Knowledge, behavior, and awareness of neonatologists and anesthesiologists about oral complications of intubation and protection methods

Abstract

Objectives: This study aimed to assess awareness of anesthesiologists and neonatologists about oral complications occurring during and after the orotracheal intubation (OTI) in premature infants and their knowledge and behavior regarding protection methods from these complications in clinical practice. Methods: This study included 94 neonatologists and 137 anesthesiologist. The final version of the questionnaire included 15 items in three main parts: (i) personal information; (ii) awareness about oral complications occurring during and after the OTI in premature infants; (iii) knowledge and behavior regarding protection methods from these complications in clinical practice. Results: A total of 95.7% of neonatologists and 83.2% of anesthesiologists were aware of oral complications related to OTI. The most common complications the anesthesiologists encountered were oral, laryngeal, or pharyngeal region injuries (60.7%) and palatal groove (52.2%) for the neonatologists. The most preferred method for stabilization of the orotracheal intubation tube (OTT) was bonding to the perioral region with an adhesive tape (98.3%). The primary determining factor in the choice of OTT stabilization method was the ease of use (28.2%). A total of 23.8% of the participants were aware of the palatal stabilization device (PSD), whereas only 1.3% used it in their routine and 57.1% of them believed it can prevent complications. Conclusions: The results showed that neonatologists were more aware of the OTI-related oral complications than anesthesiologists. The knowledge of the participants regarding prevention of these complications is insufficient. Study participants believe in the efficacy of PSD but do not use it in clinical practice for a number of reasons.

INTRODUCTION

In premature and low-birth-weight infants that suffer from respiratory distress due to immature lung development, inadequate gag reflex, poor sucking, and swallowing, intubation is a routine intervention in the neonatal intensive care units (NICUs). It is often performed with the aid of laryngoscopy and orotracheal or nasotracheal tube for respiratory support. James Blundell (1790–1878) was the first one who used a mechanical device for tracheal intubation in newborns¹. In addition to other advances in pediatric intensive care, the greater use of these devices for respiratory diseases has unquestionably reduced the mortality rate of premature infants. However, the procedure is an extremely painful situation and has potential complication risks for the airway¹.

Orotracheal tube (OTT) is preferred to avoid septal and respiratory disturbances, which is usually associated with the nasotracheal tube2., 3., but orotracheal intubation (OTI) is not uncomplicated. The potential complications occur because of malpositioning or displacement of tube, occlusion of the tube from thickened secretions, accidental tube extubation, and prolonged intubation. These complications may occur throughout the respiratory system locally as apnea, oropharyngeal aspiration, atelectasis, pneumothorax, pneumonia, vocal cord edema and perforation, granuloma formation, subglottic stenosis, tracheitis, and hemorrhage. Hypoxia, bradycardia, hypertension, and infection are systemic complications related to OTI4., 5., 6.. Specifically, the OTI may cause detrimental effects on oral development during the acute phase or later by damaging the alveolar crest and developing tooth germs in the anterior region⁷.

Complications in the oral cavity related to OTI have been reported in some studies. Displacement of OTT caused localized trauma to tooth germs that may result in the delayed eruption⁸, ectopic impaction⁹, and tooth malformation¹⁰. In addition, notching of the alveolar ridge¹¹, localized enamel hypoplasia¹², alveolar groove¹³, palatal groove¹⁴, high-arched palate¹⁵, palatal-depth and width asymmetry¹³, and acquired cleft¹⁶ were reported as complications following the OTI. Some of these complications can be temporary and clinically insignificant; however, some forms of chronic trauma may cause various degrees of anatomic and functional disabilities⁵. In addition, these oral defects indirectly can cause hearing and speech disorders, and malocclusion¹².

Ineffective stabilization of the OTT is an important problem often resulting in accidental extubation and displacement. Re-intubation following the accidental extubation causes additional pain and trauma to the infant. These complications can be avoided with well-secured OTT stabilization after the first successful OTI. Many methods of OTT stabilization have been used with different levels of success and complication risks. These methods include use of adhesive tape, sutures, silk ties, commercially available OTT holders, palatal stabilization devices (PSDs), umbilical cord clamps, head restraints and bonnets, or a combination of the above¹⁷.

