Intubating extremely premature newborns: a randomised crossover simulation study

OBJECTIVE: Determine whether tracheal intubation of extremely low birthweight (ELBW) neonates is more successful with a size-0 or size-00 Miller laryngoscope blade. DESIGN: Randomised crossover simulation study SETTING: Simulated neonatal intensive care unit environment STUDY SUBJECTS: Neonatology physicians and nurse practitioners (n=55) INTERVENTIONS: Subjects performed four intubations in succession on a high-fidelity ELBW manikin with size-0 Miller and size-00 Miller blades from two different manufacturers. The intubation sequence was randomised. Intubations were recorded and scored for time analysis. Subjects completed surveys about blade preferences before and after completing the series of intubations. MAIN OUTCOME MEASURES: Total laryngoscopy time and first attempt success in less than 30 s RESULTS: There was no difference in total laryngoscopy time (median 23.7 vs 20.6 s) or first attempt success in <30 s (67.3% vs 69.1%) between the size-0 and size-00 blades. Differences were noted between the same size blades made by different manufacturers. Among subjects expressing a prestudy blade size preference, there was no difference in laryngoscopy time or first attempt success between blades. Regardless of blade size, subjects were less successful with the first blade in the randomised sequence. CONCLUSIONS: Our findings support the Neonatal Resuscitation Program recommendation identifying the size-00 blade as optional equipment. Operators need to be aware of design variations between manufacturers and they may benefit from ‘just-in-time’ training with a manikin prior to intubating a live patient.