Supervisor instruction during neonatal intubation using video laryngoscopy: an observational study

Supervisors of intubation mostly rely on feedback from operators to guide intubation attempts using direct laryngoscopy (DL). In contrast, when using video laryngoscopy (VL), supervisors share the operators' view of the airway during intubation attempts which may allow for better guidance. We wished to analyse the instructions given by supervisors during neonatal VL intubation and assess whether they prompted operators to perform the desired actions.

We reviewed video recordings of neonatal intubations that combined the airway views captured with VL, synchronised with external video and audio recording of the procedure. We performed a thematic analysis of the supervisors' instructions and assessed whether they prompted the intended actions.

We analysed 59 intubation attempts and 158 instructions from 14 supervisors. We identified five main themes: adjusting the position of the laryngoscope blade, identifying anatomical landmarks, aligning the airway axes, introducing the endotracheal tube, and general guidance. Most instructions focused on the lift manoeuvre-aimed at aligning the oral, pharyngeal and laryngeal axes-but lacked clarity, and so were frequently misunderstood. Anatomical landmarks were seldom referenced. Two-step instructions often failed to elicit the desired actions. Overall, 47% of instructions prompted the intended actions. Based on our findings, we developed a proforma to support the supervision of neonatal intubation using VL.

Supervisor instructions during neonatal intubation with VL often lacked precision and clarity, with fewer than half resulting in the desired action. Improved communication is needed to optimise intubation attempts using VL.