Changes in neonatal airway management practice over time
OA Version
Citation
Abstract
INTRODUCTION: Many studies have found that difficult intubation and multiple attempts at intubation increase the risk of hypoxia, bradycardia, and cardiac arrest. 1 Recent research has shown that video laryngoscopy increases the success rate of first-attempt intubation. 2,3 There is limited data on current practice in neonatal airway management in the era of increased availability of appropriately sized pediatric video laryngoscopy equipment. The aim of this study is to describe airway management practices over time, report on tracheal intubation success on the first attempt, as well as the incidence of difficult intubation (3 or more attempts). We will also describe the incidence of complications including hypoxia, bradycardia, and cardiac arrest during airway management.
METHODS: Following IRB approval with waiver of informed consent, we reviewed all anesthetics in neonates and infants less than 2 months at Boston Children’s Hospital (BCH) from August 2012 to May 2024. A chart review was conducted which included demographic and medical characteristics as well as airway management technique. Data collection included assessment of airway management technique, and in cases of tracheal intubation attempts data collection included the initial technique, number of attempts, success rates, identification of difficult or failed intubation, and the incidence of adverse events. Difficult intubation was defined as 3 or more attempts at intubation. Hypoxemia was defined as 3 or more consecutive Sp02 readings less than 90% of baseline, severe hypoxemia as 3 or more consecutive Sp02 readings less than 80% baseline, and bradycardia as 3 or more consecutive heart rate readings less than 80 beats per minute. To assess changes in practice over time this large cohort was divided into 3 eras: (1) Early VL 2012-2017, (2) Increasing VL availability 2018-2021, and (3) Current 2022-2024.
RESULTS: In this study, 9325 anesthetics were performed in 6069 neonates and infants under the age of two months. The median age was 20 days, with eighteen percent of patients born preterm. Most of the procedures were cardiac surgery and catheterization (39.7%), general surgery (30.3%), and otolaryngology (5.7%). Most of the cases were managed with a tracheal tube (90.5%), with a shift of direct laryngoscopy (DL) to video laryngoscopy (VL) over time. The first attempt success rates increased over time from 76.2% in Era 1 to 84.7 % in Era 2, and in Era 3 (84.8%), (p<0.001). Difficult intubation rates fell from 6.1% in Era 1 to 3.3% in Era 2, and Era 3 (p<0.001).
CONCLUSIONS: Over time, the transition from using direct laryngoscopy (DL) to video laryngoscopy (VL) in neonates and infants, has increased first attempt success rates, reduced the number of intubation attempts, and had a lower incidence of difficult intubations overall.
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2025