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Abstract
Introduction Neonatal intubation is a challenging skill to acquire. A randomised controlled trial (RCT) found junior trainees had higher intubation success rates if their supervisor shared their airway view on a videolaryngoscope screen compared with intubations where the supervisor could not see the videolaryngoscope screen. The intubations in the trial were supervised by a group of experienced neonatologists who developed an intubation teaching package that aimed to be informative, consistent and supportive. We surveyed the trainees to assess their experiences of the intubation attempts.
Methods Trainees participating in the RCT completed questionnaires anonymously after each intubation attempt. Questionnaires used 5-point Likert scales and free comment sections. Quantitative analysis was performed using descriptive statistics. In a qualitative analysis, free comments were coded to identify central recurring themes.
Results Two hundred and six questionnaires were completed by 36 trainees. The majority reported that the guidance received during intubation was helpful, the postprocedure feedback was educational and their confidence levels were increased. Trainees appreciated a controlled environment and calm, consistent guidance. They found intubations in the delivery room, those involving unstable infants, large audiences and parental presence more stressful. Responses were positive whether the videolaryngoscope screen was visible or covered, emphasising the importance of consistent guidance. Overall, 16% of intubations were reported as intimidating.
Conclusion The shared airway view offered by videolaryngoscopy was well received. In addition, taking measures to control the setting, with standardised guidance and feedback, improved confidence and created a more positive learning experience.
- neonatology
- resuscitation
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What is already known on this topic?
Opportunities to gain neonatal intubation experience are becoming less frequent.
Intubation success rates for junior and middle-grade trainees are low and falling.
Videolaryngoscopy is an effective aid when teaching the essential skill of neonatal intubation.
What this study adds?
Provides the trainee perspective on the use of videolaryngoscopy for learning neonatal intubation.
Identifies modifiable environmental factors that alter trainee stress during early intubation experiences.
Highlights the need for standardised training packages that can be used to teach practical neonatal skills.
Introduction
Endotracheal intubation is frequently and unpredictably required for sick infants at birth and on the neonatal unit.1 It is a mandatory competency for paediatric trainees,2 but one that is increasingly challenging to master. Successful intubation relies on the intubator obtaining a view of the infant’s airway using laryngoscopy, recognising important anatomical landmarks and correctly placing an endotracheal tube. Many inexperienced intubators find this stressful and difficult.
Recently we have seen changes in the respiratory management of preterm infants, such as increasing reliance on non-invasive respiratory support and the rising evidence base for the use of less invasive surfactant administration techniques. These changes, coupled with increasing numbers of paediatric trainees and neonatal nurse practitioners, have resulted in a dramatic reduction in the number of intubation opportunities per trainee and subsequently falling success rates at both junior and middle-grade levels.3 A recent study of greater than 2000 intubations from 10 neonatal units worldwide found first attempt intubation success rates of less than 50% for all trainee grades and just 24% for junior trainees.4
There is little evidence to guide clinicians on how best to achieve competence in this complex psychomotor skill, often performed in high-stress situations. Options to overcome the lack of opportunity to practise are limited. Simulation is commonly employed using anatomically correct manikins as teaching aids; however, studies using simulation have not demonstrated improved clinical performance.5 Videolaryngoscopy allows the supervisor and trainee to share the airway view during intubation,6 although it is not routinely included in neonatal simulation training. In addition, developing situational awareness during high-risk procedures is often neglected when a new practical skill is being taught.