Perioperative oral injury related to OTI is one of the most common adverse events with anesthesia application and constitutes the main subject of a large number of malpractice claims directed against anesthesiologists. A physician who performs the OTI and mechanical ventilation should be aware of trauma that may occur to the soft tissue and bone. These procedures may cause damage to the deciduous tooth germs due to the lack of protection of the bone in which they are located¹⁸. For premature infants requiring OTI, when unexpected oral complications occur, or with a goal of prevention before they occur, consultation with a dentist is desirable.

This study aimed to assess the awareness of anesthesiologists and neonatologists about oral complications occurring during and after OTI in premature infants and their knowledge and behavior regarding protection methods from these complications in clinical practice. According to the best of our knowledge, there are no similar studies in the literature.

MATERIALS AND METHODS

This study complies with the Declaration of Helsinki and was approved by the Ethical Committee of Gazi University (77082166-302.08.01; Research Code: 2018-80). A total of 231 neonatologists and anesthesiologists working in hospitals' NICU participated in the study.

The questionnaire consisting of 18 items has been prepared by three dentists, a neonatologist and an anesthesiologist, with at least 15 years of experience. It was then assessed by a dentist, a neonatologist, and an anesthesiologist, who were blind to previous procedures, and three items were removed according to their suggestions. The final version of the questionnaire including 15 items and three parts was attained: (i) personal information; (ii) awareness of the participants about oral complications occurring during and after the OTI in premature infants; and (iii) their knowledge and behavior regarding protection methods from these complications in clinical practice (Table 1). The participants were invited to answer the questionnaire by email.

Table 1.

The distribution of all participants’ responses regarding their (A) personal information, (B) awareness about oral complications related to OTI, and (C) knowledge and behaviors regarding protection methods from these complications

Questionnaire
(A) Personal information
1. Age (y)	36.8 ± 8.4*
	n	%
2. Gender
Female	155	67.1
Male	76	32.9
3. Specialty area
Anesthesiologist	137	59.3
Neonatologist	94	40.7
4. Educational status
Physician associate	84	36.4
Specialist	84	36.4
Lecturer	63	27.3
5. Professional experience
1–5 years	93	40.3
5–10 years	53	22.9
10+ years	85	36.8
(B) Awareness of the participants about oral complications occurring during and after OTI in premature infants
6. In premature infants, are you aware of the complications that the OTI you are using can create?
No	27	11.7
Yes	204	88.3
7. Which complication do you most encounter?
Palatal groove	69	29.9
Acquired palatal cleft	23	9.9
Accidental extubation	100	43.3
Oral, laryngeal, or pharyngeal region injuries	109	47.2
Subglottic stenosis	87	37.7
Glottic cyst	16	6.9
Speech impairment	21	9.1
Time losses (due to extubation)	51	22.1
Enamel defect in deciduous teeth	18	7.8
Malocclusions in the jaws	32	13.8
(C) Knowledge and behavior of the participants regarding protection methods from aforementioned complications in clinical practice
8. What is the method you use to stabilize the OTT?
Bonding to the perioral region with an adhesive tape	225	98.3
Fixing to the head with fabric tape	19	8.3
Prefabricated PSD	2	0.9
Custom-made PSD	1	0.4
9. What is your priority for choosing a stabilization method for OTT?
Ease of use	167	28.2
Time and material effectivity	117	19.8
Patient comfort	112	18.9
Estimated duration of intubation	95	16
Possibilities offered to you in the work environment	28	4.7
Birth weight of the infant	26	4.4
The patient's gestational age	47	7.9
10. Do you know PSD?
No	176	76.2
Yes	55	23.8
11. If your answer is ‘yes’, what was your source of information?
Scientific meetings	11	14.3
Scientific articles	26	33.8
Sales representative	8	10.4
Colleagues	19	24.7
Patients' relatives	0	0
Internet	13	16.9
12. Have you ever requested PSD from the management of your hospital for using in OTI procedure?
No	225	97.4
Yes	6	2.6
13. Have you ever used a PSD?
No	222	96.1
Yes	9	3.9
14. If your answer is ‘no’, what was your reason for not using it?
I am not aware	176	75.9
I am aware, but I do not know how to use it	10	4.3
I am aware, but this device is not available at the institution I work with	36	15.5
I am aware, but this device cannot be continuously supplied to the institution where I work	6	2.6
I am aware, but there is not enough training of assistant personnel to use the device	1	0.4
I am aware but, I do not believe in the effectiveness of the device	3	1.3
15. If you routinely use the PSD, do you trust the effectiveness of the pallial stabilization device to prevent complications?
No	3	42.9
Yes	4	57.1

^*Mean ± standard deviation.

