Time to desaturation in preterm infants undergoing endotracheal intubation

Abstract

BackgroundNeonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU.MethodsObservational study at The Royal Women’s Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks’ postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%).ResultsSeventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26–29) weeks and birth weight 946 (773–1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14–32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24–44) s and to desaturation <60% was 56 (42–68) s. No episodes of bradycardia were seen.ConclusionsThis is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation.Trial registration numberACTRN12614000709640

Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial

“…In response to this, many strategies have been employed to try and either reduce the need for intubation,21–23 provide greater stability medically during the procedure24 25 or improve education and therefore proficiency of the intubator 26–36. Despite these strategies, intubation remains a problem and by comparison to adult studies our population show high rates of physiological instability and adverse events 5 37–40…”

“…Neonatal intubation is often associated with repeated attempts and is often associated with physiological instability 4. Hypoxia (as defined by SpO 2 of <90%) has been reported in up to 94% of infants during intubation, particularly those who are preterm 5. The recently completed SHINE trial has shown NHF was associated with increased success rates on first intubation attempt 6.…”

“…4 Hypoxia (as defined by SpO 2 of <90%) has been reported in up to 94% of infants during intubation, particularly those who are preterm. 5 The recently completed SHINE trial has shown NHF was associated with increased success rates on first intubation attempt. 6 Our objective was to determine whether apnoeic oxygenation with NHF 7 would reduce the duration of hypoxia in neonates undergoing intubation.…”

Implementation of a Standardized Premedication Bundle to Improve Procedure Success for Nonemergent Neonatal Intubations

“…Additional considerations that may account for the rise in hypoxemia include masking hypoxemic bradycardia with atropine, and hypoventilation-induced hypoxemia with paralytic use. 29 , 30 Our protocol attempted to minimize these causes by limiting views to 30 seconds. 29 , 31 Of note, a recent randomized control trial using a high-flow nasal cannula offers a potential intervention to reduce hypoxemia.…”

“… 29 , 30 Our protocol attempted to minimize these causes by limiting views to 30 seconds. 29 , 31 Of note, a recent randomized control trial using a high-flow nasal cannula offers a potential intervention to reduce hypoxemia. 32 …”