Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

Mitchell David Johnson; David Gerald Tingay; Elizabeth J Perkins; Arun Sett; Bianca Devsam; Ellen Douglas; Julia K Charlton; Paul Wildenhain; Jennifer Rumpel; Michael Wagner; Vinay Nadkarni; Lindsay Johnston; Heidi M Herrick; Tyler Hartman; Kristen Glass; Philipp Jung; Stephen D DeMeo; Rebecca Shay; Jae H Kim; Jennifer Unrau; Ahmed Moussa; Akira Nishisaki; Elizabeth E Foglia; National Emergency Airway Registry for Neonates (NEAR4NEOS) investigators

doi:10.1136/archdischild-2023-326501

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

Arch Dis Child Fetal Neonatal Ed. 2024 Feb 28:fetalneonatal-2023-326501. doi: 10.1136/archdischild-2023-326501. Online ahead of print.

Authors

Mitchell David Johnson^{1

2}, David Gerald Tingay^{3

2}, Elizabeth J Perkins², Arun Sett^{2

4}, Bianca Devsam^{3

2}, Ellen Douglas², Julia K Charlton^{5

6}, Paul Wildenhain⁷, Jennifer Rumpel⁸, Michael Wagner⁹, Vinay Nadkarni¹⁰, Lindsay Johnston¹¹, Heidi M Herrick¹², Tyler Hartman¹³, Kristen Glass¹⁴, Philipp Jung¹⁵, Stephen D DeMeo¹⁶, Rebecca Shay¹⁷, Jae H Kim¹⁸, Jennifer Unrau¹⁹, Ahmed Moussa^{20

21}, Akira Nishisaki²², Elizabeth E Foglia¹²; National Emergency Airway Registry for Neonates (NEAR4NEOS) investigators

Affiliations

¹ Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia mitchell.johnson@rch.org.au.
² Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
³ Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.
⁴ Newborn Services, Western Health, St Albans, Victoria, Australia.
⁵ Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.
⁶ Division of Neonatology, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.
⁷ The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
⁸ Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
⁹ Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University Vienna, Vienna, Austria.
¹⁰ Department of Anesthesiology, Critical Care, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
¹¹ Department of Pediatrics, Yale University, New Haven, Connecticut, USA.
¹² Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
¹³ Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.
¹⁴ Department of Pediatrics, Penn State Health Children's Hospital/Penn State College of Medicine, Hershey, Pennsylvania, USA.
¹⁵ Department of Pediatrics, University Hospital Schleswig-Holstein, Luebeck, Germany.
¹⁶ Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina, USA.
¹⁷ Department of Pediatrics, Division of Neonatology, University of Colorado, Aurora, Colorado, USA.
¹⁸ Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
¹⁹ Newborn Critical Care, Alberta Children's Hospital, Calgary, Alberta, Canada.
²⁰ Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.
²¹ CHU Sainte-Justine Research Centre, Université de Montréal, Montreal, Quebec, Canada.
²² Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

PMID: 38418208
DOI: 10.1136/archdischild-2023-326501

Abstract

Objective: To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.

Design: Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS).

Setting: Eighteen academic NICUs in NEAR4NEOS.

Patients: Neonates requiring two or more attempts at intubation between October 2014 and December 2021.

Main outcome measures: The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice.

Results: 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs.

Conclusions: Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.

Keywords: Intensive Care Units, Neonatal; Neonatology; Resuscitation.