Assessing Intubation Competence During Neonatal Fellowship Training

The ability to provide competent airway management and respiratory support for compromised neonates necessitates critically important skills. Fortunately, only 4% to 10% of newborns need positive pressure ventilation immediately after birth, and appropriate bag mask positive pressure ventilation is often sufficient.¹  When neonatal tracheal intubation (NTI) is needed, either for resuscitation in the delivery room or for more chronic ventilation, competence with NTI is a lifesaving skill. Opportunities to intubate in the neonatal period have decreased over time for a number of reasons. Routine transient intubation to suction meconium from the trachea is no longer recommended, even when an infant is depressed at birth.²  Laryngeal mask airway, which requires little training to place, is now available to help support some infants’ respiratory needs for an intermediate period of time, either eliminating the need for intubation or providing respiratory support until a more skilled intubator is available.¹  Noninvasive ventilator strategies such as continuous positive airway pressure and noninvasive positive pressure ventilation can support some infants’ respirations without the need for NTI. Even the smallest premature infants are often able to avoid the need for mechanical ventilation by using a combination of prenatal steroids, surfactant, optimal nutrition, and noninvasive modes of respiratory support. This has led to significant practice changes to decrease the length of time premature infants are supported with invasive ventilation if it is even required.³  Quality improvement projects focusing on minimizing unplanned extubations in the NICU also decrease the number of NTI experiences.⁴  The Accreditation Council for Graduate Medical Education trainee work hour rules decrease the time neonatal-perinatal medicine (NPM) fellows spend in the NICU. The need to train advanced practice providers who work in many NICUs further decreases opportunities for NPM fellows to gain proficiency with NTI. Although these are positive improvements in patient care and workforce considerations, the issue of addressing how to ensure that NPM fellows are adequately trained in the lifesaving technique of NTI is crucial.

In this issue of Pediatrics, Evans et al⁵  sought to characterize NPM fellows’ level of competence as they progressed through fellowship, with the ultimate goal of defining the number of intubation encounters needed for an NPM fellow to achieve competence. In the retrospective cohort study, the authors used prospectively gathered data from a multicenter neonatal airway registry. They analyzed data from 92 NPM fellows at 8 teaching hospitals over a period of 4 years, including 2297 intubation encounters. Using cumulative sum analysis and defining intubation competence as 80% overall success rate within 2 intubation attempts, 77% of NPM fellows were successful within 2 attempts. The number of intubations needed to achieve competence had a broad range from 8 to 46 procedures. The authors noted that although the median number of intubations needed to achieve competence among the NPM fellows was 18, they observed that some fellows did not meet the accepted definition of competence after 50 encounters and some did not demonstrate improvement of successful intubation over time in fellowship. This points to the need to identify those trainees who would benefit from focused remediation for developing competence in NTI early in their training.

It is important to prioritize training for NTI to minimize complications. After basic NTI techniques have been mastered by using texts, videos, and observation, simulated NTI experiences using mannequins, although not totally imitating the stress of intubating a newborn with bradycardia, help trainees become familiar with key airway landmarks. Next, learners intubate patients under direct supervision, choosing lower-risk situations and limiting the number of attempts per provider to optimize patient safety. Video laryngoscopy, although not available to all, can be a useful adjunct to help give real-time feedback to trainees as they master their intubation skills.^6,7  With their work, Evans et al⁵  have provided important information regarding the mean number of intubations NPM fellows need to attain competence. The authors also demonstrated that most fellows who did not develop NTI competence during their fellowship could have been identified earlier in their training, allowing opportunities for remediation. An NTI competency assessment tool has been developed and validated for simulation training.⁸  Assessing competence of NTI, first in simulation training and subsequently in patients, can lead to timely remediation opportunities for needed NTI skills and optimize patient safety.

NPM

neonatal-perinatal medicine

NTI

neonatal tracheal intubation