Newsletter January 2024: ESAIC and BJA Join forces to shape guidelines for Neonatal Airway Management

Interview with Prof. Nicola Disma on addressing challenges and enhancing care for neonates and infants

Could you share insights into the key motivations behind the ESAIC and BJA joining forces to develop these guidelines? 

Over the past few years, we have conducted two Clinical Trial Networks named APRICOT and NECTARINE, both funded by the ESAIC. The main results from NECTARINE were published in the British Journal of Anaesthesia (BJA). Since the publication of NECTARINE’s main results, it became immediately clear the neonatal and infant population represents the most vulnerable segment within the entire paediatric population. They face the highest risk of critical events during anaesthesia, which could result in poor outcomes if not immediately recognised and adequately treated. Specifically, the occurrence of difficult intubation requiring multiple attempts of laryngoscopy or the use of advanced techniques occurs in more than 5% of neonates and young infants undergoing anaesthesia. The primary reason is associated with the distinct and unique physiology of the neonatal age and the frequent co-existence of co-morbidities and congenital abnormalities. Moreover, most of the recently published studies demonstrating advancements in airway management are conducted in the neonatal age.  

For all the above reasons, the Editor in Chief of the BJA proposed forming a task force to develop new neonatal and infant airway management guidelines. Twenty-three experts in paediatric airway management were invited to join the task force and tackle the challenge of developing these new guidelines. Subsequently, a formal proposal was submitted to the Guidelines Committee of the ESAIC, which was promptly approved. The ESAIC and BJA signed a joint agreement before the guidelines development process started.  

In your opinion, what are the most significant challenges healthcare providers face in neonatal airway management, and how do these guidelines address them? 

In 2003, Sir Dave Brailsford was appointed as the performance director of the British Cycling Team. He developed the theory of “the aggregation of marginal gains”*. Brailsford and his coaches initiated minor adjustments that one might expect from a professional cycling team. However, they didn’t stop there. Brailsford and his team continued to find 1%improvements in overlooked and unexpected areas. With hundreds of small improvements accumulated, the results surpassed anyone’s expectations. In just five years, the British Cycling team dominated the road and track cycling events at the 2008 Olympic Games in Beijing and later at the Olympic Games in London, where they established nine Olympic and seven world records.  

Similar to the aggregation of marginal gains described above, the success rate of tracheal intubation in the neonatal age can improved by continuous small improvement in daily practice. The new guidelines address all aspects of tracheal intubation, from pre-anaesthesia assessment to the selection of devices and equipment, pharmacology treatment and the assessment of correctness of intubation. Both categories of expected and unexpected difficult intubation patients were taken into consideration. An extubation plan is also included. Finally, aspects such as non-technical skills and human factors were examined and included. The new guidelines serve as a comprehensive guide for physicians undertaking the challenge of neonatal tracheal intubation in the operating room. Achieving excellence in airway management is not solely possible by implementing the use of new devices like video laryngoscopy but rather by aggregating marginal gains in daily practice, including skills and competencies.  

Considering the collaborative nature of this effort, what impact do you envision these guidelines having on the broader medical community and, ultimately, on the well-being of neonates and infants? 

The ideal goal is to perform successful airway management with first-attempt intubation and no adverse events in 100% of neonates and infants. However, healthcare providers with other specialities perform neonatal tracheal intubation for various reasons in different settings. For this reason, the ESAIC-BJA guidelines aimed to focus on airway management in the operating room by anaesthesiologists. Every anaesthesiologist working in a paediatric setting and dealing with neonatal and infant practice can benefit from these guidelines. The advice is to read the guidelines, discuss with the team on an institutional level, and readapt to the local practice. Then, the team can work on implementing practices to improve performance where needed. The future challenge will be to work and produce “universal guidelines” applicable in all settings by all providers: anaesthesiologists, intensivists, emergency paediatricians, etc. The ultimate common intent is to provide the best possible medical care to all small patients needing airway management in the hospital setting, despite the different backgrounds of healthcare providers. Aspects like competencies, practice, simulation, and curriculum should be considered as an integral part of the future universal guidelines. The road is indicated; we need to take the first step.     

* The “Aggregation of Marginal Gains” theory, popularised by Sir Dave Brailsford, advocates achieving significant performance improvements by making small, incremental enhancements across various aspects rather than relying on a single revolutionary change. More information: https://champions-speakers.co.uk/news/ultimate-guide-marginal-gains 

Prof. Nicola Disma – Consultant Pediatric Anaesthetist, Head of the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy