VL vs DL for intubating Neonates

Nov 07, 2024

I would consider intubation of the neonate(<28 days old) to be a very stressful event. This is not only because the size of the patient makes it technically potentially more difficult, but that we know that repeated intubation attempts in neonates is associated with oral trauma, severe oxygen desaturation and resultant bradycardias (1,2)

This trial looked at "whether indirect laryngoscopy with a video laryngoscope would result in increased success on the first attempt at urgent oral endotracheal intubation in neonates".

The Study

Geraghty L E. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. NEJM 390;20. May 30 2024 pp 1885-1894.

Bottom Line

Significantly more neonates were succesfully intubated on first attempt with video laryngoscopy (VL) than with direct laryngoscopy (DL)

What They Did

This was a single-center, randomized clinical trial in Dublin.

Following exclusions there were 107 patients were in each of the VL and DL arms of the study.

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This trial looked at "whether indirect laryngoscopy with a video laryngoscope would result in increased success on the first attempt at urgent oral endotracheal intubation in neonates".

The Study

Geraghty L E. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. NEJM 390;20. May 30 2024 pp 1885-1894.

Bottom Line

Significantly more neonates were succesfully intubated on first attempt with video laryngoscopy (VL) than with direct laryngoscopy (DL)

What They Did

This was a single-center, randomized clinical trial in Dublin.

Following exclusions there were 107 patients were in each of the VL and DL arms of the study.

Neonates were randomised in a 1:1 ratio to intubation with VL or DL.

The decision to intubate and the designation of the intubating clinician was made before randomisation.
- Intubation was usually first attempted( maximum of 3 attempts allowed) by a doctor training in pediatrics or neonatology.
- A neonatologist could attempt intubation at any time at their discretion.
- All intubations used the oral route
- Supplemental oxygen was not given during intubation attempts in either group
- Breach of the designated device used, was only allowed after an unsuccessful attempt by a neonatologist or in exceptional circumstances.
Medication was administered in the NICU (except in very urgent situations) before attempts at intubation. Medications were not administered in the delivery room, as no intravenous access was available. Medications included:
- Fentanyl (2 μg per kilogram of body weight iV)
- Atropine (20 μg per kilogram IV), and
- Suxamethonium (2 mg per kilogram IV).

Equipment used included:
- Uncuffed endotracheal tubes (ETTs) sized according to the birth weight of the neonates (e.g., 2.5 mm weight < 1kg, 3.0 mm for those 1-2 kg, and 3.5 mm for those 2-4 kg).
- Stylets could be used at the clinicians' discretion.
- A C-MAC video laryngoscope with Miller blades was used (size 0 for neonates weighing < 1.5 kg and size 1 for those ≥1.5gk).
- In the DL group, a standard laryngoscope (HEINE, Optotechnik) and straight laryngoscope blades were used (size 00 for <1 kg, size 0 for 1-3kg, size 1 for >3 kg)

Inclusion Criteria

Neonates where intubation was attempted in the delivery room or NICU were eligible for inclusion. Intubated neonates transferred from other hospitals were included if they required subsequently intubation.

Exclusion Criteria

Neonates with upper airway anomalies.

Primary Outcome

Successful first attempt intubation determined by colorimetric exhaled CO₂detector.

Secondary Outcomes

Lowest oxygen saturation recorded.
Lowest heart rate recorded.
Number of attempts required to intubate successfully.
Duration of successful attempts.
Crossover to the alternative device,
Correct positioning of the ETT on a chest radiograph.

What They Found

Primary Outcome

Significantly more neonates were succesfully intubated on first attempt in the VL group 79/107 (74%) than the DL group 48/107(45%)

Secondary Outcomes

Median number of attempts for successful intubation:1 (95% CI, 1 to 1) in VL vs and 2 (95% CI, 1 to 2) with DL.
Median duration of successful first attempts: 61 seconds (95% CI, 52 to 66) with VL vs 51 seconds (95% CI, 43 to 60) with DL.
Intubation with the non-assigned device in 3% (95% CI, 0 to 6) of VL group vs 29% (95% CI, 20 to 38) in the DL group.
Oral Trauma occurred in 0% of VL vs 1% in the DL group.

54 clinicians attempted intubation in at least one infant, with doctors in training performing the majority of first attempts at intubation in both groups.

Strengths and Limitations

This was a well done trial, with randomisation and enrollment of all-comers and the protocol was well adhered to.
It was a small study with only 107 neonates in each group and it was only performed in a single centre.
It was not powered to detect the effects on adverse outcomes.
Only one type of VL was tested.
Doctors in training in paediatrics and neonatology were used in the study, with aNeonatologist available to intubate, making it difficult to apply to the emergency department setting. The docotrs performing the intubations, however, had relatively little intubation experience with neonates.
We know the number of first attempt success rate but do not know the number of insertion attempts.
The views obtained were not recorded.

My Take On This

The study is small and was conducted in a single centre study in NICU or the delivery suite. Although there was no emergency department arm to this and there was a neonatologist present, most of the intubations were performed by doctors-in-training who had not perfomed a large number of prior intubations in this patient age group.

I think that I can say that the original fears that video laryngoscopy should not be used because the blade would be too large, is not well founded and based on this study.

I will change my practice and use VL when neonates are involved, however I already use it for all my patients.

References

Sawyer T, et al. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2019;104:F461-F466.
Singh N, et al. Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 2022;42:1221-7.