To coincide with their presentation at the Pediatric Academic Societies meeting in Toronto, the paper reporting the results of the VODE (Video Or Direct laryngoscopy for Endotracheal intubation in newborns) trial has been published today in the New England Journal of Medicine (NEJM). This randomised trial performed at the National Maternity Hospital (NMH) demonstrated that videolaryngoscopy resulted in greater success at first intubation attempt than direct laryngoscopy for urgent intubation of newborn infants.
Endotracheal intubation is a difficult skill to learn and maintain. Adults and children are most often electively intubated by anaesthesiologists for surgical procedures in the operating room. In contrast, neonates are most often urgently intubated by neonatologists or paediatricians for resuscitation or for respiratory failure in the delivery room (DR) or in the neonatal intensive care unit (NICU). When clinicians view the airway in newborns directly with a laryngoscope (direct laryngoscopy, DL), fewer than half of first attempts succeed. Repeated intubation attempts are associated with increased adverse events in neonates. Videolaryngoscopes (VL) use a camera at the tip of the blade to display a view of the airway on a screen, and lead to greater first attempt success in adults and children. The team wished to determine whether VL resulted in greater success at first attempt at urgent oral endotracheal intubation in neonates.
The study was co-ordinated by lead author Dr Lucy Geraghty and performed with colleagues from NMH, UCD School of Medicine and the UCD Centre for Support and Training (CSTAR) within UCD School of Public Health, Physiotherapy and Sports Science, under the supervision of Professor Colm O’Donnell, Consultant Neonatologist at NMH and UCD School of Medicine. Dr Geraghty performed the research while working as the UCD Special Lecturer in Neonatology at the NMH, which formed the central part of the thesis that she submitted for the Degree of Doctorate of Medicine at UCD.
Dr Geraghty highlights the significance of the research, saying, ‘‘It is a proud day for our team to see the results of this work published in such a wide-reaching peer-reviewed medical journal, so that our findings can hopefully benefit neonatal patients all over the world. Intubation is a procedure that is risky for babies and the aim of our research was to try to improve that. We discovered that using videolarynogscopy makes it more likely that newborn babies will be successfully intubated at the first attempt than the traditional method.
I am personally so proud of the work of our team and grateful to our supportive colleagues in NMH and UCD. I’m especially thankful to the families who participated in the trial, recognising the importance of high-quality research trials in informing the evidence-based medical care of newborn infants.’’
In this single centre trial, neonates of any gestational age (GA) undergoing intubation in the delivery room (DR) or neonatal intensive care unit (NICU) were randomly assigned to VL or DL, stratified by GA (<32 and ≥32 weeks’ gestation). The primary outcome was success at first intubation attempt determined by exhaled carbon dioxide detector.
The team enrolled 226 neonates and analysed data for 214, 63 (29%) of whom were intubated in DR and 151 (71%) in NICU. Success at the first intubation attempt occurred in 79/107 (73.8%, 95%CI [Confidence interval] 65.5 – 82.2) of neonates in the VL group and in 48/107 (44.9%, 95%CI 35.4 – 54.3) in the DL group (P <0.001). The median (95% CI) number of attempts taken to intubate was 1 (1-1) in the VL group and 2 (1-2) in the DL group. The median lowest oxygen saturation during intubation was 73.5% (95% CI, 65-78) in the VL group and 68% (62-74) in the DL group; the lowest heart rate was 153 beats per minute (148-158) and 148 (140-156), respectively.
Corresponding author from UCD School of Medicine, Professor Colm O’Donnell, points out the importance of these results, stating, ‘‘We found that many more babies were intubated at the first attempt with the videolaryngoscope than with direct laryngoscopy. This is important information for clinicians who care for newborn babies around the world. It suggests that videolaryngoscopy should be the standard of care and is likely to change treatment recommendations. However, videolaryngoscopes are considerably more expensive than standard laryngoscopes, so this will have resource implications, particularly in low and middle-income countries.’’
The paper can be found on the NEJM website here.
Author information:
Lucy E. Geraghty MB,1, 2
Emma A. Dunne MB PhD,1
Caitríona M. Ní Chathasaigh MB,1, 2
Akke Vellinga PhD,3
Niamh C. Adams MB,4
Eoin M. O’ Currain MB PhD,1, 2
Lisa K. McCarthy MB PhD,1, 2
Colm P.F. O’Donnell MB PhD 1, 2
1. Department of Neonatology, National Maternity Hospital, Dublin, Ireland
2. School of Medicine, University College Dublin, Ireland
3. Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland.
4. Department of Radiology, National Maternity Hospital, Dublin, Ireland