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Summary: Nasal High-Flow Therapy during Neonatal Endotracheal Intubation.
Topic: Intubation
Hodgson KA, Owen, LS, C. Omar F, et al. Nasal High-Flow Therapy during Neonatal Endotracheal Intubation. N Engl J Med 2022; 386:1627-1637
Hodgson and colleagues published the results of a randomized, controlled trial, “Nasal High-Flow Therapy during Neonatal Endotracheal Intubation,” in the New England Journal of Medicine comparing nasal high-flow therapy, conducted exclusively with Vapotherm high velocity therapy, with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. In this study, the researchers sought to determine if nasal high-flow therapy, which may extend the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt.
Hodgson and colleagues included 251 intubations in 202 infants; 124 intubations were assigned to the high velocity group and 127 to the standard-care group with infants in both groups sharing similar baseline demographic and clinical characteristics. Multiple intubations per infant were included so long as they could be considered independent events. The infants had a median gestational age of 27.9 weeks and a median weight of 920 g at the time of intubation. The primary outcome was successful intubation on the first attempt without physiological instability in the baby. The authors defined physiological instability as desaturation of more than 20% or bradycardia with a heart rate of <100 beats per minute. The intubations were recorded on video for data accuracy and interpretational bias reduction.
The study results demonstrated that successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high velocity therapy group and in 40 of 127 intubations (31.5%) in the standard-care group. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high velocity therapy group and in 54.3% of the intubations in the standard-care group. Subgroup analyses showed that the effect on the likelihood of success was larger in physicians who have less experience with neonatal intubations.
The researchers note several limitations with the trial. First, the treatment assignments were not concealed. However, to limit bias, outcomes were determined through video review objective outcome criteria, and the findings with respect to the primary outcome were corroborated by an independent reviewer. The researchers did not collect information on race or ethnic group, but the participants appeared to be representative of neonates who undergo intubation at birth, in terms of sex and gestational age at birth. In addition, the study randomly assigned intubation episodes, rather than infants, however, sensitivity analysis showed that the results for the primary outcome were consistent after adjustment for repeat randomization events in individual infants.
The results of this trial involving neonates and the use of high velocity therapy during oral endotracheal intubation led to a greater likelihood of successful intubation on the first attempt without physiological instability in the infant.
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