Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

Abstract

Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations.Objective: Aim of this study was to determine the frequency of tracheal intubation–associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit.Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded.Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (<10 intubation encounters) (OR = 2.15; 95% CI, 1.257–3.685) and equipment problems (OR = 3.43; 95% CI, 1.12–10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06–0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25–0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08–4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265–2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04–2.46) were associated with unsuccessful intubation attempts.Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.

Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS

“…Our fourth finding was that VL use was associated with lower TIAEs. This is consistent with a recently published single-site observational study by Tippmann et al where VL use was predictive of an intubation encounter without TIAEs [ 29 ]. Our study adds strength to this finding with its larger sample size and multicenter design.…”

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

“…Neonatal intubation is an essential procedure that all neonatologists need to be competent and proficient in performing. The procedure in this population is complicated not just by the small size of the baby but also by the unique physiology of the newb,orn which leads to decreased reserve and less apnoeic tolerance during laryngoscopy 10–16. As infants are surviving at lower gestational ages and birth weights than before, the procedure is only likely to become more challenging.…”

“…The procedure in this population is complicated not just by the small size of the baby but also by the unique physiology of the newb,orn which leads to decreased reserve and less apnoeic tolerance during laryngoscopy. [10][11][12][13][14][15][16] As infants are surviving at lower gestational ages and birth weights than before, the procedure is only likely to become more challenging. As the difficulty increases, procedural experience is decreasing due to greater use of non-invasive ventilation, a reduction in working hours and significantly increased numbers of not just trainees but also consultants.…”

Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting

“…VL improved the view of the glottis in both uncomplicated and difficult intubation situations, increased the success rate in the first attempt at intubation, and reduced the rate of complications, such as damage to oral structures, bradycardias and brief hypoxia (7)(8)(9)(10)(11)(12). Furthermore, several studies in children have confirmed the advantages of VL in difficult intubation conditions and the possibility to reduce TIAEs (tracheal intubation associated events) (13)(14)(15). In particular, VL has shown that it is a suitable and helpful tool for teaching inexperienced medical professionals (13,(16)(17)(18).…”