success
For training institutions, one approach to optimize intubation outcomes is to ensure the intubation provider, encounter, and patient are appropriately matched (Table 2). For example, it may be appropriate to prioritize more challenging intubation procedures for experienced providers. Increasing patient weight is associated with increased odds of procedural success in observational studies.16–17 Gariépy-Assal recently demonstrated the impact of a specialized “tiny baby intubation team” on intubation outcomes for patients with weight <1000 grams or postmenstrual age <29 weeks. First intubation success rates for “tiny babies” improved from 44% before implementation to 59% post-implementation.18
Table 2:
aOR | 95% CI | P value | |
---|---|---|---|
Training quarter | 1.10 | 1.07, 1.14 | <0.001 |
Muscle relaxant premedication | 1.77 | 1.35, 2.33 | <0.001 |
Video laryngoscopy | 1.67 | 1.19, 2.33 | 0.003 |
Patient weight <1000g | 0.61 | 0.48, 0.77 | <0.001 |
Premedication is an important factor associated with intubation success. Although premedication is recommended for non-emergent neonatal intubation,19,20 its use is inconsistent, and important variability exists around the types of medications included in premedication regimens.21,22 In an analysis of 2260 intubations in the NEAR4NEOS registry, intubations performed with sedation plus neuromuscular blockade were more likely to be successful on the first attempt (56%) compared with sedation only (34%) or no medication (47%).23 These data support the inclusion of muscle relaxants as a component of intubation premedication, and are consistent with previous studies of premedications in neonatal intubation.24
Intubation equipment such as a video laryngoscope or stylet may influence intubation success. A video laryngoscope provides an improved view of the glottis and airway structures that is displayed on a screen visible by all clinicians involved in the procedure. Early neonatal trials demonstrated improved procedural success outcomes for resident providers when their supervisors could see the video laryngoscope screen and provide guidance to the resident.25,26 A recent meta-analysis of 8 trials favored video laryngoscopy over traditional (direct) laryngoscopy for the outcome of first attempt success during neonatal intubation (number needed to treat of 7, 95% confidence interval 5–13).27 Outside of the controlled trial setting, video laryngoscopy is associated with improved success for fellows in NEAR4NEOS,16 but the results were not consistent when all providers were assessed.28 Video laryngoscopy is further discussed in Chapter 4. Stylet use during intubation has also been investigated but was not associated with procedural success in a randomized trial29 or observational study.17
Neonatal Intubation Adverse Events
In addition to suboptimal success rates, adverse events complicate 18% of neonatal intubations, with rates ranging from 9–50% across centers.5, 30–32 Neonates experience much higher rates of tracheal intubation associated adverse events compared with older patients, likely due to the unique anatomic and physiologic characteristics described earlier (Figure 1).5,33–37
NEAR4NEOS’ comprehensive list of adverse tracheal intubation associated events (TIAEs) is the most frequently used tool to assess neonatal intubation safety. NEAR4NEOS identifies adverse TIAEs based on standard consensus-based operational definitions and classifies these as severe and non-severe (Table 3). NEAR4NEOS separately reports the rate of severe oxygen desaturation, which is defined as a decline of ≥20% in peripheral oxygen saturation (SpO2).
Table 3:
Listed in order of frequency | |
---|---|
Severe TIAEs | Non-severe TIAEs |
Esophageal intubation, delayed recognition | Esophageal intubation, immediate recognition |
Cardiac compressions <1 minute | Dysrhythmia* |
Laryngospasm | Mainstem intubation |
Cardiac arrest, patient survived | Gum or dental trauma |
Emesis with aspiration | Emesis without aspiration |
Pneumothorax/pneumomediastinum | Pain/agitation requiring additional medication |
Direct airway injury | Epistaxis |
Hypotension requiring intervention | Lip trauma |
Cardiac Arrest, patient died |
Including bradycardia <60 beats per minute without chest compressions
TIAE: Tracheal Intubation Associated Events
In response to the high rates of adverse events, numerous observational studies and quality improvement projects have aimed to identify factors to improve neonatal intubation safety. These factors can be divided into patient, provider, and practice characteristics. For patients, an indication for intubation of ‘unstable hemodynamics’ was independently associated with an increased odds of adverse TIAEs (adjusted odds ratio [aOR] 3.85, 95% confidence interval [CI] 1.59–9.35) in an observational study of 2607 intubations across 10 sites.5 In a single center study, Glenn et al. demonstrated that increased chronological age and decreased weight at the time of intubation were associated with an increased aOR of adverse events.31
Provider training level has inconsistently been associated with TIAEs.38–40 In two single center observational studies, an attending level provider was associated with a decreased aOR of any TIAE as compared to a resident provider.39,40 Conversely, in a study of 2608 intubations across 11 sites, Johnston et al. demonstrated no association between provider training level and adverse TIAEs.38
Modifiable practice characteristics associated with decreased TIAEs include muscle relaxant premedication, video laryngoscopy, decreased number of intubation attempts, and improved preparation. The use of muscle relaxant premedication has consistently been associated with a decreased odds of TIAEs across numerous multicenter and single center observational studies.5,23, 39–41 These associations remain significant after adjusting for patient, provider, and practice characteristics. In a study of 2260 neonatal intubations across 11 centers, Ozawa et al. demonstrated the use of muscle relaxant premedication was associated with a significantly decreased aOR of any adverse TIAE compared with no premedication (aOR 0.47, 95% CI 0.34–0.67).23 Interestingly, the use of sedation premedication alone was associated with an increased aOR of any adverse TIAE compared with no premedication (aOR 1.48, 95% CI 1.11–1.96).23 The authors postulate this may have been due to adverse effects of the medications (such as chest wall rigidity or decreased upper airway tone) or insufficient doses to achieve optimal intubating conditions.
