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How to Successfully Intubate a Neonate on the First Attempt

June 3, 2024

Written by Aaron Lacy

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In this RCT, successful intubation on the first attempt in critically ill neonates was much higher in patients when video laryngoscopy (VL) was used compared to direct laryngoscopy (DL).

Give your neonate more than a coin flip’s chance
In this single center RCT, 214 neonates requiring urgent intubation in either the NICU or delivery suite were randomized to intubation via VL (Miller style blade) or DL. Those randomized to intubation via VL were substantially more likely to be successfully intubated on the first attempt (79/107; 74%, 95%CI 66-82) compared to DL (48/107; 45%, 95%CI 35-54) (p<0.001). There was no statistically significant difference in hypoxemia or bradycardia noted between groups.

While 45% success in the DL groups sounds concerningly low, this number is consistent with prior registry (NEAR4NEOS) data. Notably, 94% of airway attempts in this study were initially done by a resident or fellow. This could limit generalizability to an experienced neonatologist who is proficient in DL. However, in general, the results are compelling. VL has been shown to substantially increase first attempt success in the ED and ICU, the operating room, the prehospital setting, and now in another population. I think everyone would agree 45% success is not good enough, and if you want to give your smallest patients the best shot at a successful intubation, you should strongly consider VL.

How will this change my practice?
I infrequently intubate neonates and am a firm believer that VL is superior to DL. This research only affirms that if faced with a situation that requires urgent airway management in a neonate, I would be reaching for VL. Given the alarmingly low rates of first attempt success in this patient population, I will be encouraging others to do the same.

Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. NEJM. 2024 May 5. Online ahead of print. DOI: 10.1056/NEJMoa2402785

What are your thoughts?