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  • Quality Improvement Article
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Eye-tracking during simulated endotracheal newborn intubation: a prospective, observational multi-center study



The aim was to assess health care providers’ (HCPs) visual attention (VA) by using eye-tracking glasses during a simulated neonatal intubation.


HCPs from three pediatric and neonatal departments (Feldkirch and Vienna, Austria, and Edmonton, Canada) completed a simulated neonatal intubation scenario while wearing eye-tracking glasses (Tobii Pro Glasses 2®, Tobii, Stockholm, Sweden) to record their VA. Main outcomes included duration of intubation, success rate, and VA. We further compared orotracheal and nasotracheal intubations.


30 participants were included. 50% completed the intubation within 30 s (M = 35.40, SD = 16.01). Mostly nasotracheal intubations exceeded the limit. Experience was an important factor in reducing intubation time. VA differed between more and less experienced HCPs as well as between orotracheal and nasotracheal intubations. Participants also focused on different areas of interest (AOIs) depending on the intubator’s experience. More experience was associated with a higher situational awareness (SA) and fewer distractions, which, however, did not transfer to significantly better intubation performance.


Half of the intubations exceeded the recommended time limit. Differences in intubation duration depending on type of intubation were revealed. VA differed between HCPs with different levels of experience and depended on duration and type of intubation.


  • Simulated neonatal intubation duration differs between orotracheal and nasotracheal intubation.

  • Visual attention during simulated neonatal intubation shows differences depending on intubation duration, intubator experience, type of intubation, and level of distraction.

  • Intubator experience is a vital parameter for reducing intubation duration and improving intubator focus on task-relevant stimuli.

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Fig. 1: Eye-tracking data.
Fig. 2: Eye-tracking data.
Fig. 3: Eye-tracking data.

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Data availability

The dataset generated and analyzed during this study is available from the corresponding author on reasonable request.


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We acknowledge and thank all participants from the three centers for their contributions to this study.


All authors disclose any type of financial interest related to the manuscript. This study was supported financially by the State of Vorarlberg, Austria (IIb-11.04/35-1/2018). This study was supported by a research grant (Forschungsförderungspreis) from Netzwerk Kindersimulation e.V.

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Authors and Affiliations



Conception and design: B.S., M.W., G.S., and L.K. Data collection: G.A., H.A., M.W., G.S., and L.K. Analysis and interpretation of data: P.G. and L.K. The manuscript was drafted and reviewed by all authors and finally approved by all of them.

Corresponding author

Correspondence to Lisa Kessler.

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The authors declare no competing interests.

Ethics approval and consent to participate

The study was approved by each local ethics committee or data protection committee (Ethics Committee of the State of Vorarlberg, Protocol Number: EK-2-7/2018; Health Research Ethics Board – Health Panel in Edmonton, Study ID: Pro00096926; no ethical vote was necessary for this simulation-based study in Vienna).

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Kessler, L., Gröpel, P., Aichner, H. et al. Eye-tracking during simulated endotracheal newborn intubation: a prospective, observational multi-center study. Pediatr Res 94, 443–449 (2023).

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