Two recent randomized trials, one from our group, and another one from Melbourne have evaluate the role of the videolaryngoscope (VL) in teaching trainees in neonatology to perform endotracheal intubations. The two trials are structured differently and tell us different things about the use of the VL in teaching.
The first, from the Melbourne group, (O’Shea JE, et al. Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial. Pediatrics. 2015;136(5):912-9) used the VL for all intubations, but covered the screen in a randomly selected half of the intubations. Just over 200 intubations were randomized, and there were 36 residents with less than 6 months NICU experience who performed them. During the intubation the residents were supervised, therefore during the study many of the residents were accumulating some experience, however there were 42 intubations performed by residents with no previous successful intubations, (so residents who failed an intubation were counted in that group each time they attempted until they got one) most of the residents therefore had very little experience in intubation. Residents had simulation training before attempting intubation of a real baby, and intubations in the delivery room or in the NICU were eligible.
Intubations were supervised using a fairly standardized script by a group of more senior people who could guide the intubation, and identify the structures for the residents during the procedure when the screen was uncovered, or just give tips about technique when it was covered. Each intubation was individually randomized, so a resident could potentially have several covered (or uncovered) intubations in a row.
The primary outcome was success during the first attempt at intubation. (I’m not sure what happened for subsequent attempts when the first failed, if the resident might try again or if someone else then took over.)
Intubations with the screen visible were much more likely to be successful on the first attempt than those with the screen covered (66% vs 41%), this was particularly so for premedicated intubations in the NICU, (72% vs 44%). In the delivery room the subgroup analysis was no longer statistically significant, but remained better for the uncovered group, 50% vs 30%. The duration of the intubations was the same and the number of babies desaturating was similar. Interestingly the first attempt at intubation averaged over 50 seconds duration, but was no different between groups. As the residents gained experience in intubating there was no improvement in success rate for the intubations with covered screen, but the uncovered, screen visible intubations became more and more likely to be successful at the first attempt.
In the other study, from our expert in pedagogical research, Ahmed Moussa and a group of colleagues at our institution (Moussa A, et al. Videolaryngoscope for Teaching Neonatal Endotracheal Intubation: A Randomized Controlled Trial. Pediatrics. 2016;137(3):1-8.) it was the residents who were randomized, not the intubations. So a resident with little prior experience of intubation was randomized, after the initial simulation training in the simulation center, to intubate either with the videolaryngoscope (this group had some extra training in the use of the VL, but no extra training in how to intubate) or a standard laryngoscope. Most of the residents had not previously intubated a neonate, although some of them did have a few prior attempts, and only intubations in the NICU were included. All of the resident were supervised by an attending or a fellow, many of the intubations were nasotracheal, about 70% (especially for the larger babies, that remains our standard in the NICU, if the tube cannot be passed easily through the nose then orotracheal intubation is performed) and 100% of the intubations were premedicated with atropine, fentanyl and succinylcholine.
The study was performed before we introduced our tiny baby intubation team, which I have mentioned here previously, so some of the babies being intubated were very immature, the median gestation was 29 weeks. The overall success of the intubation attempt was significantly higher with the VL than with a conventional laryngoscope, 75% compared to 63%, and the majority of the intubations were successful on the first attempt. Residents were allowed up to 3 attempts, if the baby is tolerating the procedure well, and the intubation was considered a success if the resident was able to insert the tube in those 3 attempts. By the 7th intubation the residents randomized to the VL were successful over 90% of the time.
What Ahmed had thought when designing the study is that most of our residents, after graduation, will be covering delivery rooms, and neonatal nurseries in level 2 centers, where they won’t necessarily have access to a VL, so he wanted to ensure that if you learnt how to intubate with the VL, you could still intubate with a conventional device; The second phase of the study was that all residents intubated with a standard laryngoscope, the success rate of the VL residents dropped a little, but was not statistically different from the conventional group who continued to do their intubations with the standard device. He didn’t get as many intubations in phase 2 as he wanted, because the residents graduated from the program, which was very ungrateful of them. Therefore the power of the 2nd phase of the study was not as good as he had wanted.
Of note the intubations were initially a bit longer with the VL, frequently the supervisor was able to redirect the resident to the cords and get the tube in, but that took up a few extra seconds. The median duration of the attempt (from insertion to removal of the blade from the mouth) ended up about 50 to 60 seconds after the first few trials.
The VL used in the 2 studies was not the same. In our hospital the Storz device was used, in Melbourne they chose the Laryflex. In the study from Montreal there were a few of the VL babies where the blade was felt to be too big, which wasn’t mentioned by the Melbourne group. The minor differences in blade design might be important for the tiniest babies.
It certainly looks like this is a great way to teach people how to intubate, I think it should become the standard for teaching, based on these data. If we can train residents to intubate with simulations, followed by more stable babies at lower risk of complications using the VL, then when they have proven they are competent they can proceed to intubation of more high-risk infants. It is a skill that many of them will need when they are out in practice, for those who need to be competent for future babies, ensuring that they are capable of intubating by the time they leave residency is an on-going struggle.