P2.J182: Use of Multi-angle Video to Describe Ergonomics of Simulated Neonatal Intubation

Background: Describing differences in technique between novice and experienced intubators can optimize training. We used multi-angle video to describe the differences in laryngoscope grip between inexperienced and experienced intubators during simulated neonatal intubation in term and preterm manikins.

Methods: Study subjects included neonatologists, hospitalists, neonatology fellows, pediatric residents, and neonatal nurse practitioners. “Novices” were defined as having < 10 successful neonatal intubations and < 1 year of experience working in a NICU. All other subjects were deemed “experts”.

Thirty-eight subjects performed three intubation attempts on both term and preterm neonatal manikins. Overhead, over-shoulder, and lateral views were recorded. Laryngoscope hold was classified as either “handle”, “fulcrum”, or “indeterminate” (Figure 1). Intubation was deemed successful if chest rise was visualized. Differences in laryngoscope hold were analyzed using chi-squared tests.

Results: Data from 18 novices and 20 experts were analyzed, including 108 novice trials (54 preterm and 54 term) and 120 expert trials (60 preterm and 60 term). Two novice trials, performed by two distinct subjects, were unsuccessful. Four expert trials, performed by three distinct subjects, were unsuccessful.

The number of handle, fulcrum, and indeterminate holds used by novices and experts in term and preterm manikins is shown in Table 1A. Out of 108 novice trials, 37 (34.3%) used a handle hold, 32 (29.6%) used a fulcrum hold, and 39 (36.1%) used an indeterminate hold. In 120 expert trials, 27 (22.5%) used a handle hold, 60 (50%) used a fulcrum hold, and 33 (27.5%) used an indeterminate hold. Chi-square analysis between novice and expert trials yielded a chi-square statistic of 9.98 (p=0.0068).

The variability of laryngoscope holds within intubation trials performed by each subject is shown in Table 1B. Of the 18 novices, 12 (66.7%) used the same hold for all trials, 4 (22.2%) used two different holds, and 2 (11.1%) used all three holds. For the 20 experts, 10 (50%) used the same hold for all trials, 8 (40%) used two holds, and 2 (10%) used all three holds. Chi-square analysis between novice and expert subjects yielded a chi-square statistic of 1.41 (p=0.493).

Conclusion: In this observational study, an intubation by an expert subject was more likely to be performed using a fulcrum hold than an intubation by a novice subject. Novices may be applying intubation techniques learned previously on a pediatric or adult patient or manikin, where a handle hold is likely most appropriate. Experts may have gravitated over time to using a fulcrum hold, which might subjectively allow more control of a neonatal airway. Understanding that novice and expert neonatal intubators may hold the laryngoscope differently should inform the instruction of neonatal intubation. Learning a fulcrum hold in neonatal patients might enable novices to attain procedural competency more effectively.