A randomised controlled trial (RCT) exploring videolaryngoscopy for teaching neonatal intubation to junior trainees (less than 6 months neonatal experience) found success rates of inexperienced trainees to be higher when their supervisor could share the airway view on a videolaryngoscope screen, compared with intubations where the supervisor could not see the videolaryngoscope screen.7 To minimise differences between the video screen visible (intervention) and video screen covered (control) groups, guidance given to trainees during the attempts was standardised, with all supervisors using the same proforma. This is described in detail in the original publication of the RCT.7 It included standardised equipment preparation, positioning of the infant, guidance given during intubation, criteria for ceasing intubation attempts and structured feedback. The guidance was not scripted and will have varied between supervisors, but efforts were made to create a supportive environment. Trainees were actively reassured that their responsibility was limited to identifying anatomical structures and correct endotracheal tube placement. The clinical stability of the infant was the responsibility of the supervisor, emphasising the importance of having a team leader maintaining situational awareness while the trainee focuses on learning the skill. Predefined criteria for stopping an attempt included falling heart rate, oxygen saturations <70%, attempt lasting >60 s, or at the supervisor’s discretion. Most intubation videos were recorded, and trainees had the opportunity to watch them with the supervisor and receive feedback.
Using data acquired from this RCT, we aimed to assess trainees’ perspective on the use of videolaryngoscopy as an intubation teaching aid, alongside the standardised method of supervision.
Methods
A questionnaire was designed to assess the trainee’s experience of videolaryngoscopy and the guidance received during intubation attempts. The questionnaire ascertained their clinical experience in neonatology and previous level of intubation success. Five statements about elements of the guidance received during the intubation were answered using a 5-point Likert scale (strongly disagree to strongly agree). The statements were: (1) I found the verbal advice I received during the intubation attempt useful, (2) I found the verbal advice provided helped me get a better view of the vocal cords, (3) I found the experience intimidating, (4) I received useful feedback after the procedure, and (5) I feel more positive about future intubation attempts because of this experience. The questionnaire concluded with a free text section. Participating trainees completed the questionnaires anonymously as soon as possible after each intubation attempt.
Data analysis was completed independently by two authors (JEOS, SK). Likert responses were compared for the two groups and described using descriptive statistics. Free text responses were analysed using grounded theory methodology and coded by hand. Constant comparative method was used to derive codes and categories by clustering repetitive concepts. The clustered categories were grouped together to form the larger themes presented. For clarity, the primary outcomes of the original RCT are summarised here again. The clinical characteristics and outcome variables were analysed by using X2 test, t-test and Mann-Whitney U test as appropriate. P values were two sided, and <0.05 was considered statistically significant.
Results
Two hundred and thirteen intubations in 168 infants (median of one intubation per infant, range 1–4) were randomised from February 2013 to May 2014. Two hundred and six of these were included for analysis; 104 where the video screen was visible and 102 where the video screen was covered. Those excluded from the analysis in the original trial were so due to consent being denied, infants who died or airway anomalies.7 Premedication was given before 157 intubations (78 screen visible, 79 screen covered), all of these occurred within neonatal intensive care unit (NICU). The 49 intubations occurring in the delivery room were not premedicated (29 screen visible, 26 screen covered).7 Intubations were performed by 36 trainees (median of seven intubations per trainee, range 2–11). The success rate when the videolaryngoscope screen was visible was 66% (n=69/104) compared with 41% (n=42/102) when the screen was covered (p<0.001).7 Questionnaires were completed following each intubation attempt, with a 100% response rate. The intubators were inexperienced, with 83% attempting their first intubation as part of this trial. Less than 7% had intubated successfully more than 10 times.
Eighty-three per cent of trainees agreed strongly or very strongly that the guidance they received during intubation helped them achieve a better airway view (87% in the screen visible group, 78% in the control group (p=0.13)). Ninety-three per cent in both groups found the feedback following intubation to be helpful or very helpful (p=0.73). Ninety-two per cent reported that they felt strongly or very strongly that their confidence for future intubations was improved (95% in the screen visible group, 87% in the control group (p=0.04)).
Negative responses were reported following unsuccessful attempts or delivery room intubations. Five per cent (n=11) were neutral and 2% (n=4) disagreed with the statement ‘I feel more positive about future intubations because of this experience’. Overall, 16% reported finding the intubation experience intimidating (14% in the screen visible group, 19% in the control group (p=0.42)).
