Ellen de Kort

10 Chapter 1 the premedication regimen should have a rapid onset and a short duration of action, and possess no substantial side effects. The American Academy of Pediatrics suggested the ideal premedication strategy to consist of a vagolytic drug to prevent bradycardia, an analgesic or hypnotic drug to control pain and/or reduce the level of consciousness, and a muscle relaxant to provide ideal intubating conditions. 22-24 In the last decade, however, the focus changed more and more towards research into a single drug regimen such as propofol, remifentanil or fentanyl. Today, almost 40 years after the first report on the harmful effects of awake endotracheal intubation, the optimal premedication strategy for endotracheal intubation in newborns is still not known. 25 Even with the use of premedication, endotracheal intubation in newborns remains a difficult and high-risk procedure that often requires multiple attempts for successful completion. The overall first attempt success rate is only about 50%, with variations depending on the level of experience of the provider. 26-33 Several studies have shown that endotracheal intubation is frequently accompanied by severe and non-severe adverse events. 26,31,34-36 These data suggest that there is an urgent need to improve success and safety in neonatal endotracheal intubations. Although patients within the field of neonatology seem rather uniform, there are remarkable differences between the larger late preterm and term born neonates on one side and the much smaller very and extremely preterm infants on the other side. These differences lie for example in the underlying diseases causing respiratory insufficiency, and in the risk of developing ventilator-induced lung injury and bronchopulmonary dysplasia (BPD). In late preterm and term born neonates respiratory distress is mostly caused by perinatal associated complications, for example asphyxia, group B streptococcus infection/pneumonia or meconium aspiration syndrome. These diseases have a longer duration of recovery and, therefore, often need mechanical ventilation for a period of several days or more. Despite this, the risk of ventilator-induced lung injury for this category of patients is limited. Although in smaller preterm infants diseases such as infection, pneumonia or necrotizing enterocolitis are also frequent causes of respiratory insufficiency, one of the major conditions for respiratory insufficiency is respiratory distress syndrome (RDS). 37 A substantial part of the preterm population requires surfactant therapy for RDS, which is historically administered as a bolus via the endotracheal tube during a period of mechanical ventilation. 38 Mechanical ventilation in preterm infants can further disrupt alveolarization and growth of the pulmonary vasculature, and activate inflammatory pathways which can lead to damage to the preterm lung. Eventually, this can result in BPD. 39