EBNEO Commentary: Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants
MANUSCRIPT CITATION
Geraghty LE, Dunne EA, Chathasaigh CMN, Vellinga A, Adams NC, O’Currain EM, McCarthy LK, O’Donnell CPF. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med 2024; 390:1885-94. PMID 38709215.
REVIEWED BY
Sara Neches, MD
University of Washington & Seattle Children’s Hospital
sara.neches@seattlechildrens.org
Rebecca Shay, MD, MAS
University of Colorado Hospital, Children’s Hospital Colorado
rebecca.shay@childrenscolorado.org
TYPE OF INVESTIGATION
Treatment
QUESTION
In newborn infants undergoing urgent intubation in the delivery room or neonatal intensive care unit (P), does the use of video laryngoscopy (I) compared to direct laryngoscopy (C) improve the success rate of intubation on the first attempt (OT)?
METHODS
Design: A single center randomized clinical trial
Allocation and Stratification: Eligible infants were neonates of any gestational age intubated in the delivery room (DR) or neonatal intensive care unit (NICU). Once the decision was made to intubate, a sealed envelope was opened, and the infants were randomized 1:1 to indirect intubation with video laryngoscopy or direct laryngoscopy. The infants were stratified by gestational age (GA) of <32 weeks or ≥ 32 weeks.
Blinding/Consent: Informed consent was obtained prospectively from families in the cases of anticipated premature birth or congenital anomalies requiring intubation; otherwise, consent was obtained at the time of randomization or deferred until feasible in cases of emergent intubations.
Follow-up period: Infants in the trial were not followed beyond the recorded intubation encounter.
Setting: National Maternity Hospital (NMH) in Dublin, Ireland; a teaching hospital with approximately 7000 annual births.
Patients: Eligible infants were neonates of any gestational age intubated in the DR or NICU during the study period of September 2021 to November 2023. The study team excluded infants if they had upper airway anomalies.
Intervention: At the beginning of their NICU rotations, trainees (pediatric residents, neonatology fellows), were provided education on both direct and video laryngoscopy from the trial team, and they had the opportunity to practice with manikins. The first attempt provider was usually a resident or fellow and was predetermined before randomization. Trainees were allowed up to 3 intubation attempts before the senior provider would step in. An intubation attempt was defined as any time the laryngoscope entered the patient’s mouth regardless of whether an endotracheal tube was attempted to be passed. No direct coaching was described during the intubation. A standard direct laryngoscope (HEINE, Optotechnik) was used with straight blades ranging in size from 00, 0 and 1 for infants weighing <1000 g, 1000-3000g and >3000g respectively. The Karl Storz CMAC was used for video laryngoscopy, with blade sizes 0 for neonates weighing <1500g and 1 for infants weighing >1500g.
While premedication was used before any NICU intubation where time allowed, it was not used in DR intubations. Premedication drugs utilized in this study included atropine, fentanyl, and suxamethonium. Standard intubation tools were used, including uncuffed endotracheal tubes, and stylets were used at the discretion of the clinician. No supplemental oxygen was used. Crossover to the non-randomly assigned device was discouraged but did occur. A member of the research team attended all intubations and collected data.
OUTCOMES
Primary outcome: First attempt success rates comparing direct vs. indirect video laryngoscopy. Subgroup analyses evaluated the primary outcomes according to gestational age at birth <32 w, birth weight <1000g, and location of intubation (DR vs. NICU).
Secondary outcomes: Assessed between the two groups, direct vs. indirect video laryngoscopy: Median lowest oxygen saturation and heart rate during the procedure, need for chest compressions or cardiac medications (e.g., epinephrine), median number of intubation attempts, median duration of successful first attempt, oral trauma, crossover to an alternative device, and whether endotracheal tube was in the correct position post-intubation.
Analysis and Sample Size: Of the 246 infants screened for eligibility, 241 met the criteria for enrollment, and 226 underwent randomization; 115 infants were assigned to video laryngoscopy, and 111 were assigned to direct laryngoscopy. After accounting for exclusions based on deferred consent not obtained or intubation deferred, data for n=107 infants were evaluated from both the video laryngoscopy and the direct laryngoscopy group using an intention-to-treat analysis.
