Journal Club - safe emergency neonatal airway management - challenges and potential approaches

[Stefan Johansson]

On behalf of the 99nicu Team, I would like to invite you to participate in our 2nd Journal Club! 

The article we chose this time is a review article on "Safe emergency neonatal airway management: current challenges and potential approaches" by Joyce E O'Shea, Alexandra Scrivens, Gemma Edwards, and Charles Christoph Roehr. This artile is not Open Access, but I hope you can get it from your hospital library.

The review article examines how to acutely manage the neonatal airway, and the challenges related facemask ventilation and intubation.  Some of the key messages in this paper are:

• Intubation success rates are low, especially for inexperienced trainees
• Universal intubation competency for all pediatric and neonatal trainees and consultants may no longer be possible
• Videolaryngoscopy can help increase rates
• The laryngeal mask airway (LMA) is a promising alternative to intubation

Some of the questions we would like to discuss are:

• What is current practice in your department? How to do you manage the airways and who is doing what?
• What do you think are the strengths of this review article?
• What do you think are some of the limitations?
• Will this review have an impact in your department?
  • If no - why?
  • If yes, how?

We are looking forward to hearing your thoughts and opinions!

 

UPDATE: More information on the virtual journal club on June 9th here: https://99nicu.org/99nicu-news/join-our-virtual-journal-club-meetup-on-neonatal-airway-management-9-june-1630-1715-cet-r124/

 

Edited May 31, 2021 by Francesco Cardona
added date of virtual journal club

[Vicky Payne]

There has been a lot of thoughts on this in the neonatal Twitter community!

is intubation a mandatory competency for trainees in your country? Should it be? How do you as a neonatal physician/ANNP/NNP keep your skills up to date? How many is “enough” to be deemed proficient?

🤔🧐🤓

 

[bimalc]

The point about the VL is an important one. If intubation becomes a high risk/low frequency event, we should take a safety perspective and engineer our systems for safety, not widespread procedural competency with direct laryngoscopy. I am a physician-scientist who primary covers a level IV NICU without a delivery service. The over all number of intubations is relatively low and in most emergency circumstances there is a front line provider (typically NNP), a (very) experienced charge NNP, and a neonatal fellow available for managing the airway while I run the code. I can now count on one hand the number of times per year I even pick up a laryngoscope outside of a simulation (and as often as not, given that several experienced providers have tried to intubate before me, I'm busy re-engineering the situation to improve success or avoid need for intubation rather than somehow getting the tube in when others could not). I am confident that I've probably reached the point where I am significantly safer/better with VL than DL. This isn't just about trainees any more.

[piatkat]

Great comment @bimalc! 
I have discussed this topic also with one of my very experienced coworkers. Since our hospital trains also pediatric trainees that then leave to work in rural areas, she was strongly leaning towards intubation being a mandatory competency. She motivated her point of view saying that somewhere up in the North there might be nobody else to perform the intubation, so the trainee has to be able to intubate. But then I asked, "is intubation the goal, or securing the airways?". I think we need a shift in thinking- intubation is not the only way to secure the airways. Saying that I know that not many colleagues in the unit have had experience with LMA (basically only those who have had some experience in the surgery dept.). We would need to change the way we think and we teach-but it might be that currently the teachers might not have enough experience with the LMA to act as confident instructors. Many things to consider!

[Terry]

Familiarity with equipment is very important.
There is little point having videolaryngoscopy at the bottom of your difficult airway algorithm, if the machine spends the year sat in the corner gathering dust.
You need to be familiar with it, if you're going to call upon it in an emergency.
The same goes for LMAs and guedels.   

[Stefan Johansson]

Intubation, feels like a topic where science and art (and opinions!) meet! And, a sensitive topic as well, when intubation is discussed, it can almost feel we discuss a ritual rather than a medical procedure

In my first years as fellow, doing intubations was something that was quite stressful for myself, and early on the learning curve also for the infants... so, I think the question on how and who to train is well put but this paper.

In our hospital , we have a video laryngoscope, but as trained to do direct laryngoscopy I admit I have never tried in on a patient, only in a simulation setup.
But recently I had a live experience that was very positive, where the an anaesthesiologist did a video-guided intubation after a failed try with the regular laryngoscope, and it just seemed to much easier, and better for all (also the infant!)

LMAs - our pediatrics fellows has been trained to use those, and our experience is very good, an airway can be almost always be secured until more experienced clinicians arrive. If you don't have LMAs in your emergency cart in the delivery room, I can only recommend to get it.

