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.