Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey

Abstract

We would like to comment on, and correct some misunderstandings in, the paper by Foy et al., which suggests that there are major gaps in optimal airway management in neonatal intensive care units (NICUs) in the UK, particularly lack of continuous waveform capnography and/or videolarygoscopy [1]. We are in full agreement with the NHS Improvement recommendation that undetected oesophageal intubation should be a 'Never Event', but note that detection of this event relates mostly to the use of capnography at intubation, rather than during ongoing ventilatory support.It is well recognised that detection of exhaled CO 2 using a colorimetric device facilitates confirmation of tracheal tube placement in newborn babies, despite being subject to both false-positive and false-negative results, and this is recommended by international guidelines [2]. A recent survey of UK neonatal units reported routine use of CO 2 monitoring in 84-88% of neonatal intubations in the labour ward [3], considerably at odds with the reported availability of 'capnography' of between 18% and 48% in Foy et al.'s paper. The phrase 'continuous waveform capnography' may not be one with which most staff working in a UK NICU will be familiar, and it is not clear from the paper whether the question regarding capnography was, or could have been, interpreted as including single use colorimetric CO 2 detector devices at neonatal intubation. Based on a single personal communication, Foy et al. state that capnography is 'routinely' used in 'many' neonatal transfers. This contradicts data presented in Fig. 2, but accords with a recent informal survey of 15 UK transport services, of which 13 routinely use capnography (personal communication -Dr A. Jackson). The transport neonatal population differs in several regards from the NICU population and continuous waveform capnography may be more useful in sedated babies, and when the environment means that the ventilator may not reliably produce flowgraphs. As acknowledged by Foy et al., there is no evidence of reduction in harm from intubation with the use of continuous waveform capnography in the NICU. Interpretation of continuous waveform capnography is likely to be complicated by the fast ventilator rates and short expiry time used in neonates, routine use of uncuffed tracheal tubes and the relatively large dead space in the smallest preterm infants. Most neonatal ventilators now incorporate flow graphs, with which neonatal nursing and medical staff are familiar, and which provide an opportunity to recognise accidental extubation. There has been no direct comparison of continuous waveform capnography and ventilator flow graphs in terms of efficacy and safety in ventilated preterm infants. Videolaryngoscopy has potential to facilitate teaching and practice of neonatal intubation [4] and videolaryngoscopes suitable for very preterm infants are now available. We anticipate therefore that availability of and (just as importantly) familiarity with videolaryngoscopy within UK neonatal units will continue to increase alt...

Versorgung und Reanimation des Neugeborenen nach der Geburt

“…Studien bei Erwachsenen legen nahe, dass eine quantitative Kapnographie beim Nachweis des etCO 2 empfindlicher sein kann als eine kolorimetrische Bestimmung. Da jedoch keine Validitätsdaten zur Haupt- oder Nebenstrommessung bei Neugeborenen vorliegen, ist bei der Verwendung einer quantitativen Kapnographie Vorsicht geboten [ 265 , 267 , 268 ].…”

Is waveform capnography reliable in neonates?

“…Although interpreted by mainstream media and the British Medical Journal as a potential shortcoming,14 the evidence for the superiority of waveform capnography over transcutaneous capnometry (common in neonates, perhaps due to their comparatively thinner skin) in neonatal practice is less convincing. A British Association of Perinatal Medicine working group has recently commented on the survey by Foy et al 15. A survey of NICUs in Germany, Switzerland and Austria by Rüdiger et al 8 found that 95% of NICUs used TCCO 2 8…”

Results from capnography studies in adults may not apply to neonates

“…In response to the editorial by Cook and Harrop-Griffiths on capnography,1 we reiterate the British Association of Perinatal Medicine’s position statement on waveform capnography in newborn infants2 published in response to the article by Foy et al in Anaesthesia 3…”