Applied forces during neonatal intubation with direct and video laryngoscopy at different bed elevations: a randomized crossover manikin study

We compared intubation forces, success of the first attempt, intubation time, and participant’s opinions using direct and video laryngoscopy at umbilical and xiphoidal bed heights in a neonatal manikin. A randomized controlled crossover trial of intubation using direct and video laryngoscopes at two different table elevations (operator’s xiphoid or navel) in a neonatal manikin model. Thirty-two neonatologists and pediatric residents participated. The primary outcome measure was the force applied to epiglottis and palate of neonatal manikin during intubation. The secondary outcome measures included success of the first attempt, intubation time, and participants’ opinion on the procedures. Intubating the neonatal manikin with the videolaryngoscope and the resuscitation table leveled at operator’s navel was associated with the lowest forces applied to the epiglottis and the hard palate. On the other hand, the combination of direct laryngoscope and resuscitation table leveled at operator’s xiphoid was associated with the highest applied forces. The success rate at the first attempt and the intubation time were not statistically different among the combinations of laryngoscopes and table elevations. In contrast to actual measurements, most participants believed to have used less forces when the table leveled at operator’s xiphoid.

Conclusions : In a neonatal manikin model, the lower force applied during intubation with a videolaryngoscope and the resuscitation table leveled at operator’s navel may be a desirable objective, but the clinical implications should be evaluated in clinical studies.

Trial registration :clinicaltrial.gov NCT06474572

What is Known: • Intubation success may be influenced by procedure-related aspects such as the position of the patient in relation with the operator .• The Neonatal Resuscitation Program recommends adjusting the bed height to align the baby's head with operator's upper abdomen or lower chest, while positioning the bed height at approximately elbow height is also suggested .• The bed height might affect the applied forces during neonatal intubation and the intubation success, but such information is currently lacking .

What is New: • In a neonatal manikin model, intubating with a videolaryngoscope and the resuscitation table leveled at operator’s navel was associated with the lowest forces applied to the epiglottis and the hard palate .• The participants achieved a high success rate at the first attempt and comparable procedure times with all combinations of direct/video laryngoscope and low/high bed elevation .• Applying lower forces during neonatal intubation may be desirable but the clinical implications remain to be evaluated in clinical studies .