Associate Professor of Pediatrics Baylor College of Medicine Houston, Texas, United States
Background: Neonates with congenital heart disease (CHD) may have delayed transition from fetal to extrauterine circulation. They may require modifications to the Neonatal Resuscitation Program (NRP) algorithm to provide better oxygen delivery and meet metabolic demands via an endotracheal intubation (ETT) or supraglottic airway. Objective: To describe the delivery room (DR) presentation of prenatally diagnosed CHD patients admitted to the cardiovascular intensive care unit (CICU) who did and did not require an alternative airway as part of DR resuscitation. Design/Methods: Inborn patients admitted to the CICU at a large children's hospital and delivered between 10/1/2020 and 09/30/2025 were identified from the electronic health record. Baseline characteristics and details of the DR interventions were abstracted from neonatology DR notes. Palliative care patients, patients with fetal demise, and patients admitted to the neonatal intensive care unit were excluded. Results: The table shows baseline characteristics of 416 inborn patients admitted to the CICU; 39 (9%) patients required alternative airway support in the DR. Neonates requiring an alternative airway were significantly more likely to be preterm (p < 0.001) and delivered by cesarean section (p=0.006).
The neonatal resuscitation team arrived prior to delivery for all infants. Fetal distress and / or meconium were present for 16 (41%) patients. Twelve (31%) patients had delayed cord clamping and 9 (23%) patients were not vigorous on arrival to the warmer. Most patients 31/38 (82%) were intubated within 2 attempts.
One patient was briefly supported with a supraglottic device and then extubated. One patient initially required a supraglottic device and was then was intubated with an ETT. For 37 patients, ETT was the initial alternate airway. Fetal CHD diagnoses of patients receiving an alternate airway included transposition of the great arteries (14, 36%), total anomalous pulmonary venous return (6, 15%), hydrops (6, 15%), absent pulmonary valve (2, 5%), hypoplastic left heart with intact atrial septum (2, 5%), Epstein anomaly (2, 5%) complete heart block (2, 5%), supraventricular tachycardia (1, 3%), heart failure (1, 1%), and other diagnoses (7, 18%).
Conclusion(s): Nine percent of inborn neonates admitted to the CICU with fetal diagnosis of CHD required an alternate airway. Neonates requiring DR alternative airway were significantly more likely to be preterm and delivered by cesarean section. Detailed evaluation of individual lesions, modifications to NRP, medications administered other than prostaglandin E, and analysis of cord gases is ongoing.
Table. Baseline Characteristics of Neonates with Prenatally Diagnosed Congenital Heart Disease by Need for Alternative Airway
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