Four main themes emerged from analysis of the free text comments (table 1).
Free text comments from trainee surveys following intubation attempts
Guidance and feedback
Comments relating to the guidance received during intubation attempts formed the largest recurring theme. The guidance was universally positive in the free text. Trainees felt they were given practical advice that helped facilitate obtaining an airway view. Comments acknowledged that the guidance received created a more supportive environment that was described as calm and consistent. This theme featured equally in both intervention and control groups. The ability to review the video of the intubation and receive feedback was felt to be helpful in explaining why an attempt may have been unsuccessful, thereby aiding future attempts.
Feelings of the intubator
This theme revealed both positive and negative feelings during intubation attempts. Positive feelings described include feeling supported, reassured and growing in confidence. These were prominent when the intubation was successful, particularly if the intubator had achieved previous successful intubations. The negative feelings described included uncertainty, inexperience or feeling intimidated. Negative feelings were reported more frequently when the attempt was unsuccessful, when the intubation occurred in the delivery room, if the baby was unstable during the attempt or if the video screen was covered from the supervisor.
Equipment
Comments reflected the benefits of the shared airway view in enhancing the guidance received and allowing for troubleshooting. In addition, there were several comments relating to challenges directing the endotracheal tube around the blade or manoeuvring the blade around the tongue. This may be accounted for by the design of the videolaryngoscope blade which encompasses a fibre-optic camera at the tip. The blades have a subtly different shape compared with conventional laryngoscope blades and may contribute to some of these challenges.
Clinical setting
Comments about the clinical setting referred to other factors that increased the difficulty of the intubation. Intubations that were perceived to be more difficult were those occurring in awake infants in whom no premedication was given, that is, intubations in the delivery room, or when the baby became unstable during the attempt. Some reported that parental presence and large audiences negatively impacted their confidence during intubation.
Discussion
This trainee survey identified several factors impacting on the experience of intubation in the early stages of learning. The shared airway view provided by videolaryngoscopy was well received and has already been shown to improve intubation success rates. The findings emphasise the importance of a holistic approach to teaching this important skill. Not only did the use of videolaryngoscopy contribute to an enhanced learning experience, but there was a focus on maintaining calm, consistent guidance and controlling the environment where possible.
Some reported difficulty directing the endotracheal tube around the videolaryngoscope blade despite having a clear airway view. There are subtle differences between conventional and videolaryngoscope blades. Videolaryngoscope blades have a reduced vertical height, a curved tip and curved body.8 This results in the direct view obtained using the videolaryngoscope being narrower than the view seen on the screen or the direct view obtained using a conventional laryngoscope. Subsequently, there may be less space in which to guide the endotracheal tube and this likely explains the difficulties reported by the trainees. There are currently no neonatal videolaryngoscopes whose blades match the shape of conventional laryngoscopes.
In the modern era when intubation opportunities are declining, it is imperative to maximise the learning potential of each attempt. An early negative experience can have a long-standing impact on a trainee’s confidence and affect subsequent learning. DeMeo et al studied the trajectory towards neonatal intubation competency.9 They found that the outcome of the first two intubation opportunities was associated with the number of attempts needed before becoming competent. If the first two intubations were unsuccessful, the trainee needed twice as many attempts before reaching competency compared with when early attempts were successful. This suggests that early successes improve confidence, while early failures and stressful experiences reduce confidence. It is well recognised that feeling stressed can impact on learning and performance. Lupien et al show that moderate levels of stress can improve performance and working memory, but high levels can reduce performance.10 Repeated exposure to stressful events can lead to burn-out, demotivation and anxiety.11 Trainee reports of finding parental presence and larger audiences stressful are consistent with the findings of Bensouda et al who examined the impact of this on performance during simulated neonatal intubation. They found that the intubator’s heart rate was higher with larger audiences, but the success rates were comparable.12 Delivery room intubations were reported in our study to be more stressful. This RCT, consistent with other studies, found delivery room intubations to have lower success rates.4 7 We would therefore suggest that where possible delivery room intubations are not an ideal setting for a trainee’s first intubation attempt.