The use of the video laryngoscope is independently associated with decreased odds of adverse TIAEs across multiple observational studies.5,39,40,28
In two multicenter studies, an increased number of intubation attempts was independently associated with adverse TIAEs.5,42 In a study of 7708 intubations across 17 sites, Singh et al. demonstrated significant increase in the aOR of any TIAE, a severe TIAE, and severe desaturation with each additional attempt.42 Thus, factors that improve intubation success are also likely to improve intubation safety.
Figure 2 demonstrates our conceptual model of the relationship between patient, provider, and practice factors to improve intubation outcomes. Strategies to improve intubation safety should focus on increasing the use of established interventions to reduce adverse events and ensuring the patient and provider are well matched. Two quality improvement initiatives showed improved rates of adverse events after implementation of interventions to promote evidence-based practices.32,43 Hatch et al. demonstrated a decrease in adverse events from 46% to 36% with the implementation of an intubation checklist used immediately prior to intubation.32 Herrick et al. implemented a prospective individualized airway bundle to improve communication and preparation for neonates at risk for intubation, resulting in a 66% decrease in severe TIAEs.43 The ongoing Optimizing Intubation Outcomes and Neonatal Safety (OPTION SAFE) trial builds on the single center project led by Herrick. OPTION SAFE will assess the impact of a personalized intubation safety bundle on intubation adverse events across eight NEAR4NEOS centers.44
Despite the number of modifiable practice factors identified to improve neonatal tracheal intubation safety, no factors have consistently improved desaturation events. Apneic oxygenation, defined as the application of free-flowing oxygen during the apneic phase of laryngoscopy and intubation, prevents or delays oxygen desaturation during intubation among older children and adults.45–47 Apneic oxygenation during neonatal intubation represents a potential promising intervention to reduce rates of desaturation. Two trials to date have demonstrated mixed results with the use of nasal high flow therapy to deliver apneic oxygenation. Hodgson et al. demonstrated a significant improvement in their primary outcome of first attempt success without physiological instability (50% versus 31%). Neonates undergoing TI in the delivery room or in the neonatal unit were randomized to 8 L/min nasal high flow therapy versus standard care (no additional support) during intubation. The trial included 251 intubations among 202 neonates with a median post menstrual age of 27.9 weeks. It is important to note that this was a trial of procedural (not apneic) oxygenation, as not all patients in that trial received muscle relaxant premedication.48 In a smaller pilot trial, Foran et al. showed no difference in the primary outcome of duration of oxygen desaturation, however the trial was not powered to detect a difference.49 This trial included 50 intubations among 43 neonates in the neonatal unit. Neonates were randomized to 6 L/min nasal high flow or to a control sham procedure where nasal cannulae were placed but no flow provided. A third ongoing trial, Providing Oxygen during Intubation in the NICU Trial (POINT), is underway.50 POINT will assess the impact of apneic oxygenation administered via regular (non-humidified) nasal cannula on the primary outcomes of magnitude of desaturation during premedicated intubation in the NICU setting.
Conclusion:
Neonatal endotracheal intubation is a challenging procedure with suboptimal success and adverse event rates. Strategies to improve intubation success are often associated with improved safety. It is imperative to systematically track intubation outcomes to understand both universal and site-specific barriers to intubation safety. Methods to improve intubation safety include ensuring the intubation provider and situation are appropriately matched, the increased adoption of evidence-based practices such as muscle relaxant premedication and video laryngoscope, and potentially new interventions such as procedural oxygenation.
Practice Points:
Neonatal tracheal intubation success and adverse event rates are suboptimal.
Systematically tracking intubation outcomes can identify universal and site specific barriers to intubation success and safety.
Muscle relaxant premedication and video laryngoscopy are associated with improved neonatal intubation safety.
New strategies with the potential to improve intubation safety include procedural oxygenation and prospective airway bundles.
Footnotes
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