Associate Professor Stony Brook Children's Hospital Stony Brook, New York, United States
Background: Neonatal intubation is lifesaving, but malposition of the endotracheal tube (ETT) tip can result in morbidity or death. To overcome malposition in neonates, the Neonatal Resuscitation Program (NRP) replaced the previously recommended 7-8-9 rule (weight in Kg + 6cm) with the Naso-tragus length (NTL) formula or the gestational age-based (GA) table. However, despite this NRP recommendation, some clinicians still use the 7-8-9 rule. By surveying the American Academy of Pediatrics (AAP) Section on Neonatal-Perinatal Medicine (SONPM) members to evaluate provider’s compliance with the NRP recommendations, we hypothesized that most providers would prefer the 7-8-9 rule. Objective: This study aims to evaluate the compliance of neonatal care providers to the current NRP recommendation for ETT depth determination and the reasons for either compliance or non-compliance. Design/Methods: A cross-sectional survey of the AAP SONPM members approved by the SONPM leadership and the Stony Brook Institutional Review Board was conducted from September 2022 to March 2023. The survey questions included provider training, years of experience, intubation frequency, the neonatal intensive care unit (NICU) levels, who frequently performs intubation, ETT depth determination methods for neonates ≤1500g and >1500g at birth, reasons for the method chosen, and the reason for non-compliance with the NTL or GA table. A priori sample size calculation based on 4,500 SONPM members indicated that 642 survey responses would provide a confidence level of 80% and a confidence interval of 5%. Categorical variables were compared using chi-square or Fisher’s exact test, and the significance level was set at P < 0.05. Results: The 716 responders were 0.42%, 4.62%, 40.98%, and 53.99% from level 1, level 2, level 3, and level 4 NICU, respectively. 77.5% were neonatologists, 59.% had >10 years of intubation experience, 19.3% intubated ≥3 per month, and most intubations (33.08%) were by nurse practitioners. The 7-8-9 rule was the preferred method for ETT depth determination (p-value < 0.0001). “Simplicity” was the reason for the 7-8-9 preference in 66.6% (≤1500g) and 69.7% (>1500g) of responders. While “unavailable measuring tape” was the reason for non-compliance in 60.3% (≤1500g ) and 63.1% (>1500g) of the responders, “unavailable GA table” was the reason for non-compliance in 53.7% (≤1500g) and 62.8% (>1500g) respectively.
Conclusion(s): Our survey showed that most neonatal care providers use the 7-8-9 rule for ETT depth determination. Our result underscores the need to refine and modify the current insertion depth guidelines.
