Flow disruptions during delivery room intubation of neonates with congenital diaphragmatic hernia.

Aim: Flow disruptions (FDs) are deviations in the progression of care that compromise safety and efficiency of a specific process. Neonatal intubation is a life-saving high-risk procedure required for delivery room (DR) management of neonates with moderate to severe congenital diaphragmatic hernia (CDH). This study evaluated FDs during DR intubation of neonates with CDH and their association with process and outcome measures.

Methods: Single-center observational study of video-recorded DR intubations of neonates with CDH. FDs were measured from birth through commencement of invasive endotracheal tube ventilation and classified using a neonatal FD tool and impact score. The primary outcome was time to invasive ventilation. Secondary outcomes were time to oxygen saturation (SpO) ≥ 85%, time to electrocardiogram signal, time to pulse oximetry signal, and time to secured endotracheal tube. Linear regression models evaluated the association of FD rate/minute before ventilation and outcomes.

Results: Between 11/2021-4/2023, 29 video-recorded resuscitations were included. A mean of 7.1 FDs/minute (±3.2) occurred before ventilation. Rate of high impact FDs was associated with a ventilation delay; a one FD/minute increase in rate of high impact FDs was associated with a 19.0 second (95% confidence interval 4.6-33.4) ventilation delay and delay in pulse oximetry acquisition. Rate of medium impact FDs was associated with a delay in SpO≥ 85%.

Conclusion: FDs occur frequently during DR intubation of neonates with CDH, and high impact FDs are associated with longer time to initiate invasive ventilation. FDs represent modifiable targets to improve CDH intubation and may generalize to other neonatal intubations.

Abbreviations: CDH: congenital diaphragmatic hernia, DR: delivery room, , ETT: endotracheal tube, FDs: flow disruptions, IQR: interquartile range, LHR: lung to head ratio, NRP: Neonatal Resuscitation Program, O/E LHR: observed to expected lung to head ratio, PICU: pediatric Intensive care unit, SD: standard deviation, SDU: Special Delivery Unit, SpO: oxygen saturation.