EBNEO COMMENTARY: VIDEO VERSUS DIRECT LARYNGOSCOPY FOR URGENT INTUBATION OF NEWBORN INFANTS

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ACTA COMMENTARY:

Acta Paediatrica - 2025 - Neches - EBNEO Commentary Video Versus Direct Laryngoscopy for Urgent Intubation of Newborn.pdf

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.