540 - Apneic oxygenation with nasal high flow during neonatal intubation: a prospective audit

Publication Number: 3521.540

Tugba Alarcon Martinez, The Royal Women's Hospital, Melbourne, Victoria, Australia; Brett J. Manley, The University of Melbourne, Kensington, Victoria, Australia; Louise S. Owen, Royal Women's Hospital, Melbourne, Victoria, Australia; Peter G. Davis, University of Melbourne, Melbourne, Victoria, Australia; Kate Hodgson, Royal Women’s Hospital, Parkville, Victoria, Australia

Background: Neonates are more prone to instability during intubation than children and adults. The SHINE trial (N Engl J Med 2022;386:1627-1637) demonstrated that using nasal high flow (nHF) during intubation increased the rate of intubation success at first attempt, whilst reducing oxygen desaturation. The safety and efficacy of this procedure outside the context of a randomized trial are uncertain.

Objective: To review the implementation of nHF during elective intubation at The Royal Women's Hospital (RWH) Neonatal Intensive Care Unit (NICU), by assessing the procedural and clinical outcomes associated with this practice.

Design/Methods: Following the formulation of a treatment protocol and intensive education of nursing and medical staff, the use of nHF during intubation was introduced for premedicated patients in NICU. Data were collected from Nov 2022 to Sept 2025. The clinical team recorded baseline and procedural data during intubation. Demographic data, observations, and subsequent adverse events were collected from medical records. The study was approved by the RWH Human Research Ethics Committee (AQA 25.13)

Results: Of 302 intubations performed in the NICU, 158 (52%) utilized nHF in 148 infants. The median gestational age of infants was 28 (interquartile range [IQR] 25-36) weeks and median birth weight 1129 (IQR 731, 2512) g (Table 1). The most common nHF settings used were; flow 8L/min (77%), fraction of inspired oxygen 1.0 (64%) (Table 2). Among survey respondents, 67/90 (75%) reported time to apply prongs was < 10 seconds. Twenty-three respondents (26%) reported challenges with nHF use, most commonly difficulty inserting prongs (8/90, 9%) and prongs falling out (13/90, 14%). A successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia to a heart rate of < 100 beats per minute) was achieved in 71/120 intubations (59%) (Table 3). This was similar to the success rate in the premedicated treatment group in the RCT (54%). 80% of intubations using nHF were successful on the first attempt, regardless of physiological stability. No infant experienced an intubation-related severe adverse event, defined as cardiac arrest or pneumothorax.

Conclusion(s): Implementation of apneic oxygenation with nHF during neonatal intubation is safe and effective, when supported by appropriate education and protocol development. This practice enhances the rate of successful first-attempt intubations, corroborating findings from the SHINE trial.

Table 1- Characteristics of infants and intubations performed by using nasal high flow
*Analysis was performed in 148 infants. #Data are available from 150 intubations. IQR denotes interquartile range.

Table 2- Characteristics of high flow application


Table 3- Outcomes of intubations performed using nasal high flow
#Data are available from 147 intubations.
*Physiological instability was defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute.