Interventions
All neonates were monitored using a Philips monitor (IntelliVue MX450)
that displayed the real-time peripheral oxygen saturation
(SpO2) and heart rate prior to, during, and after the
procedure.
The patients were divided into two groups: the NIPPV group and the
standard care group. In the NIPPV group, NIPPV was implemented during
the entire intubation process (pre-intubation to intubation to the end
of successful intubation). Appropriately-sized short binasal prongs
(Fisher & Paykel, New Zealand) were placed prior to laryngoscopy as
interface for NIPPV implementation. NIPPV was implemented using Leoni
Plus (Löwenstein Medical, Bad Ems, Germany) mechanical ventilator.
Non-synchronized NIPPV was implemented. NIPPV was initiated prior to
intubation, with the peak inspiratory pressure set to 16–20
cmH2O (selected according to the infant’s birth weight
and chest wall expansion), positive-end expiratory pressure (PEEP) set
to 6 cmH2O, breathing rate set to 40–50 breaths/min,
inspiratory time set to 0.40–0.45 s, and flow rate set to 8–12 L/min.
After the first successful intubation attempt, NIPPV was discontinued.
Prior to laryngoscopy, the fraction of inspired oxygen
(FiO2) was adjusted to maintain SpO2above 90%. In the standard care group, the intubation attempt proceeded
without NIPPV or supplemental oxygen. In the event of failure in the
intubation attempt, SpO2 was increased above 90%, and
the heart rate was increased above 120/min by applying positive pressure
ventilation using a face mask prior to initiating the next intubation
procedure.
If the infant was crying or agitated, midazolam was administered as
pre-medication. No medication other than midazolam was used for sedation
or premedication. The size of the intubation tube was determined based
on the baby’s body weight.13 Stylet was not used
during intubation.
Endotracheal intubations were performed either by pediatric research
assistants or a neonatologist. A conventional laryngoscope with a
straight blade was used for the intubation. Video laryngoscope was not
used. Data accuracy was ensured by videotaping the monitor-displayed
heart rate and SpO2 during the intubation procedure.
After intubation, an independent assessor who was not part of the
intubation team reviewed all recorded videos to document the obtained
data on a case report form.