Orotracheal intubation in infants performed with a stylet versus without a stylet

O’Shea, Joyce E; O'Gorman, Jennifer; Gupta, Amrita; Sinhal, Sanjay; Foster, Jann P; o’connell, liam; Kamlin, C. Omar F.; Davis, Peter G

doi:10.1002/14651858.cd011791.pub2

Cited by 9 publications

(14 citation statements)

References 40 publications

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“…18 Neonatal intubation is a mandatory skill for neonatal trainees, but one that is increasingly difficult to master and maintain, possibly due to increasing use of non-invasive ventilation and less-invasive surfactant administration techniques. 19 To date, very little evidence is available to guide the optimal duration of an intubation attempt. Even when practitioners with considerable experience attempt intubation, many preterm infants are not intubated within the 30 s limit suggested by the Neonatal Resuscitation Program.…”

Section: Discussionmentioning

confidence: 99%

Time to desaturation in preterm infants undergoing endotracheal intubation

Kothari

Hodgson

Davis

et al. 2021

Arch Dis Child Fetal Neonatal Ed

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BackgroundNeonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU.MethodsObservational study at The Royal Women’s Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks’ postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%).ResultsSeventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26–29) weeks and birth weight 946 (773–1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14–32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24–44) s and to desaturation <60% was 56 (42–68) s. No episodes of bradycardia were seen.ConclusionsThis is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation.Trial registration numberACTRN12614000709640

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Section: Discussionmentioning

confidence: 99%

Time to desaturation in preterm infants undergoing endotracheal intubation

Kothari

Hodgson

Davis

et al. 2021

Arch Dis Child Fetal Neonatal Ed

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“…Finally, most airway and intubation training focuses on optimizing the view of the glottis 40 . Outside of the use of a stylet, a few exist assessing methods to improve the delivery of the ETT 31 . Klotz et al 40 completed a literature review on the training gaps in assessing and instructing intubation of both pediatric and neonates, finding that there is still a need to develop better methods to analyze competency, maintenance of skills, and the need to identify a superior training model.…”

Section: Discussionmentioning

confidence: 99%

Don't Hold Your Breath—A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation

Shah¹,

Edmunds²,

Dean

et al. 2021

Pediatr Emer Care

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Objective: Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED).Design: This was a retrospective, observational study of RSI.Setting: An academic PED. Patients: A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019.Measurement and Main Results: Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, −10.5; 95% confidence interval [CI], −17.0 to −4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, −3.5; 95% CI, −8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, −12.5; 95% CI, −17.0 to −4.0). These results did not change when adjusting for age or clustering by provider. Conclusions:We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.

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“…We did not consider the ETT insertion technique, whether a stylet was used or not, though studies showed no difference in the incidence of airway trauma. 24 The number of attempts taken for ETT insertion and experience of the clinician performing the intubation were not recorded. In practice, the most experienced clinician available performed endotracheal intubation in this group of infants.…”

Section: Discussionmentioning

confidence: 99%

Weight-Based Guide Overestimates Endotracheal Tube Tip Position in Extremely Preterm Infants

2019

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Objective To evaluate the association between endotracheal tube (ETT) tip position and adverse pulmonary outcomes using chest X-ray (CXR) in extremely preterm infants in whom ETT insertion length was estimated using weight + 6 guide (adding 6 cms to the infant’s weight in kg). Study Design CXRs of 85 infants performed in the first week were reviewed for right-sided atelectasis, air leaks, and uneven lung inflation. The first CXR was later reviewed to document the ETT tip. Regression analysis was performed to find the association between ETT tip position and adverse outcome after adjusting for other confounders. Results Forty (46%) infants had ETT tip placement between the first and second thoracic vertebrae (optimal position) compared with 45 (53%) who had the ETT tip placement outside this range (suboptimal position). Infants with suboptimal ETT were ventilated for a longer period (6.1 vs. 15.9 days; p = 0.004). The odds of adverse outcomes was 11.6 (95% confidence interval: 3.03, 44.1) times higher among infants who did not have ETT at the optimal position compared with infants who had ETT at the optimal position. Conclusion Weight + 6 guide is not recommended to estimate ETT insertion length in extremely preterm infants. Gestation-based guide may be more appropriate to estimate ETT insertion length in this group of infants.

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Orotracheal intubation in infants performed with a stylet versus without a stylet

Cited by 9 publications

References 40 publications

Time to desaturation in preterm infants undergoing endotracheal intubation

Time to desaturation in preterm infants undergoing endotracheal intubation

Don't Hold Your Breath—A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation

Weight-Based Guide Overestimates Endotracheal Tube Tip Position in Extremely Preterm Infants

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