Stabilisation with Nasal High Flow for Intubation of Neonates: The SHINE Trial

All neonates being intubated in the delivery room or neonatal intensive care unit will be eligible for inclusion. Subsequent intubations in the same neonate will be eligible for inclusion if 1. The premedication/no premedication stratum differs OR 2. There is at least one week between intubations. Patients in the nasal High Flow (nHF) group will receive standard care up until the time of the continuous positive airways pressure (CPAP) face mask or prongs being removed for intubation. At this time, nHF will be applied, with gas flow 8L/min and with FiO2 starting at the previous value. Nasal HF will be applied by one of the researchers. The aim is for babies in both groups to be stable prior to the randomisation and commencement of the intubation attempt. For non-urgent intubations it is expected that the oxygen saturations will generally be >90%. If the infant desaturates to <90%, the FiO2 will be increased to 1.0. In patients receiving premedications for intubation, nHF will be applied after the patient becomes apnoeic (i.e. medications will be administered, intermittent positive pressure ventilation (IPPV) will be provided if required, the CPAP face mask will be removed and then the nHF will be applied). Prongs will be secured underneath the patient’s head, but not with adhesive tape to the face. Nasal HF will continue during laryngoscopy, either until the first intubation attempt is successful, or abandoned and mask CPAP/IPPV is reinitiated, however long this may be. The intubation attempt will be abandoned at clinician discretion. At this time, nHF prongs will be removed. Nasal HF will not be reapplied for subsequent intubation attempts. IPPV will be provided using a standard bag-mask or T-piece (Neopuff), with the nHF prongs removed. Nasal HF will be administered using a portable Vapotherm Precision Flow device and binasal prongs. Only the first intubation attempt will be analysed for the primary and relevant secondary outcomes.