Intubation Competence During Neonatal Fellowship Training: A Trainee’s Perspective

January 13, 2022


Evans P, Shults J, Weinberg DD, Napolitano N, Ades A, Johnston L, et al. Intubation Competence During Neonatal Fellowship Training. Pediatrics 2021; 148. PMID 34172556.


Kelsey R. Anderson, MD
Neonatal Fellow
The University of Texas Health Science Center at McGovern Medical School

Rajesh Pandey, MBBS, MD
Assistant Professor
The University of Texas Health Science Center at McGovern Medical School


Quality improvement or continuing medical education


Does progression in Neonatal-Perinatal Medicine (NPM) fellowship training experience (over three years, measured quarterly from 1 to 12) improve intubation competency resulting in increased intubation success?


  • Design: multi-center cohort study
  • Allocation: not applicable
  • Blinding: none
  • Follow-up period: October 2014-December 2018
  • Setting: eligible National Emergency Airway Registry for Neonates (NEAR4NEOs) North American academic centers
  • Population:
    • Inclusion criteria:
      • NPM fellows between 2014-2018 NEAR4NEOs in the United States (US) and Canada
      • At least 90% fellows’ intubation attempts captured in NEAR4NEOs database
      • Direct method of linking each intubation encounter to a specific NPM fellow
      • All intubations with any fellow participation as an airway provider within the intubation encounter included, regardless of whether the fellow was the first airway provider or not
      • All intubations in both the Neonatal Intensive Care Unit (NICU) and delivery room (DR)
    • Exclusion criteria:
      • Tracheal tube exchanges
  • Intervention: Not applicable
  • Outcomes: Primary outcome for both analyses (cumulative sum control chart [CUSUM] and aggregate) was intubation success confirmed by chest rise, auscultation, second independent laryngoscopy, carbon dioxide detection, and/or chest radiography
  • Analysis and Sample Size:
    • Aggregate analysis
      • 92 fellows participated in the 2297 tracheal intubation (TI) encounters representing 8 hospitals and 6 fellowship training programs
      • Assessed impact of fellow experience on intubation success with a mixed effects logistics model using the independent variable of the quarter of fellowship training (from 1 to 12) and a random intercept for individual fellows and fixed effect for the hospital
      • Model included a priori characteristics that have been associated with success during neonatal intubation: paralytic premedication use, use of video larnygoscopy, and patient weight at the time of intubation
    • CUSUM analysis
      • 40 fellows from 4 US training programs
      • Assessed individual performance with success rate of set at 80% (based on definitions used in previous neonatal studies), acceptable failure rate set at 20% for successful intubation within 2 attempts, and unacceptable failure rate set at 40%
      • Post hoc sensitivity analysis evaluated different definitions of success, using less and more stringent values, such as acceptable failure rate set at 30% and 10% (corresponding to 70% and 90% success, respectively)
  • Patient follow-up: % included in analysis not applicable/not reported


The primary objective was to define the number of intubation encounters necessary for individual NPM fellows to achieve procedural competence as well as assess the impact of training duration on intubation competence using a more granular exposure of quarter of fellowship training.

  • Aggregate analysis:
    • Out of the 2297 intubation encounters performed by 92 fellows in 8 hospitals, 77% (1766/2297) were successful within 2 attempts
    • Increasing quarter of fellowship training was associated with an increasing odds of intubation success (AOR 1.10; 95% CI 1.07-1.14) after adjusting for paralytic premedication, video laryngoscopy use, and patient weight < 1000g
  • CUSUM analysis (Figure 1):
    • Out of the 40 fellows assessed from the start of training, 45% (18/40) achieved procedural competence (though the median number of intubations needed to meet this threshold was variable with a median of 18 and IQR of 15-25), 30% (12/40) met the failure threshold, and 10 fellows (10/40) remained undifferentiated at the completion of their fellowship training using competence as defined at 80% success within 2 attempts
    • After post hoc sensitivity analysis using variable definitions for competence, 73% (29/40) of fellows reached competence defined at 70% success within 2 attempts with a median of 7 intubations needed to achieve this less stringent competence definition, though no fellows achieved competence using a more stringent definition of 90% success within 2 attempts


The authors concluded that the number of intubations required to achieve procedural competence is variable. Given this variability, the authors recommended individualized intubation training during the fellowship.


Evans et al. have provided important information in variability regarding the number of TIs required to achieve procedural competence for NPM fellows (median of 18 for threshold set to 80% success within 2 attempts) and raise the need for further discussion surrounding individualized educational strategies to better support NPM fellowship training that has also been addressed in supporting commentary (1).

The goal of this study was to characterize NPM fellows’ progression toward neonatal intubation procedural competence during fellowship training where consensus lacks, and the ACGME guideline is not apparent (2). This article provided operational definitions of intubation encounter, attempt, and success and is one of the few articles to evaluate NPM fellows’ TI competency. However, more research, including evaluation in diverse settings, and consistent definitions are needed on this topic within and across specialties incorporating anesthesiology (3,4), emergency medicine (5,6), pediatric critical care (7), as well as pediatric resident literature (8). This lack of consensus makes it difficult to determine competency given the diversity of clinical settings and the variability of intubation encounters. 

CUSUM analysis, a type of control chart used to monitor deviation from the prescribed target value, is a unique way to present the procedural learning curve (9). Compared to the moving range control chart, CUSUM can identify a process shift quickly. However, the main disadvantage of CUSUM is its inability to control for differences in baseline characteristics of patients and fellows in addition to educational structure in different hospitals. Some of these factors are based on patient and procedural aspects including, but not limited to, airway and other congenital anomalies, airway edema, reason for intubation, urgency of intubation, location of intubation, as well as equipment used for intubation, such as a video laryngoscope. The use of video laryngoscopy is inconsistent and depends on provider preferences and size limitations in extremely low and very low birth weight infants. Institutions may have restricted access to when and where this tool can be used, such as in the NICU but not in the DR where an emergency occurs resuscitation may also occur. These factors should ideally be addressed with analysis considering each successive intubation attempt. Elements are also based on program characteristics, including NPM fellowship service month, call structure, and frequency of procedures offered to other learners as fellows advance in training and experience, such as to more novice fellows and advanced practice providers.

Lastly, this study used prospectively collected data on intubations in the NICU and DR with an innovative database named NEAR4NEOs, a multi-center, prospective registry to improve intubation safety in the NICU. However, it is not clear if experiences in these large research institutes participating in NEAR4NEOs are generalizable to all NICUs.

Overall, we applaud the authors for utilizing data collected from a large international airway registry database for intubation safety that brings attention to the need for a consensus definition of intubation competence and more individualized NPM medical education with CUSUM analysis highlighted as a unique tool to guide appropriate intervention before independent practice.


  1. Chess PR. Assessing Intubation Competence During Neonatal Fellowship Training. Pediatrics 2021; 148:e2021050765.
  2. ACGME Home [Internet]. ACGME Program Requirements for Graduate Medical Education in Neonatal-Perinatal Medicine. [cited 2021 Sep 5]. Available from:
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