Successful tracheal intubation in neonates and young children is an elementary procedure in the operating room with only limited data available to inform best practice and subsequent outcomes. The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) study of the European Society of Anaesthesiology and Intensive Care (ESAIC) Clinical Trial Network has provided new important information on the incidence of interventions in response to critical events in neonates and infants.1,2 This large prospective observational study reported data from more than 5500 patients and indicated a very high (5.8%) incidence of difficult intubation. Although the vast majority of these children with a difficult intubation were successfully intubated within three attempts (97%), severe desaturation and/or bradycardia occurred in six out of 10 of them. Reassuringly, subsequent propensity score analysis showed that the difficult intubation event per se did not lead to an increase in postanaesthesia morbidity and mortality at 30 and 90 days.
The reported high incidence of difficult intubation in the NECTARINE cohort may be the consequence of the definition adopted in the study: ‘two failed attempts by direct laryngoscopy and/or the need of specific intervention’. Unfortunately, this extended definition makes a direct comparison to other published data focussing solely on the number of attempts in older children very difficult3 and, therefore, this high incidence needs to be considered within the clinical context. In addition, neonates and infants are prone to rapid desaturation, which is likely to further explain the high number of multiple laryngoscopy attempts. Despite an adequate laryngeal view, clinicians may have decided to interrupt tracheal intubation and to re-start face-mask oxygenation and ventilation before initiating a new attempt, especially in a training environment. This frequently occurs during neonatal intubation.4
To improve the overall success rate of tracheal intubation, and hence significantly reduce the associated overall peri-operative risk, several solutions could be considered. First, clinical acumen and early identification of the hallmarks of difficult airway management such as micrognathia, macroglossia, hypoplastic midface or facial asymmetry (ears!) is a critical step. Second, use videolaryngoscopy! Due to reduced working hours and changes in clinical practice, occasions to acquire technical skills related to laryngoscopy are becoming scarce, and consequently also the teaching opportunities, especially when patients are critically ill. So, why is direct laryngoscopy still the initial widely practiced technique of choice for intubation despite recent data showing that video-laryngoscopy increases the chance of first-attempt tracheal intubation, especially in patients younger than one year?5 NECTARINE reported that video-laryngoscopy was used as a rescue technique in 13% of cases partially due to the lack of technology available in many of the participating centres as well as the lack of adequate training for new devices.6 Third, systematic use of oxygen before laryngoscopy or perhaps, even better, during the whole procedure with continuous high or low flow nasal cannulae, is known to improve oxygenation during prolonged apnea time and significantly increases the success at first attempt even in less experienced hands. This appears to be a logical option.
Although not explicitly reported in NECTARINE or other recent cohort studies, human factors are increasingly recognised in airway management, especially when difficulties, either expected or unexpected, occur. Tracheal intubation for medical or surgical indications in very young patients should always be performed by experienced physicians and, after hours, by the most experienced available person on call.
So, who is the expert? Physicians involved in tracheal intubation do come from different specialties: anaesthesia, neonatology, emergency medicine and intensive care medicine. They all are expected to, or have been taught to perform tracheal intubation for various indications. Invariably, the number of tracheal intubations each of them is exposed to on an annual basis differs according to the caseload of the hospital and local policies. As children are less likely to require tracheal intubation when compared with adults, centralisation of expertise is crucial to achieving a sufficient caseload and subsequent exposure to achieve and maintain such expertise. The principal factor here is the number of tracheal intubations performed by each physician per year.
Providing optimal intubation conditions will also contribute to success and minimise morbidity. Neonates are frequently affected by comorbidities and if not delicately managed, short and long-term sequelae may arise.7 Hence, patients must be adequately sedated, or anaesthetised and paralysed as appropriate. These clinicians must possess deep understanding of the pharmacology and physiology of very young patients and be familiar with and proficient in the use of alternative techniques and available devices. Finally, support and access to other specialties should always be readily available, for example an expert otolaryngologist capable of performing emergency tracheostomy or an ECMO team if severe cardiorespiratory failure is anticipated.
Psychological factors can affect difficult intubation scenarios. For example, ‘task fixation’ can happen when a child is difficult to intubate and the senior physician in charge continues performing multiple attempts without taking into consideration the opportunity to switch to another technique or call for help. The vortex approach has been advocated to reduce the risk of persisting with the same failing procedure when it occurs (www.vortexapproach.org). Similarly, a team leader can enter into a state of fear of ‘losing acclaim’: such fear of losing credibility within the team can be very risky for the patients. Awaking the child and postponing the procedure may, on occasion, be the best choice for the child. For the safety of the patient, the ‘Stop, Think, Communicate’ approach should always be applied in the case of multiple attempts
Finally, commitment to continuing education and training is required to raise the standard of airway management in the very young child. A paediatric anaesthesia diploma is one potential solution, as training includes a dedicated curriculum for airway management. In both paediatric anaesthesia and airway management, technical and nontechnical skill are required. The competency-based curriculum of the paediatric anaesthesia diploma will enhance the skills of those doctors who are involved in treating children, especially very young children. An inter-specialty exchange of knowledge should be implemented, including the development of clear and well defined algorithms aimed at guiding clinicians to undertake the correct pathway especially in the case of unexpected difficult situations. Ideally, this can be practiced, supervised and accomplished in a low intensity and controlled environment with low-risk patients and surgeries. Anaesthesiologists who wish to work in a paediatric environment should be required to have recognised paediatric anaesthesia training, which includes an airway management curriculum, and who are committed to ongoing education and training. Paediatric anaesthesiologists will then have a prominent role in teaching airway management to nonanaesthesiologists. Defining the who, where, what, when and how remains at the core of improving skills and reducing morbidity (www.safetots.org).
Neonatal airway management and tracheal intubation is still an art, but with emerging data, an evidence-based practice should soon be within our reach.
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Conflicts of interest: ND and TE declare no conflicts of interest. TGH is a Deputy Editor of the EJA.
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