Measured variables:
Key Outcomes
CONCLUSION
For infants undergoing urgent intubation, indirect video laryngoscopy resulted in a greater number of successful intubations on the first attempt compared with direct laryngoscopy. However, the authors acknowledged that this study was underpowered to detect effects on adverse outcomes, so larger studies are necessary to establish whether video laryngoscopy reduces harm.
COMMENTARY
Research on optimal neonatal intubation conditions often examines modifiable practices such as premedication, neuromuscular blockade, oxygen supplementation, and laryngoscopy type (e.g., video (VL) vs. direct (DL)). This single-center randomized study by Geraghty et al. focuses solely on laryngoscopy type while maintaining standardized premedication, including neuromuscular blockade. Key commentary opportunities include adverse intubation-associated events, the impact of standardized coaching during VL for trainees, and crossover data analysis.
Intubation success and safety are closely linked, with adverse events occurring in approximately 20% of cases and ranging in severity (1). Less severe events include mainstem intubation, esophageal intubation with immediate recognition, emesis without aspiration, hypertension, epistaxis, medication error, dysrhythmia, pain, and gum/lip/oral trauma. Severe events include cardiac arrest, hypotension requiring intervention, pneumothorax/pneumomediastinum, direct airway injury, esophageal intubation with delayed recognition, laryngospasm, malignant hyperthermia and emesis with aspiration (1). Increased intubation attempts correlate with higher adverse event rates (2-4), underscoring the importance of addressing tracheal intubation-associated events to optimize outcomes. While this study monitored heart rate, oxygen saturation, and the need for chest compressions or epinephrine, other adverse events were not assessed. Among 198 intubations, 6% of VL cases and 5% of DL cases involved cardiac arrest requiring chest compressions, with three deaths occurring across both groups. In comparison, a study from a large international airway registry of over 2700 intubations reported rare rates of chest compressions – 0.6% for VL and 1% for DL (5). Although underpowered to detect adverse event patterns, the current study raises important questions about rates of severe adverse event rates and whether specific factors in infants requiring advanced resuscitation merit further investigation.
The use of VL for training is well-documented (6-9), with growing evidence highlighting the benefits of coaching, teaching, and simulation. Shared airway visualization with a senior provider or coach may enhance experience, competence, and confidence and result in educational impact across different trainee experience levels. Given the two-year study period, analyzing month-to-month trainee success could clarify whether skills improved over time and amplify the impact of VL on skill acquisition and patient outcomes. Incorporating quality improvement tools like Statistical Process Control charts may add valuable insights.
This randomized clinical trial (RCT) employed an intention-to-treat approach, analyzing participants based on their original group assignments regardless of crossover. Crossover, where participants switch groups, complicates analysis, dilutes treatment effects, and obscures the true impact. Intention-to-treat analysis reflects real-world treatment performance and reduces bias. In this study, 3% of participants crossed over from VL to DL, while 29% switched from DL to VL, potentially influencing results. While this crossover may have occurred in the setting of provider preferences or technical challenges, the impact of the crossover may be an underestimation of the benefits of VL.
Given the multifactorial approach to neonatal intubation, subgroup and post-hoc analyses could clarify the impact of provider and practice variables on procedural success. Including indication for intubation may highlight success and safety profiles related to various procedural practices and patient populations. For instance, premedication practices affecting intubation success may differ between patients needing Intubation-Surfactant-Extubation (INSURE) and those requiring prolonged mechanical ventilation.
In the future, the safety and success of neonatal intubation may be further enhanced by implementing tailored protocols that provide specific guidance on premedication, types of laryngoscopy, oxygen provision during intubation, and standardized intubation checklists. These protocols may be based on individual patient needs or the specific indication for intubation. Additionally, strategies could be developed to address the unique requirements of the intubating provider, such as a “first-year doctor in training” protocol or an “emergency re-intubation” approach for an attending neonatologist managing a patient with a difficult airway. These efforts could further optimize outcomes by aligning techniques and resources with both patient and provider considerations.
REFERENCES
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