Respiratory support during neonatal intubation and procedural success: A systematic review and meta-analysis

Neonatal intubation is a high-risk, lifesaving procedure with reported first-attempt success rates of only 50–60%, and significantly lower rates among less experienced practitioners (1-3). Changes in neonatal care practices have led to a reduction in the frequency of neonatal intubations, thereby limiting opportunities for junior doctors to acquire proficiency in this technically demanding skill(4-5). Most neonatal intubations are performed for respiratory indications, and the inherently limited respiratory reserve in neonates increases the risk of oxygen desaturation during the procedure. Desaturation episodes during neonatal intubation are common (6) with severe desaturations (>20% below baseline) reported as high as 69% of cases (1). Such episodes may precipitate bradycardia and necessitate termination of the intubation attempt. The need to call out desaturation events can also increase psychological stress for junior doctors, further contributing to failed attempts. Importantly, successful first attempt intubation has been associated with improved neurodevelopmental outcomes in extremely low birth weight (ELBW) infants (7). Although the introduction of video laryngoscopy has improved first attempt intubation success rates among junior doctors, the incidence of desaturation episodes remains comparable to that observed with direct laryngoscopy (8). Neonates, particularly those born preterm, are at increased risk of desaturation. This vulnerability is attributable to several factors, including a high basal metabolic rate, low functional residual capacity, underlying pulmonary pathology, intrapulmonary shunting, and the use of pre intubation medications such as Suxamethonium, which increases oxygen consumption through muscle fasciculations. In addition, a small calibre airway with a tendency to collapse and a relatively higher physiological dead space further predisposes neonates to desaturation. Unlike paediatric and adult populations, neonates tolerate only brief periods of apnoea before desaturation occurs, leaving a very limited time window for clinicians to perform technically demanding procedures such as endotracheal intubation (6,9). There is a pathophysiological plausibility that oxygen administration or respiratory support during apnoea or intubation episodes might improve oxygenation. Systematic reviews of paediatric studies have shown that providing respiratory support or supplemental oxygen during paediatric intubation is associated with a lower incidence of hypoxaemia and higher first-attempt intubation success rates (10,11). However, these paediatric studies generally included only a small number of term neonates and did not encompass the most vulnerable preterm neonates. To the best of our knowledge, there has not been any systematic review on this subject in neonatal population. Therefore, we plan to conduct a systematic review to evaluate the effectiveness of respiratory support during neonatal intubation in improving procedural success rates.