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Re: Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey

Last post 16 Oct 2018, 5:09 PM by Tim Cook. 1 replies.
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  •  12 Oct 2018, 7:47 PM 2669

    Re: Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey

    We would like to comment on, and correct some misunderstandings in, the paper by Foy et al., which suggests that there are major gaps in optimal airway management in neonatal intensive care units (NICUs) in the UK, particularly lack of continuous waveform capnography (CWC) and/or videolarygoscopy [1]. We are in full agreement with the NHS Improvement recommendation that undetected oesophageal intubation should be a ‘never event’, but note that detection of this event relates mostly to the use of capnography at intubation, rather than during ongoing ventilatory support.

    It is well recognised that detection of exhaled CO2 using a colorimetric device facilitates confirmation of tracheal tube placement in newborn babies, despite being subject to both false positive and false negative results, and this is recommended by international guidelines [2]. A recent survey of UK neonatal units reported routine use of CO2 monitoring in 84 - 88% of neonatal intubations in the labour ward [3], considerably at odds with the reported availability of ‘capnography’ of between 18 and 48% in Foy et al.'s paper.

    The phrase ‘continuous waveform capnography’ may not be one with which most staff working in a UK NICU will be familiar, and it is not clear from the paper whether the question regarding capnography was, or could have been, interpreted as including single use colorimetric CO2 detector devices at neonatal intubation.

    Based on a single personal communication, Foy et al. state that capnography is "routinely" used in "many" neonatal transfers. This contradicts data presented in Fig. 2, but accords with a recent informal survey of 15 UK transport services, of which 13 routinely use capnography (personal communication - Dr Allan Jackson). The transport neonatal population differs in several regards from the NICU population and CWC may be more useful in sedated babies, and when the environment means that the ventilator may not reliably produce flow graphs.

    As acknowledged by Foy et al., there is no evidence of reduction in harm from intubation with the use of CWC in the NICU. Interpretation of CWC is likely to be complicated by the fast ventilator rates and short expiry time used in neonates, routine use of uncuffed endotracheal tubes and the relatively large dead space in the smallest preterm infants. Most neonatal ventilators now incorporate flow graphs, with which neonatal nursing and medical staff are familiar, and which provide opportunity to recognise accidental extubation. There has been no direct comparison of CWC and ventilator flow graphs in terms of efficacy and safety in ventilated preterm infants.

    Videolarygoscopy has potential to facilitate teaching and practice of neonatal intubation [4] and videolarygoscopes suitable for very preterm infants are now available. We anticipate therefore that availabiltiy of and (just as importantly) familiarity with videolarygoscopy within UK neonatal units will continue to increase although its routine use in the labour suite may prove challenging.

    The physiology of the newborn is very different from that of older children and adults, and practices of proven benefit for older patients may not apply in the NICU. Any new technology should be shown to provide greater benefit than risk in the relevant setting. An additional stream of data does not necessarily help to provide better care; indeed it might actually delay effective management. We note that neither the Royal College of Paediatrics and Child Health nor the British Association of Perinatal Medicine (BAPM) was represented in the NAP4 Review Panel [5] and draw attention to the fact that BAPM is currently developing a Framework for Practice to inform management of the difficult airway in neonatal practice.

    We strongly suggest that the paper by Foy et al. does not accurately reflect current neonatal practice and, by making an unjustified extrapolation to the newborn of accepted practice in adults and older children, greatly underestimates the safety of neonatal intubation in UK NICUs.

    H. Mactier

    A. Jackson

    Princess Royal Maternity,

    Glasgow, Scotland.

    J. Davis

    University of Western Australia,

    Crawley, Australia.

    G. Menon

    Simpson Centre for Reproductive Health,

    Edinburgh, Scotland.

    C. J. Morley

    University of Cambridge,

    Cambridge, UK.

    C. C. Roehr

    University of Oxford,

    Oxford, UK.

    R. J. Tinnion

    The Newcastle upon Tyne Hospital NHS Foundation Trust,

    Newcastle, UK.


    on behalf of the British Association of Perioperative Medicine.

