More Newborns Intubated on First Try With Video Laryngoscopy

Video laryngoscopy for the urgent intubation of neonates led to higher rates of success on the first attempt than direct laryngoscopy, a single-center randomized trial from Ireland found.

Of more than 200 newborns intubated in the delivery room or neonatal intensive care unit (NICU), successful intubation on the first attempt occurred in 74% of those randomized to video laryngoscopy versus 45% of those assigned to direct laryngoscopy (P<0.001), reported Colm P.F. O'Donnell, MB, PhD, of the School of Medicine at University College Dublin, and colleagues.

"The data reported in this trial represent an unusually high degree of first-attempt success involving this population in a randomized trial," the researchers wrote in the New England Journal of Medicine. "The percentages of neonates who had low oxygen saturation, oral trauma, and correctly placed ETTs [uncuffed endotracheal tubes] on chest radiographs were in keeping with previous studies."

Findings from the study were also presented at the Pediatric Academic Societies annual meeting in Toronto.

Multiple intubation attempts in neonates can lead to a higher number of adverse events, including bradycardia, oral trauma, and severe oxygen desaturation, explained O'Donnell and colleagues.

Standard laryngoscopes have a light at the end of the blade to view the airway directly while video laryngoscopes have a light and a camera that displays the view on a screen. When compared with direct laryngoscopy, the use of video laryngoscopy in large trials of adults and children has demonstrated higher rates of successful intubations on the first attempt, though whether that benefit extended to newborns had been unclear.

"Programs that teach neonatal intubation do not generally recommend or discuss video laryngoscopy," O'Donnell and coauthors noted. "Our findings suggest that this practice should be reconsidered."

They pointed out that the current trial included a relatively large number of inexperienced doctors (physicians in training performed more than 90% of the first attempts).

The so-called VODE (Video- Or Direct Laryngoscopy for Endotracheal Intubation in Newborns) trial randomized 226 neonates who required intubation in the NICU or delivery room at the National Maternity Hospital in Dublin to either video or direct laryngoscopy.

A total of 214 neonates were available for data analysis. A little less than half were girls (46%), with 43% born prior to 28 weeks' gestation and two-thirds born before 32 weeks' gestation. A majority were having their first intubation and on the first day of life. Most intubations occurred in the NICU (71%) while the remaining 29% occurred in the delivery room.

Overall, 45 different clinicians made at least one initial attempt at an intubation: 32 doctors training in pediatrics (136 attempts); nine doctors training in neonatology (36 attempts); and four neonatologists (11 attempts). Typically neonatologists at the hospital had performed over 100 procedures, noted O'Donnell and colleagues, while doctors in training for neonatology had performed 20 to 40 and doctors in training for pediatrics had no prior experience.

The median number of attempts to intubate was 1 in the video group and 2 in the direct group, with a median duration of 61 seconds versus 51 seconds for the first attempt, respectively. On subsequent intubation attempts, 3% of neonates from the video group crossed over to direct laryngoscopies, while 29% of those in the direct group crossed over to video laryngoscopy.

Secondary endpoints included the median lowest oxygen saturation (74% for the video-laryngoscopy group versus 68% for the direct-laryngoscopy group), lowest heart rate (median 153 vs 148 bpm, respectively), chest compressions (6% vs 5%), need for epinephrine (3% vs 1%), and oral trauma (0% vs 1%), among others.

Three infants died during the study, though none were considered to be related to the intubation procedure: one infant in the video-laryngoscopy group died as a result of hydrops fetalis; one infant in the direct-laryngoscopy group died from twin-to-twin transfusion syndrome and another in this group died from severe congenital heart disease.

Beyond the single-center design, other potential study limitations were that only one type of video laryngoscope was used and that clinicians' history of previously performed intubations was not collected, said O'Donnell and coauthors.

Strengths, however, included "enrollment of a large proportion of eligible neonates, including the smallest neonates who would have been ineligible for previous studies owing to concerns that the video laryngoscopy blade would have been too large for them," they said.

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