[Stuart Hildage]

During the development of our Premature Baby Manikins (first the 28/29 week gestation and then the more recent 22/23 week gestation) we have observed a lack of suitably sized DL & VL equipment designed to deal with these extremely low birth weight babies (i.e. the blade sizes are simply too big!).

It would be interesting to share what DL & VL devices you are using as we see a fairly high proportion of failed intubations (or at best too much force being applied to achieve intubation) in the training / simulation setting. While the cause, in part, can be associated with variances in an individuals technique, it is not helped by the seeming lack of suitable equipment.

As the 'gestation / viability window' has come down over time, has equipment design kept pace with this and do you use different protocols (including different devices) for different gestations?

[bimalc]

On 5/20/2021 at 9:43 AM, Stuart Hildage said:

we have observed a lack of suitably sized DL & VL equipment designed to deal with these extremely low birth weight babies (i.e. the blade sizes are simply too big!).

I will assume for a moment that you refer to 22/23 week neonates weighing <500g as I would argue that a 28 weeker can easily be secured with either a Miller 0 or a 00 blade which have been available as long as I have been in practice. More recently our hospital began demo-ing a variety of new laryngoscope blades and I got to try out a miller 000 blade from intubrite that, to me, looked comically small, but was surprisingly effective in our micro preemie manakin. Which is to say I'm not sure there's much of a shortage of equipment for DL.

I have NOT seen good VL equipment for the 22/23 week population. On this I would agree and would welcome input from anyone who is aware of VL equipment for this size patient.

[Jummy]

Great discussion! I work in a level 2 unit with many experienced intubators but I worry proficiency is on the decline in line with the concerns raised by the authors. So how are we mitigating this?

1. Use of vIdeolaryngoscope to allow a team/shared view, it’s very satisfying as it always feel like team success. We also do our LISA using the VL. I must however say it doesn’t always work as the catheter doesn’t always obey instructions 😂 The blade is also wide and doesn’t work well for smaller babies. 

2. We’re investing into the Mac blade laryngoscopes which could be used for smaller babies and is quite sleek. 
 

3. Junior doctors rotate between tertiary and a district hospital like ours and are often skilled in intubation from their tertiary experience. 
 

4. We’ve adopted the BAPM difficult airway guidelines which limits the number of attempts at intubation before trying things like LMA or asking for help from anaesthetist/ENT. It’s a brilliant ‘challenge and response’ approach. This means a simple airway is unlikely to be converted to difficult airway from multiple attempts and subsequent laryngeal oedema. We’ve stocked up size 1 i-gels which theoretically could  be used on babies as little as 1.5kg. They are easy to use. 
 

5. We do 1-2 weekly neonatal simulation for junior doctors, they increase confidence and team working as well as keeping up to date with what works 

6. Quarterly skills training for consultants- likely group to lose skills as not rotating to tertiary centres. 
 

Hope that helps 

 

Jummy 

[Gazmend Berisha]

Greetings to all 🙂

I hope You all are doing fine and soon having your summer holidays!

Interesting topic, and I will take part in the webinar tomorrow. 

I am an anesthesiologist, intensivist with special interest in neonatal resuscitation and airway management. I have also recently written an article about the unexpected difficult airway in neonates (in the resuscitation setting) but the same practical experiences can be used in the NICU or ER (infants) when doing intubations there. As the article is sent to a journal for consideration for publication, I cant say so much more. 

The intubation procedure can be exciting, stressful, scary, sometimes all at once. Preparation, simulation training, the real experience and learning curve, and good "teachers" who teach in a good, pedagogical way is everything / very important to the cause of learning and being competent in this procedure. 
The use of LMA is not difficult, but it has to be trained and there must be a good teacher/colleague who shows you how to do it and what difficulties you can meet. Really a good tool to have in your toolbox when meeting unexpected challenges with ventilation and intubation. 

The use of VL is a good alternative especially in trained hands. At the same time, its good for teaching and learning purposes when doing intubation for the first, second, third time. Depending on what VL you have, I have some tips I am willing to share with all of you. The VLs I know how to use are the Karl Storz CMAC, the Glidescope, and the Mcgrath VL (blade one for this VL is the one for intubations in neonates and younger children up to 2-3 years of age). 

Looking forward to the webinar tomorrow. 

Have a nice day everyone! 

[Stefan Johansson]

Great discussion here, and it was also a very interesting discussion in our live event. See the recording below.

 

[Vicky Payne]

Check out this new podcast from ADC with the authors of the above paper (and others!) related to LMA airway management! This links really nicely to the above webinar ran earlier in the year!