In the context of this RCT, a limited group of supervisors collaborated in the design of a package that was consistently used to supervise trial intubations.7 Elements of this package were specifically aimed at putting the trainee at ease. These measures were well received by trainees, possibly even more so than videolaryngoscopy. In daily practice, intubation is generally taught using the apprenticeship model where trainees are instructed by more experienced colleagues. Instructors have often received no formal training in teaching neonatal intubation. In addition, many experienced instructors are unconsciously competent themselves and therefore may not be able to break down the task into simple describable steps. In the absence of videolaryngoscopy, teaching intubation is additionally challenging as the intubator and supervisor cannot share the view of the infant’s airway. We show that making efforts to standardise the supervision of intubations and striving to reduce trainee anxiety by being calm and reassuring improves the learning experience. This may increase the slope of the learning curve towards proficiency. Importantly, taking the responsibility of the infant’s stability away from the trainee allows them to focus on learning the skill, while the supervisor maintains situational awareness without compromising the opportunity for learning. Volz et al devised a structured coaching programme used by senior clinicians to supervise intubations, comparing videolaryngoscopy with conventional laryngoscopy. They found videolaryngoscopy to improve intubation success, especially in the most junior trainees.13 This study and ours demonstrate the benefit of videolaryngoscopy together with structured instruction to assist trainees in acquiring this complex skill.
Few studies have assessed what educational models or techniques are perceived by trainees as being most beneficial in achieving competency in neonatal intubation. Brady et al conducted a mixed methods study where more experienced NICU fellows were interviewed to identify themes for achieving intubation competency.14 There is considerable agreement between their findings and ours. Our thematic analysis showed that trainees appreciated a supportive environment with calm, clear and consistent guidance. This is consistent with Brady et al’s findings under their main theme of ‘procedure’, whereby fellows reported the benefits of calm, step-by-step guidance. They also noted the advantages that videolaryngoscopy offers as a training tool. Their other key themes highlight the importance of receiving feedback and controlling the environment, in particular limiting unnecessary people present during intubation.
There are a few limitations of our study. Anonymised surveys were returned following all intubations included in the RCT; therefore, some were associated with first ever intubation attempts and others from trainees who had previous intubation attempts. Subgroup analysis based on trainee experience was not carried out, therefore it is possible that conclusions about more tailored training packages can be made based on the stage in the learning process the trainee is in. Data on how long after an intubation attempt questionnaires were returned were not collected, however given that neonatal intubations occur infrequently for junior trainees and are memorable events, we do not perceive recall bias is a significant issue. Parental attendance was not recorded as part of data collection, but one that was commented on in the free text. In addition, infants included in the original RCT ranged in gestation and birth weight, although there were no significant differences in patient demographics between the intervention and control groups. Further studies looking into trainee experiences following intubation in specified patient groups are required.
Conclusion
Learning to intubate is challenging. Trainees appreciated a controlled environment, where calm and consistent guidance was provided. The shared view enabled by videolaryngoscopy and the ability to review intubation attempts and receive feedback were felt to positively influence the learning process. Delivery room intubations, parental presence and large audiences increased stress. Regardless of whether the videolaryngoscope screen was visible to the supervisor or not, the structured guidance was felt to be of importance in the learning experience.
References
Footnotes
Contributors JEOS, MT, COFK and PGD developed the concept, designed and distributed the surveys. JEOS and SK collated the data, performed the analysis and wrote early drafts of the manuscript. All authors contributed to writing and editing the final manuscript.
Funding The original RCT was supported by The Royal Women’s Hospital, Melbourne, Australia, and the Australian National Health and Medical Research Council Program (grant 606789).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.