Indirect Versus Direct Laryngoscopy for the Endotracheal Intubation of Newborn Infants

Intubation is an essential yet difficult skill to learn. Repeated attempts at intubation pose risks to newborn infants. Fewer than half of first attempts at intubation are successful when using a standard laryngoscope and looking directly into the mouth. Videolaryngoscopes that display the view of the airway acquired by a camera at the tip of the blade on a screen (indirect laryngoscopy) have become available. These offer an indirect, magnified view of the airway that can be shared on a screen and have the potential to improve intubation outcomes for infants. First attempt success rates are higher with ideolaryngoscopy during elective and emergency intubation in adults, and during elective intubation in children. Evidence for videolaryngoscopy in neonates shows it is a useful tool for learning intubation by inexperienced intubators and may improve outcomes and reduce harm. Using mannequins, I first performed a pre-clinical randomised crossover study of indirect laryngoscopy with two videolaryngoscopes, compared with direct laryngoscopy with a standard laryngoscope. The aim was to assess the intubation success rates of clinicians in preterm and term mannequins and identify their preferences of device for use in clinical practice. I identified an increased rate of success at first attempt and faster intubation times with the C-MAC videolaryngoscope compared to both Acutronic videolaryngoscope and standard laryngoscope and found that found the C-MAC videolaryngoscope was the preferred videolaryngoscope in our tertiary level hospital. I subsequently conducted a parallel group randomised controlled trial of indirect laryngoscopy with C-MAC videolaryngosope or direct laryngoscopy with standard laryngoscope for endotracheal intubation of newborns. I discovered clinicians successfully intubated newborns at the first attempt more often when they performed indirect laryngoscopy with a videolaryngoscope compared to direct laryngoscopy with a standard laryngoscope, P<0.001. My findings have potential implications for the care of neonates in the hospital setting worldwide.