Recommendations for older children and adults during endotracheal intubation frequently include the use of free flow oxygen, indeed when I was a fellow with Neil Finer we routinely provided additional free flow oxygen from a catheter placed near the nose, a practice based on data from older subjects. As practices changed with the introduction of routine premedication I didn’t continue the practice, reasoning that intubation with premeds was a lot faster, and that the babies were not breathing anyway. This was probably a mistake. Apnoeic oxygenation is something that is well described in various situations, and I have used it to prevent desaturation during apnoea tests for brain death in the PICU. At the same time the development of readily available high-flow nasal cannulae makes provision of a free gas flow during intubation easier, and probably more effective than just holding an oxygen tube near the baby’s nose.
Studies in adults and older kids have shown that having high-flow cannulae in place during intubation delays desaturation, which is a very common reason for terminating an intubation attempt, and leads to reduction in the number of attempts prior to successful intubation.
Not surprisingly it is the Melbourne group who have taken this to a clinical trial in newborn infants. (Hodgson KA, et al. Nasal High-Flow Therapy during Neonatal Endotracheal Intubation. N Engl J Med. 2022;386(17):1627-37), the Stabilisation with Highflow for Intubation of NEonates, SHINE trial. They randomized 251 intubations (in 202 infants) to either have high-flow nasal cannulae (HFNC) placed prior to intubation, or not. Babies of all gestational ages were eligible, and intubations in the delivery room or the NICU were included, if the intubation was not an emergency.
HFNC were used at a flow rate of 8 litres for all the infants, and used the same oxygen concentration that the baby was already receiving, with the opportunity to increase to 100% if the SpO2 fell below 90%. The primary outcome variable was success on the first attempt, without instability, which was defined as hypoxia (>20% decrease in SpO2) or bradycardia (<100 bpm). Three quarters of the intubations were in the NICU, and most were pre-medicated, with the same protocol that we use in my centre, and which is recommended in several guidelines, atropine, succinylcholine and fentanyl.
As you can see from the primary outcomes, there was a much higher rate of success on first attempt without desaturation or bradycardia, which appears to be mostly because of less desaturation, and there was not any significant occurrence of hyperoxia. You can also see that the biggest gain was among those with less experience, with a dramatic improvement in success, but there is probably an improvement among those with more experience also.
If you have access to the NEJM you can watch a video of a real-life intubation with HFNC, but it really is quite simple, as the image below shows.
There doesn’t to me seem to be any good reason to not implement this widely. There were unfortunately few intubations with a video laryngoscope (only about 8%), which other data show improve success, especially with inexperienced operators. But the two approaches are not in any way exclusive, using HFNC and a video laryngoscope might be the best possible approach, especially for inexperienced intubators, which is now the majority of paediatric trainees! Now that we intubate very few meconium stained babies, we try to maintain as many babies as possible on non-invasive ventilation, and we have a tiny baby intubation team, there are few opportunities for trainees to intubate real babies. Simulation training is vital in providing initial training, but making intubation safer for real babies when it becomes necessary, and ensuring that paediatricians in training develop the expertise needed are all important.
This new publication, and the technique that it shows is safe, effective, and simple, is a big advance for neonatal intensive care.