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To intubate or not to intubate, is that the question?

Pediatric Research (2024)Cite this article

Endotracheal intubation to resuscitate neonates was used by Scheel more than two centuries ago. Endotracheal tubes and laryngoscopes specific to the newborn were refined in the 20th century to resuscitate newly born infants.1,2 With the development of newborn medicine, intubation, and mechanical ventilation became standard practice for premature infants with immature lungs and respiratory distress syndrome (RDS). In Germany, continuous positive airway pressure (CPAP) was applied in newborns with RDS in the early 1900s. Hoerder applied a bubble CPAP system to generate positive end-expiratory pressure (PEEP). Engelmann took this a step further when he applied facial CPAP to support distressed infants.3 In 1971 Gregory et al. reintroduced CPAP for premature infants with RDS, at a mean age of 6–10 h depending on birthweight. CPAP pressures between 6–12 mm Hg (8–16 cm H2O) were applied. The 20 patients described by Gregory et al. had birth weights between 930–3830 grams, of these 18 were intubated and 2 were treated with a pressure chamber, and 16 survived.4

In 1980 Fujiwara et al. demonstrated that surfactant and mechanical ventilation improved oxygenation in newborns with RDS.5 In the early surfactant era from 1980, prophylactic surfactant therapy was popular requiring immediate intubation. The INSURE (INtubation, SURfactant, Extubation) technique propagated early intubation, and rapid extubation as soon as surfactant had been instilled.6

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Fig. 1: Airway and related factors associated with good outcomes (in green squares) and poor outcomes (in red squares).

References

  1. Obladen, M. History of neonatal resuscitation—part 3: endotracheal intubation. Neonatology 95, 198–202 (2009).

    Article  PubMed  Google Scholar 

  2. Geraghty, L. E., Curraín, E. Ó., McCarthy, L. K. & O’Donnell, C. P. F. The history of neonatal intubation. Semin. Fetal Neonatal. Med. 28, 101481 (2023).

    Article  PubMed  Google Scholar 

  3. Sammour, I. & Karnati, S. Non-invasive respiratory support of the premature neonate: from physics to bench to practice. Front. Pediatr. 8, 214 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  4. Gregory, G. A., Kitterman, J. A., Phibbs, R. H., Tooley, W. H. & Hamilton, W. K. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N. Engl. J. Med. 284, 1333–1340 (1971).

    Article  CAS  PubMed  Google Scholar 

  5. Fujiwara, T. et al. Artificial surfactant therapy in hyaline-membrane disease. Lancet 1, 55–59 (1980).

    Article  CAS  PubMed  Google Scholar 

  6. Blennow, M. & Bohlin, K. Surfactant and noninvasive ventilation. Neonatology 107, 330–236 (2015).

    Article  CAS  PubMed  Google Scholar 

  7. Verder, H. et al. Nasal continuous positive airway pressure and early surfactant therapy for respiratory distress syndrome in newborns of less than 30 weeks’ gestation. Pediatrics 103, E24–E29 (1999).

    Article  CAS  PubMed  Google Scholar 

  8. Verder, H. et al. Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. Danish-Swedish Multicenter Study Group. N. Engl. J. Med. 331, 1051–1055 (1994).

    Article  CAS  PubMed  Google Scholar 

  9. Rojas-Reyes, M. X., Morley, C. J. & Soll, R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst. Rev. 3, CD000510 (2012).

    Google Scholar 

  10. Sweet, D. G. et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 update. Neonatology 120, 3–23 (2023).

    Article  PubMed  Google Scholar 

  11. Thamrin, V. et al. Preterm infant outcomes after randomization to initial resuscitation with FiO2 0.21 or 1.0. J. Pediatr. 201, 55–61.e1 (2018).

    Article  PubMed  Google Scholar 

  12. Kapadia, V. et al. Outcomes of delivery room resuscitation of bradycardic preterm infants: a retrospective cohort study of randomised trials of high vs low initial oxygen concentration and an individual patient data analysis. Resuscitation 167, 209–217 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  13. Haumont, D. et al. Evaluating preterm care across Europe using the eNewborn European Network database. Pediatr. Res. 88, 484–495 (2020).

    Article  PubMed  Google Scholar 

  14. Tamai, K. et al. Delivery room intubation and neurodevelopment among extremely preterm infants. Pediatr. Res. https://doi.org/10.1038/s41390-023-02993-5 (2024).

  15. Ni Chathasaigh, C. M., Davis, P. G., O’Donnell, C. P. & McCarthy, L. K. Nasal interfaces for neonatal resuscitation. Cochrane Database Syst. Rev. 10, CD009102 (2023).

    PubMed  Google Scholar 

  16. Abdel-Latif, M. E. et al. Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst. Rev. 5, CD011672 (2021).

    PubMed  Google Scholar 

  17. Chan, C. S. et al. Evaluation of a respiratory care protocol including less invasive surfactant administration in preterm infants. Pediatr. Res. https://doi.org/10.1038/s41390-023-02963-x (2023).

  18. Gaertner, V. D., Thomann, J., Bassler, D. & Rüegger, C. M. Surfactant nebulization to prevent intubation in preterm infants: a systematic review and meta-analysis. Pediatrics 148, e2021052504 (2021).

    Article  PubMed  Google Scholar 

  19. Murphy, M. C. et al. Prophylactic oropharyngeal surfactant for preterm newborns at birth: a randomized clinical trial. JAMA Pediatr. 178, 117–124 (2024).

  20. Roberts, C. T. et al. Supraglottic airway devices for administration of surfactant to newborn infants with respiratory distress syndrome: a narrative review. Arch. Dis. Child. Fetal Neonatal Ed. 106, 336–341 (2021).

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Pediatric Research, University of Oslo, Oslo, Norway

    Ola Didrik Saugstad

  2. Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA

    Ola Didrik Saugstad

  3. Department of Pediatrics, University of California at Davis Children’s Hospital, Sacramento, CA, USA

    Satyan Lakshminrusimha

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  2. Satyan Lakshminrusimha
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Both authors took part in writing the manuscript. The figure is made by S.L. Both authors approved the final manuscript

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Correspondence to Ola Didrik Saugstad.

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Saugstad, O.D., Lakshminrusimha, S. To intubate or not to intubate, is that the question?. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03073-y

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