    Email: Helen.mactier@ggc.scot.nhs.uk


    No external funding and no conflicts of interest declared.



    1. Foy KE, Mew E, Cook TM et al. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2018

    2. Resuscitation Council (UK). https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth (accessed 11/09/2018).

    3. Charles E, Hunt K, Milner A, Greenough A. UK neonatal resuscitation survey. Archives of Disease in Childhood 2018; 103: A83

    4. O'Shea JE, Thio M, Kamlin CO et al. Videolarygoscopy to teach neonatal intubation: a randomized trial. Pediatrics 2015; 136: 912-9

    5. Royal College of Anaesthetists. Major complications of airway management in the United Kingdom. https://www.rcoa.ac.uk/document-store/nap4-full-report (accessed 13/09/2018).


  •  16 Oct 2018, 5:09 PM 2670 in reply to 2669

    Re: Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey

    We thank Mactier et al. for their comments, which we have considered carefully. From the outset, we should make clear we are not seeking to undermine or criticise colleagues working in neonatology, undoubtedly a challenging area of critical care. On reflection, our use of the term ‘major gaps in optimal airway care’ [1] may have been injudicious, and might better have been phrased as ‘significant areas worthy of examination and improvement where indicated’.

    Mactier et al. state that our survey does not represent current practice. Our survey took place in 2016, and it is quite possible that changes in practice have occurred since. However, the responses we presented (from 90% of all UK neonatal intensive care units (NICUs)) are likely to be representative of the practices at that time. Our overall findings are notable in two respects. Firstly, there is a marked difference between practices in paediatric ICUs (PICUs) compared to NICUs. Secondly, and perhaps more notably, is the variation in practice reported between NICUs. Before publication, the PIC-NIC survey was presented at two neonatal conferences, one European and one in the United Kingdom [1]. Both presentations were followed by animated discussions, which highlighted variations in practice and opinions, particularly concerning capnography.

    Mactier et al.’s letter and much discussion on social media have focused on capnography, but it is worth noting that we examined considerably more than that. Compared to PICUs (whose practice largely mirrors adult ICU practice), we found that NICUs were notably less likely to have a difficult airway policy and a difficult airway trolley, to use a pre-intubation checklist and to report death or serious harm resulting from airway management complications.

    Airway management is challenging in all areas of critical care. In neonatology, challenges include high rates of intubation failure, severe hypoxia and bradycardia being common during intubation and frequent accidental extubations. In 2016, Hatch examined 273 neonatal intubations; first attempt success was 47%, adverse events (which excluded bradycardia and hypoxia) occurred in 39% of cases, and hypoxia (SpO2<60%) and bradycardia (heart rate <60 bpm) occurred in 44% and 24% of cases, respectively [2]. They identified emergency intubation as the most significant risk factor for serious complications at intubation and noted that 62% of cases of emergency intubation on NICU were the result of accidental extubation. The authors went on to perform a quality improvement program, which included a pre-intubation checklist which significantly reduced rates of adverse events, severe hypoxia and bradycardia [3].

    As Fawke and Wyllie have identified, capnography is a complex and perhaps vexed topic. Our survey focused only on waveform capnography, so would have underestimated the use of ‘capnometry’ overall and at intubation in particular. Mactier et al. list some of the difficulties of using waveform capnography in the neonatal setting. In our paper, we listed these explicitly and explained that this is an area meriting further research. However, it is notable that many NICUs do use waveform capnography, and both parties agree that it is widely used during transfer of small infants, suggesting it is feasible. There is clearly variation in practices and this merits exploration. The literature suggests waveform capnography is effective and practical in babies as small as ~500g [4]. The UK Resuscitation Council guidelines recommend detection of ‘exhaled carbon dioxide’, but do not specify that this should be colorimetric [5]. In researching this letter, we identified a previous survey from 2013, which reported that 34% of level 3 NICUs did not use capnometry to confirm successful tracheal intubation and 32% only used it if there were difficulties [6]. These results are consistent with our findings.        

