Introduction
The newborn period, in the first 28 days of life, is the highest risk period in a child’s life. Currently, there are an estimated 2.5 million global newborn deaths annually, representing nearly half of all deaths in children under the age of five.1 Although this represents significant progress from 1990, when there were 5 million newborn deaths annually, rapid progress is still needed to achieve the Sustainable Development Goals (SDGs).2 SDG three aims to reduce neonatal mortality rate (NMR) to 12 deaths per 1,000 live births in all countries.3 Unfortunately, if current trends continue, it is estimated that 60 countries will miss this target by 2030.2
The burden of neonatal deaths is not equal across the world, and the vast majority occur in low- and middle income-countries (LMICs), particularly in sub-Saharan Africa and Central and Southern Asia. Pakistan had 251,000 neonatal deaths in 2018 and an estimated NMR of 42.2 Half of all under-five deaths occurred in just five countries, including Pakistan.2 To decrease the newborn deaths, the main causes of these deaths must be addressed: preterm births, intrapartum-related complications (birth asphyxia), and infections.
Intrapartum-related complications, if not fatal, are also a leading cause of long-term morbidity. Lack of oxygen to the brain in the critical few first minutes of life can result in hypoxic-ischemic encephalopathy, cerebral palsy, developmental delays, and behavioral problems.4,5 To prevent these deaths, misclassified stillbirths, and significant morbidity, a skilled birth attendant should be present at every birth to provide immediate care to the newborn including resuscitation.6 In facilities with neonatal intensive care units (NICU), newborn resuscitation also includes endotracheal intubation and mechanical ventilation. Unfortunately, it is common for the endotracheal tube (ETT) to be misplaced into the esophagus, depriving the lungs of oxygen at a critical period. This is less likely with providers who have more experience but has been reported to be as high as 19% in a study of varied skill level providers in 5 NICUs.7
To determine proper position of the ETT, several techniques can be used. Traditional clinical signs include auscultation of bilateral breath sounds, absence of breath sounds in the epigastrium, condensation in the ETT during expiration, an increase in heart rate, and chest wall movement.8 Capnography is also commonly used which detects exhaled CO2, and the combination of clinical signs and capnography is currently recommended for ETT confirmation in international neonatal resuscitation guidelines.9CO2 detection devices may, however, result in false negative results with infants in severe respiratory failure or without cardiac output.10,11 Chest X-ray (CXR) is the most common method of confirming ETT position; however, it requires a significant amount of time, resources, and exposes the neonate to radiation.12
Point of care ultrasound (POCUS) is a powerful tool that has been adapted for many uses in neonates. International evidence-based guidelines from the European Society of Pediatric and Neonatal Intensive Care determined that lung POCUS, for example, is helpful for respiratory distress syndrome (RDS), pneumonia, lung aeration, meconium aspiration syndrome (MAS), bronchiolitis, pneumothorax, chest tube insertion, pleural effusions, thoracentesis, lung edema, and atelectasis.13 POCUS can also be helpful in determining esophageal versus tracheal ETT placement and has been shown to be faster than auscultation and capnography in adults.14 In children, the sensitivity and specificity for POCUS ETT placement has been shown to be 98.9% and 94.1%, respectively.15 In neonates, POCUS has mainly been used in stable intubated NICU patients to determine ETT depth,16-20 and only few studies have compare tracheal POCUS with standard methods of intubation confirmation.21,22
Our group previously described a novel ultrasound simulator to train health care providers in distinguishing tracheal versus esophageal ETT placement.23 Results of the training sessions using this simulator demonstrated decreased interpretation time and improved POCUS interpretation accuracy with repeat testing among novice users.24 In this study, we present the findings of the application of this training program on neonates undergoing intubation, both in terms of accuracy and a time comparison to standard-of-care methods.