Towards better and safer intubation

We are the victims of our own success.  Over the last decade, the approach to respiratory support of the newborn with respiratory distress has tiled heavily towards non-invasive support with CPAP.  In our own units when we look at our year over year rates of ventilation hours they are decreasing and those for CPAP dramatically increasing.  Make no mistake about it, this is a good thing.  Seeming to overlap this trend is a large increase in demand by learners as we see the numbers of residents, subspecialty trainees, nurse practitioners on the rise.  The combined effect is a reduction is the experience trainees can possibly hope to obtain when these rarer and rarer opportunities arise.  The result of all of this is that at least by my eyes (although we haven’t documented it) the number of attempts for intubations seems to be much higher than it once was.  It is not uncommon to see 3-4 attempts or sometimes more whereas in days gone by 1-2 attempts was the norm.  We do our best to deal with these shortages using simulation as an example but nothing quite compares to dealing with the real thing even if it comes close.

The Less Practice You Get The More Adverse Events You Can Expect

This is just the way it is.  Perfect practice makes perfect and it has been well documented that intubations can lead to many complications such as desaturation, bradycardia, bleeding, airway edema from multiple attempts and a host of other issues.  Hatch and colleagues first described their experience with 162 intubations in which they found adverse events in 107 (39%) with 35% being classified as non-severe and severe events in 8.8%.  Not surprisingly one of the factors associated with adverse events was the need for multiple intubation attempts.  Based on this initial experience they determined that as a unit they could do better and soon after undertook a series of PDSA Quality Improvement cycles to see if they could reduce these events and that they did.  What follows are the lessons learned from their QI project and it is my hope that some or all of these ideas may help others elsewhere who are experiencing similar frustrating rates.

Steps To A Better Intubation

The findings of their QI study were published last month in Pediatrics in their paper Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit.  The strategies they used were threefold.

  1. Standardized checklist before intubation – This used a “do-confirm” approach in which the individuals on the team “do” what they need to prepare and then confirm with the group that they are done.  An example might be an RRT who states “I have three sizes of ETT ready with a stylet already inserted, surfactant is thawed and the ventilator is set with settings of … if needed etc”.  Another critical part of the checklist includes ensuring that everyone knows in advance their roles and who is responsible for what.
  2. Premedication algorithm – Prior to this project the use of premedication was inconsistent, drug selection was highly varied and muscle relaxation was almost non-existent.  The team identified from the literature that a standard approach to premedication had been associated with reductions in adverse events in other centres so adopted the same here using fentanyl with atropine if preterm and muscle relaxation optional.
  3. Computerized order set for intubation – interestingly the order set included prompts to nursing to make sure intervention 1 and 2 were done as well.

The results of there before and after comparison were numerous but I have summarized some of the more important findings in the table below.

Outcome Period 1 (273 intubations) Period 2 (236 intubations) p
Any AE 46.2% 36.0% 0.02
Severe events 8.8% 6.4% 0.04
Bradycardia 24.2% 9.3% <0.001
Hypoxemia 44.3% 33.1% 0.006
Esophageal intubation 21.3% 14.4% 0.05
# attempts 2 2 NS
<10 intubations experience 15.1% 25.5% 0.001

The median number of attempts were no different but the level of experience in the second epoch was less.  One would expect with less experienced intubators this would predict higher risk for adverse events.  What was seen though was a statistically significant reduction in many important outcomes as listed in the table.  I can only speculate what the results might have been if the experience of the intubators was similar in the first and second periods but I suspect the results would have been even more impressive.  The results seem even more impressive in fact when you factor in that the checklist was used despite all of the education and order set 73% of the time and muscle relaxation was hardly used at all.  I believe though what can be taken out of these results is that taking the time to plan each intubation and having a standard approach so that all staff practice in the same way reaps benefits.  If you already do this in your unit then congratulations but if you don’t then perhaps this may be of use to you!

What About Intubation For INSURE?

We are in the process of looking in our own centre at the utility of providing premedication when planning to give surfactant via the INSURE technique.  I couldn’t help but notice that this paper also looked at that very issue.  Their findings in 17 patients all of whom were provided premedication were that only one could not be extubated right after surfactant.  The one who was not extubated however was kept intubated for several hours without any reasoning provided in the records so it may well be that the infant could have been electively kept ventilated when they may have indeed been ready for extubation.  The lesson here though is that we likely do not need to exclude such patients from premedication it will reduce the likelihood of complications without prolonging the time receiving positive pressure ventilation.

Whatever your thoughts may be at this time one of the first questions you should ask is what is our local rate of complications?  If you don’t know then do an audit and find out.  Whatever the result, shouldn’t we all strive to lower that number if we can?

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2 thoughts on “Towards better and safer intubation

  1. The decrease in intubation experience has led to the change in NRP for meconium deliveries. As a very experienced intubator, I believe it is still better to intubate an apneic child with meconium stained fluid and remove meconium from the airway than bagging the meconium into the lungs and promoting lung inflammation. The answer is to improve intubation skills of those providing NRP, not lessen resuscitation requirements.

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  2. Agreed, but I would never sanction routine use of a stiff unforgiving and proven damaging stylet. This is for the difficult airway box and not routine practice. These tissues are simply too delicate for such a device. It’s kinder and actually easier without.

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