    Safe airway management extends well beyond the period of intubation and it is highly unlikely that colorimetric capnometry will monitor airway integrity and patency as well as a waveform device would. Using ventilator waveforms to determine precisely what is happening with ventilation is likely to be complicated by airway leak when uncuffed tubes are used. It also involves monitoring something that is at least one step distant from what is happening to the patient’s physiology – waveform capnography on the other hand gives a breath-by-breath indication of that physiology, and is the ideal monitor of airway position and patency. The focus of this discussion is on capnography for airway monitoring, not respiratory monitoring, but waveform capnography provides many other benefits: in this regard Kugelman et al. reported that continuous waveform capnography significantly improved ventilation accuracy and reduced intracranial bleeding complications in ventilated neonates [7].

    Mactier et al. refer to a survey abstract presented by Charles et al., which does not state when it was undertaken [8]. This reported ‘routine’ use of capnography (likely capnometry) during intubation in delivery suites in 81-88% of units, but was far less extensive than our survey and had a lower response rate (83%). It may well be that airway management practices in NICUs have changed since our survey, but this survey does not provide robust evidence of that.

    There is an inevitable and perhaps unavoidable sense of ‘confrontation’ in letters criticising articles and the resulting responses, but we hope we can all avoid that. We are delighted that the British Association of Perinatal Medicine is conducting a review of airway management in NICUs and would encourage the Association not to restrict the review to the difficult airway but also to consider routine airway management and monitoring. The NAP4 study in adults might serve as an equivalent [9]. Its findings were not welcomed by all anaesthetists, but three years after its publication, 80% of UK adult ICUs had made changes in their practices, closing the safety gap between actual and optimal practice by 60% [10]. There is a significant challenge in determining whether new technology improves safety, and balancing the evidence requires considerable effort. Regarding rare and serious harm events, such as airway-related deaths, the answer rarely lies in randomised controlled trials [11]. We hope the findings of our survey will be of use in the BAPM review and would encourage the specialty to repeat our in-depth survey if they wish to see how practices have changed.


    T. M. Cook 

    K. Foy

    F. E. Kelly

    Royal United Hospitals Bath NHS Foundation Trust,

    Bath, UK.

    Email: timcook007@gmail.com


    No external funding and no conflicts of interest declared.



    1. Foy KE, Mew E, Cook TM et al. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2018; 73: 1337-44.
    2. Hatch LD, Grubb PH, Lea AS, et al. Endotracheal intubation in neonates: a prospective study of adverse safety events in 162 infants. Journal of Pediatrics 2016; 168: 62-6.
    3. Hatch LD, Grubb PH, Lea AS et al. Interventions to improve patient safety during intubation in the Neonatal Intensive Care Unit. Pediatrics 2016; 138: e20160069.
    4. Salthe J, Kristiansen SM, Sollid S, Oglaend B, Søreide E. Capnography rapidly confirmed correct endotracheal tube placement during resuscitation of extremely low birthweight babies (< 1000 g). Acta Anaesthesiologica Scandinavica 2006; 50: 1033-6.
    5. Resuscitation council [UK]. Resuscitation and support of transition of babies at birth. https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth/ (accessed 21/10/2018).
    6. Whitby T, Lee DJ, Dewhurst C, Paize F. Neonatal airway practices: a telephone survey of all UK level 3 neonatal units. Archives of Disease in Childhood. Fetal Neonatal Edition 2015; 100: F92-3.
    7. Kugelman A, Golan A, Riskin A et al. Impact of continuous capnography in ventilated neonates: a randomized, multicenter study. Journal of Pediatrics 2016; 168: 56-61.
    8. Charles E, Hunt K, Milner A, Greenough A. UK neonatal resuscitation survey. Archives of Disease in Childhood 2018; 103: A203.
    9. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2 Intensive Care and Emergency Department. British Journal of Anaesthesia 2011; 106: 632-42.
    10. Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. British Journal of Anaesthesia 2016; 117: 182-90.
    11. Cook TM. Airway complications – strategies for prevention. Anaesthesia 2018; 73: 93-111.

    Tim Cook
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