Data analysis

In this study, the SPSS 22 package program (SPSS Inc., Chicago, IL) was used for analyzing the data. The chi-square (χ²) test was used to test the relationships between the variables. The upper limit for significance was taken as 0.05 with minimal threshold test of 95%.

RESULTS

Table 1, which is the questionnaire, provides the distribution of all responses for all participants as numerical quantities and percentages.

According to personal information, there was a statistically significant difference between awareness of the complication and specialty area (P = 0.004), educational status (P = 0.01), and professional experience (P = 0.01; Table 2).

Table 2.

Statistical analysis between personal information of the participants and their awareness of the complications

Personal information of the participants	Participants’ awareness of the complications				Total	χ2	P-value
	No		Yes
	n	%	n	%
Gender
Female	19	12.3	136	87.7	155	0.148	0.700
Male	8	10.5	68	89.5	76
Specialty area
Anesthesiologist	23	16.8	114	83.2	137	8.484	0.004*
Neonatologist	4	4.3	90	95.7	94
Educational status
Physician associate	21	25.0	63	75.0	84	22.748	<0.001**
Specialist	4	4.8	80	95.2	84
Lecturer	2	3.2	61	96.8	63
Professional experience
1–5 years	21	22.6	72	77.4	93	18.746	<0.001**
5–10 years	4	7.5	49	92.5	53
10+ years	2	2.4	83	97.6	85

χ², chi-square test.

^*P < 0.05, **P < 0.01; statistically significant difference.

The most common complications encountered by anesthesiologists were oral, laryngeal, or pharyngeal region injuries (60.7%), accidental extubation (50.9%), and stenosis (47.3%); for neonatologists, the most common complications included palatal groove (52.2%), accidental extubation (47.8%), and oral, laryngeal, or pharyngeal region injuries (45.6%), respectively.

The most common OTT stabilization method was bonding to the perioral region with adhesive tape for both anesthesiologists (97.8%) and neonatologists (98.4%). It appears that some participants have been using more than one stabilization method. In routine clinical practice, no anesthesiologists have used a PSD before, and only two neonatologists (2.1%) have used prefabricated PSD and one (1.1%) has used custom-made PSD. Nine of the participants previously used PSD at least once; five were neonatologists (5.3%) and four were anesthesiologist (2.9%).

Only 55 (23.8%) participants were aware of PSD. There was no statistically significant difference between the PSD awareness and sex, specialty, educational status, and professional experience (P > 0.05; Table 3).

Table 3.

The relationship between personal information and awareness of PSD (n = 231)

Personal information of the participants		Being aware of PSD				Total	χ2	P-value
		No		Yes
Variables	Value	n	%	n	%
Sexes	Female	120	77.4	35	22.6	155	0.392	0.531
	Male	56	73.7	20	26.3	76
Specialty area	Anesthesiologist	109	79.6	28	20.4	137	2.110	0.146
	Neonatologist	67	71.3	27	28.7	94
Educational status	Physician associate	70	83.3	14	16.7	84	5.513	0.064
	Specialist	64	76.2	20	23.8	84
	Lecturer	42	66.7	21	33.3	63
Experience	1–5 years	78	83.9	15	16.1	93	5.515	0.063
	5–10 years	36	67.9	17	32.1	53
	10+ years	62	72.9	23	27.1	85

χ², chi-square test.

P < 0.05; statistically significant difference.

