Background Adults and children are most often intubated by anesthetists in controlled conditions.
In contrast, newborn intubations are performed by neonatologists and paediatricians,
in urgent circumstances within the NICU and delivery room (DR). Neonatal intubation
is a difficult skill to learn and maintain, involving correctly identifying airway
anatomy. Success rates, in NICU and DR are around 50% using direct laryngoscopy (DL),
with a lower success rate in junior intubators. Video laryngoscopy (VL) uses a camera
on the tip of blade, allowing real time images to be displayed on screen, with this
coaching and technique adjustment can be done. A lower number of intubation opportunities
has been seen in recent years, making it difficult to achieve proficiency, anesthetic
literature suggests that over 40 intubations are necessary for this. A recent Cochrane
review4 included studies where intubations were attempted by anesthetists in operating
theatres, where success rates are higher. VL is increasingly used in paediatric and
adult practice.
Objective To compare of the efficacy and safety of VL and DL, for intubation of neonates within
NICU and DR.
Design/Methods We searched CENTRAL, MEDLINE, EMBASE and CINAHL databases, for randomised and quasi-randomised
trials that compared VL to DL in neonates, up to August 2024. We excluded studies
conducted in the operating theatre. We used Cochrane methodology and RevMan. We extracted
and analysed data from the eligible studies and assessed their risk of bias [1]
[2]
[3]
[4]
[5]
[6]
[7].
Results Six studies (O'Shea 2015, Moussa 2016, Volz 2018, Bartle 2019, Tippman 2023
and Geraghty 2024) met our inclusion criteria, with a combined total of 863 intubations.
Success at first intubation attempt was reported in four studies. VL increased first
pass success rate compared to DL (RR 1.46, 95% CI 1.27-1.68), with NNT 6. An increase
in overall success rate, was shown to be statistically significant by Volz and Moussa
(VL 57% vs DL 33% p<0.05 and VL 75% vs DL 63% p 0.03). There was no difference in
the incidence of desaturation or bradycardia and mucosal trauma was similar between
the VL and DL groups. Subgroup analysis showed an increased first pass success rate
in trainees (RR 1.5, 95% CI 1.3-1.74), with NNT 5.
Conclusion(s) The use of VL in NICU and DR, produces a significant improvement in first pass success
rate for neonatal intubation, without an increase in adverse events. A significant
increase in first pass success rates in trainees was also found. VL should be the
standard of care for neonatal intubation, including in inexperienced intubators.
