Perth researchers who were involved in an international study which examined two different techniques used to intubate newborns and young babies during surgery expect the findings to lead to a change in global practice.
The study, led by the OPTIMISE Collaboration featuring researchers from Australia, Italy, Canada, Switzerland and the United States, found video laryngoscopy combined with oxygen supplementation should be the technique of choice when seeking to insert a breathing tube during surgery on newborns and babies under the age of 12 months.
Babies in these age groups are at high risk of hypoxemia – low oxygen levels – during surgery. Tracheal intubation, or the insertion of a breathing tube, can be a life-saving procedure in these settings but can be difficult to achieve at the first attempt, with the risk of hypoxemia increasing as the number of attempts increases.
Anaesthetists use laryngoscopy, which allows them to see the vocal cords, to help guide intubation, but the evidence has been unclear as to whether video laryngoscopy (using a camera that provides a magnified image of the airway) or direct laryngoscopy (allowing direct visualisation of the vocal cords) is the better method for neonates and children younger than 12 months.
In findings published last month in the Lancet Child and Adolescent Health, researchers including paediatric consultant anaesthetists Professor Britta Regli-von Ungern-Sternberg and Associate Professor David Sommerfield – from The Kids Research Institute Australia, Perth Children’s Hospital and The University of Western Australia – found the use of video laryngoscopy with oxygen increased the success rate of first-attempt tracheal intubation in anaesthetised babies compared to direct laryngoscopy with oxygen.
Professor Regli-von Ungern-Sternberg led the Australian arm of the randomised controlled trial, where Perth Children’s Hospital was the only Australian site, and was also involved in the global steering committee for the study.
“Intubation can be life-saving and it is critical to intubate successfully at the first attempt,” Professor Regli-von Ungern-Sternberg said.
“The more attempts we undertake, the higher the incidence of life-threatening complications, so it’s really important that we get it right the first time. One of the things that can make it difficult to achieve intubation on the first attempt is differences in each child’s anatomy. The more clearly we can see what we are doing, the better the chances of successful intubation.”
Professor Regli-von Ungern-Sternberg said despite the increasing use of video laryngoscopy, no trials had yet compared successful intubation rates between direct and video laryngoscopy in babies.
“Given our goal is constantly to improve the safety of surgery and anaesthesia for babies and children, it is vital that we ensure we are working with the very latest evidence as to what works most effectively and ensures the best outcomes,” she said.
The study recruited 250 babies aged under 12 months from seven hospitals across Australia, Canada, Italy, Switzerland and the United States, between October 2020 and March 2022, and compared success rates between the two methods.
“Our results showed the first-attempt tracheal intubation success rate with no desaturation in oxygen levels was higher with video laryngoscopy (89.3%) compared to direct laryngoscopy (78.9%),” Professor Regli-von Ungern-Sternberg said.
“We conclude that video laryngoscopy with oxygen should be considered as the technique of choice when newborns and young babies are intubated.”
She said the trial added important new evidence to guide the intubation of babies.
“We expect the combination of video laryngoscopy and supplemental oxygen will become the go-to option for these vulnerable children.”
Associate Professor Sommerfield said tracheal intubation in neonates was technically difficult even for the experienced paediatric anaesthetist.
“This research will improve intubation safety in babies and will be particularly helpful for non-paediatric specialists who perform many of these procedures around the world,” he said.
- Professor Regli-von Ungern Sternberg is Chair of Paediatric Anaesthesia at The University of Western Australian, Consultant Paediatric Anaesthetist at Perth Children’s Hospital, and Head of the Perioperative Medicine Team at The Kids Research Institute Australia.
- The study – Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial – was funded by the Swiss Pediatric Anaesthesia Society, the Swiss Society for Anaesthesia and Perioperative Medicine, the Foundation for Research in Anaesthesiology and Intensive Care Medicine, the Channel 7 Telethon Trust, the Stan Perron Charitable Foundation, and Australia’s National Health and Medical Research Council.