DISCUSSION

In literature, Boice et al.¹¹ were the first to report oral complications related to the OTI in a premature infant. On the third day of the OTI, they reported a ‘noticeable concavity’ localized on the side where the OTT has been placed at the anterior alveolar ridge¹¹. This deformation may be a result of the application of unstable and continuous mechanical forces to soft tissues during this age¹⁹. Factors such as birth weight, gestational age, and duration of intubation are each thought to have independent effects on OTI-related oral defects²⁰.

In premature infants, acquired palatal groove formation is one of the most important complications related to prolonged OTI¹⁴. Duke et al.¹⁶ have suggested the duration of OTI might be related to the formation of a palatal groove and acquired palatal cleft. Erenberg and Nowak¹⁴ reported palatal groove formation was a frequent complication in infants requiring OTI after the birth, and the longer OTI period caused a higher palatal groove frequency. Their study revealed <7 days of OTI duration caused 39.5% palatal groove formation while 15 or more days of OTI duration caused 87.5%¹⁴. However, no information concerning the size, depth, or severity of the groove was reported¹⁴. In contrast, Raval et al.²¹ found palatal arch morphology was not influenced by the duration of OTI. It has been shown the palatal grooves can persist until 5 years of age, and this can lead to negative effects on dental and orofacial development²¹. Another complication of OTI is palatal asymmetry or deformation, because during this period of development of the oral cavity in infants, the palatal bone is more flexible and more sensitive to external forces²². In one study, palatal deformation was observed in 12% of premature infants who underwent OTI²³. Kopra et al.²⁴ reported that deep palate, posterior cross-bite, and speech impairment are potential complications that could occur in OTI applied infants.

Previous studies have reported that the history of OTI in premature infants is an important risk factor for enamel developmental defects of deciduous teeth²⁵. In a recent study, the prevalence of enamel defects was found higher among intubated premature infants (86.3%), when compared with non-intubated (13.7%) infants¹⁹. Seow et al.²⁵ and Vello et al.²⁶ correlated the presence of enamel defects with OTI duration and showed this potentially damaging period can be variable, ranging from 1–3 days. Seow et al.²⁵ found a relationship between the unilateral hypoplastic maxillary incisors and traumatic OTI. However, whether mechanical trauma of the laryngoscope or extensive pressure of the OTT causes enamel defects is unclear²⁵. Wetzel et al.²⁷ suggested that more severe damage on the right side was not related to the laryngoscope and could be a result of the placement of the OTT. Even though they are not life-threatening, various oral and dental complications that may affect the infant’s future life can occur related to OTI²⁰. Because the neonatologists and anesthesiologists are directly involved in OTI, they are responsible for taking the necessary precautions to protect premature infants from such complications. This study revealed that participants' awareness of oral complications they have encountered during and after the OTI in premature infants was low. The ‘oral complications’ encountered by the participants included enamel defect in deciduous teeth (7.8%), speech impairment (9.1%), cleft palate (9.9%), malocclusion (13.8%), and palatal groove (29.9%), ranked from low-to-high, respectively. The participants reported the most common two complications they encountered in NICU were accidental extubation (43.3%) and oral, laryngeal, or pharyngeal region injuries (47.2%). The awareness level of neonatologists (95.7%) about complications that they encountered was higher than anesthesiologists (83.2%).

Orotracheal tube stabilization is currently achieved in NICUs by various techniques such as twill/cotton tape, adhesive tape, gauze, or PSD to keep the patient's airway sustained and prevent or minimize the complications. The optimal OTT stabilization method should be secure, easy to use, comfortable for the patient, and cost-/time-effective²⁸. The friction of OTT stabilized with traditional taping method (fixing with twill/cotton or gauze and bonding with adhesive tape) may result in soft tissue injury followed by necrosis of the alveolar ridge and may damage both the palatal bone and the deciduous teeth buds¹⁹. In addition, the necessity for re-intubation following accidental extubation because of inadequate stabilization is a major contributor to airway trauma that can cause the development of acquired subglottic stenosis²⁹. In this study, we found that ease of use was the most important factor in choosing the stabilization method. All participants, both anesthesiologists and neonatologists, reported the most commonly OTT stabilization method they preferred is bonding to the perioral region with adhesive tape.

