Analysis of unsuccessful intubations in neonates using videolaryngoscopy recordings

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Objectives

Neonatal intubation is a difficult skill to learn and teach. If an attempt is unsuccessful, the intubator and instructor often cannot explain why. This study aims to review videolaryngoscopy recordings of unsuccessful intubations and explain the reasons why attempts were not successful.

Study design

This is a descriptive study examining videolaryngoscopy recordings obtained from a randomised controlled trial that evaluated if neonatal intubation success rates of inexperienced trainees were superior if they used a videolaryngoscope compared with a laryngoscope. All recorded unsuccessful intubations were included and reviewed independently by two reviewers blinded to study group. Their assessment was correlated with the intubator’s perception as reported in a postintubation questionnaire. The Cormack-Lehane classification system was used for objective assessment of laryngeal view.

Results

Recordings and questionnaires from 45 unsuccessful intubations were included (15 intervention and 30 control). The most common reasons for an unsuccessful attempt were oesophageal intubation and failure to recognise the anatomy. In 36 (80%) of intubations, an intubatable view was achieved but was then either lost, not recognised or there was an apparent inability to correctly direct the endotracheal tube. Suctioning was commonly performed but rarely improved the view.

Conclusions

Lack of intubation success was most commonly due to failure to recognise midline anatomical structures. Trainees need to be taught to recognise the uvula and epiglottis and use these landmarks to guide intubation. Excessive secretions are rarely a factor in elective and premedicated intubations, and routine suctioning should be discouraged. Better blade design may make it easier to direct the tube through the vocal cords.

Related collections

Most cited references 15

Record: found
Abstract: not found
Article: not found

Difficult tracheal intubation in obstetrics

R Cormack, Mike J. Lehane (1984)

0 comments Cited 201 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects.

C Omar F Kamlin, Peter Davis, Peter G Davis … (2006)

Endotracheal intubation of newborn infants is a mandatory competence for many pediatric trainees. The Neonatal Resuscitation Program recommends a 20-second limit for intubation attempts. Intubation attempts by junior doctors are frequently unsuccessful, and many infants are intubated between 20 and 30 seconds without apparent adverse effect. Little is known about the proficiency of more senior medical staff, the time taken to determine endotracheal tube (ETT) position, or the effects of attempted intubation on infants' heart rate (HR) and oxygen saturation (Spo2) in the delivery room (DR). The objectives of this study were to determine (1) the success rates and duration of intubation attempts during DR resuscitation, (2) whether experience is associated with greater success rates and shorter time taken to intubate, (3) the time taken to identify ETT position after intubation, and (4) the frequency with which infants deteriorated during intubation attempts and the time at which this occurred. We reviewed videos of DR resuscitations; identified whether intubation was attempted; and, when attempted, whether intubation was attempted by a resident, a fellow, or a consultant. We defined the duration of an intubation attempt as the time from the introduction of the laryngoscope blade to the mouth to its removal, regardless of whether an ETT was introduced. We determined the time from removal of the laryngoscope to the clinicians' decision as to whether the intubation was successful and noted the basis on which this decision was made (clinical assessment, flow signals, or exhaled carbon dioxide [ETCO2] detection). We determined success according to clinical signs in all cases and used flow signals that were obtained during ventilation via the ETT or ETCO2 when available. When neither was available, the chest radiograph on admission to the NICU was reviewed. For infants who were monitored with pulse oximetry, we determined their HR and Spo2 before the intubation attempt. We then determined whether either or both fell by > or =10% during the attempt and, if so, at what time it occurred. We reviewed 122 video recordings in which orotracheal intubation was attempted 60 times in 31 infants. We secondarily verified ETT position using flow signals, ETCO2, or chest radiographs after 94% of attempts in which an ETT was introduced. Thirty-seven (62%) attempts were successful. Success rates and mean (SD) time to intubate successfully by group were as follows: residents: 24%, 49 seconds (13 seconds); fellows: 78%, 32 seconds (13 seconds); and consultants: 86%, 25 seconds (17 seconds). Of the 23 unsuccessful attempts, 13 were abandoned without an attempt to pass an ETT and 10 were placed incorrectly. The time to determine ETT position in the DR was longer when clinical assessment alone was used. Infants who were monitored with oximetry deteriorated during nearly half of the intubation attempts. Deterioration seemed more likely when HR and Spo2 were low before the attempt. Intubation attempts often are unsuccessful, and successful attempts frequently take >30 seconds. Greater experience is associated with greater success rates and shorter duration of successful attempts. Flow signals and ETCO2 may be useful in determining ETT position more quickly than clinical assessment alone. Infants frequently deteriorate during intubation attempts. Improved monitoring of infants who are resuscitated in the DR is desirable.