, et al
Nasal high-flow therapy during neonatal endotracheal intubation
N Engl J Med

Investigators from multiple institutions in Australia conducted a randomized controlled trial to assess the effectiveness of nasal high-flow therapy in improving the success rate of the initial intubation attempt in neonates. Infants undergoing oral endotracheal intubation in the delivery room or NICU in 1 of 2 medical centers in Australia were eligible for the study. At enrollment, participants were randomized to receive high-flow therapy or standard care (no high-flow therapy or supplemental oxygen) at the time of the initial attempt of intubation. Randomization was stratified by medical center, postmenstrual age (≤28 weeks or >28 weeks), and use of premedication. For those randomized to high-flow therapy, 8 liters per minute of air were provided via nasal cannula just prior to intubation; oxygen saturation was increased to 1.0 if the neonate’s oxygen saturation fell to <90%. The primary study outcome was successful intubation on the first attempt without physiologic instability. Successful intubation was confirmed by detection of expired carbon dioxide, and physiologic instability was defined as a decrease in oxygen saturation >20% from pre-laryngoscopy baseline or bradycardia (<100 beats per minute). Secondary outcomes included median oxygen saturation during the intubation attempt and time to desaturation. Outcomes were compared in neonates randomized to the high-flow therapy or standard of care groups using regression analyses after adjusting for stratification factors.

Data were analyzed on 251 intubations, with 124 randomized to the high-flow therapy group and 127 in the standard care group. Study infants had a median postmenstrual age of 27.9 weeks and median weight of 920 grams at the time of intubation. The median age at time of randomization was 10 hours. Demographic and clinical characteristics in the 2 treatment groups were similar. Successful intubation without physiologic instability on the first attempt was achieved in 62 (50%) intubations randomized to high-flow therapy and 40 (31.5%) of those randomized to standard care (adjusted risk difference, 17.6 percentage points; 95% CI, 6.0, 29.2). The median oxygen saturations during the first intubation attempt were 93.5% and 88.5%, respectively, for those randomized to high-flow therapy or standard care (adjusted risk difference, 5.0 percentage points; 95% CI, 1.1, 8.9), and mean time to desaturation was significantly longer in those receiving high-flow therapy than in neonates randomized to standard care (44.3 and 35.5 seconds, respectively; mean difference, 8.8 seconds; 95% CI, 0.2, 17.4).

The authors conclude that the use of high-flow therapy was associated with a significantly higher rate of successful intubation on the first attempt in neonates.

Dr Alissa has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Neonatal endotracheal intubation, a crucial part of neonatal resuscitation, plays an important role in improving neonatal survival among newborns of all gestational ages but especially survival without neurodevelopmental impairment...

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