The PSDs can reduce morbidities associated with prolonged use and the OTT displacement/accidental extubation in infants30., 31.. The use of a PSD has three main goals: (i) protect the palatal region from pressure from the OTT; (ii) prevention of trauma that can occur to the tooth germs; and (iii) reduction of movement and accidental extubation risk of OTT by providing stabilization³². However, there is no consensus among the researchers about which infants should receive the PSD²⁰. It has been reported that prolonged OTI duration without using a PSD could increase the possibility of palatal groove formation and its severity³². These devices can be prefabricated or prepared custom-made. The prefabricated PSD is made from a flexible, soft silicone material that can be sterilized in an autoclave and produced in different sizes depending on the width and length of the palate in infants³³. Several commercial prefabricated PSDs are present at the market such as ‘Neobar’ (Neotech Products, Valencia, CA) and ‘Pala-nate’ (Utah Medical Products, Midvale, UT). In the literature, there are many studies that claim the PSD minimizes OTI-related complications14., 17., 32., 34., 35., 36., 37., 38.. Ash et al.³⁸ reported the unprotected palates in intubated infants were smaller, narrower, and deeper than in non-intubated infants. They also suggested the use of any PSD during the OTI could reduce palate narrowing and deepening³⁸. On the other hand, Brinsmead et al.³⁷ found no significant advantage among the methods in terms of superiority for preventing complications when they compared a prefabricated PSD (Neobar) and conventional taping method. Similarly, Volsko et al.³⁶ reported no significant difference between the PSD (Neobar) and the conventional taping methods to prevent the complications. The custom-made PSD has been proposed by some authors as an effective method for preventing the deterioration of palatal architecture14., 20., 30., 33., 34., 38.. The first step to construct this device is to craft a plaster model by taking an impression of the maxilla. A denture-like appliance with an antero-posteriorly extending groove is constructed to stabilize the OTT20., 34.. Conley et al.²⁹ emphasized that the custom-made PSD is better than the conventional taping method to prevent accidental extubation and immobilization of OTT. Fadavi et al.³⁴ reported the custom-made acrylic PSD reduced the pressure of OTT on the palate and completely prevented the palatal groove formation in infants. In another study, Fadavi et al.³³ compared a prefabricated (Pala-nate) and the custom-made PSD in terms of stability, fit, and retention. The prefabricated PSD was found to have some disadvantages for retention and stability (e.g. it can cause oral morbidity and spontaneous extubation in premature infants). Fadavi et al.³³ noted, however, that the major advantage of using any prefabricated PSD is the elimination of the necessity to take palatal impressions in high-risk infants³³. Furthermore, the use of such devices would require interdisciplinary cooperation among pediatric dentists, physicians, and nurses³³. Using PSD may become the standard of care for the OTI in infants if successful applications are increased and adapted to the routine of clinical practice²⁰. In this study, 20.4% of anesthesiologists and 28.7% of neonatologists were aware of PSD and there was a correlation between the awareness and level of education. In addition, this study revealed that for the OTT stabilization, prefabricated (0.9%) or custom-made (0.4%) PSDs are used very rarely by the participants in clinical practice when compared with bonding to the perioral region with adhesive tape (98.3%).

CONCLUSIONS

The results of this study demonstrated that neonatologists have greater awareness than anesthesiologists about the PSDs besides the OTI-related oral complications. Yet, the professional knowledge of all participants was insufficient to prevent these complications and revealed that PSD are rarely used in clinical practice.

Based on previous studies and the results of this study, the following recommendations can be made to dentists, neonatologists, and anesthesiologists to prevent OTI-related oral complications:

• •The professional training of neonatologists, anesthesiologists and staff participating in the OTI procedure should include OTI-related oral complications and precautions.
• •The above-mentioned situation is true for dentists and pediatric dentists.
• •To minimize OTI-related complications, it is appropriate to have dentists available for consultation in the NICU. Thus, the patient's first-hand follow-up is provided.
• •If the most important goal is to improve the overall health of the patient, a multidisciplinary approach is needed.

Acknowledgements

The authors would like to thank all the participants in this study.

Conflict of interest

The authors declare no conflict of interest.

Funding

This study did not receive any financial support.