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Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates
  1. Mitchell David Johnson1,2,
  2. David Gerald Tingay1,2,
  3. Elizabeth J Perkins2,
  4. Arun Sett2,3,
  5. Bianca Devsam1,2,
  6. Ellen Douglas2,
  7. Julia K Charlton4,5,
  8. Paul Wildenhain6,
  9. Jennifer Rumpel7,
  10. Michael Wagner8,
  11. Vinay Nadkarni9,
  12. Lindsay Johnston10,
  13. Heidi M Herrick11,
  14. Tyler Hartman12,
  15. Kristen Glass13,
  16. Philipp Jung14,
  17. Stephen D DeMeo15,
  18. Rebecca Shay16,
  19. Jae H Kim17,
  20. Jennifer Unrau18,
  21. Ahmed Moussa19,20,
  22. Akira Nishisaki21,
  23. Elizabeth E Foglia11
  24. for the National Emergency Airway Registry for Neonates (NEAR4NEOS) investigators
  1. 1 Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
  2. 2 Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
  3. 3 Newborn Services, Western Health, St Albans, Victoria, Australia
  4. 4 Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
  5. 5 Division of Neonatology, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
  6. 6 The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  7. 7 Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
  8. 8 Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University Vienna, Vienna, Austria
  9. 9 Department of Anesthesiology, Critical Care, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  10. 10 Department of Pediatrics, Yale University, New Haven, Connecticut, USA
  11. 11 Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  12. 12 Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
  13. 13 Department of Pediatrics, Penn State Health Children’s Hospital/Penn State College of Medicine, Hershey, Pennsylvania, USA
  14. 14 Department of Pediatrics, University Hospital Schleswig-Holstein, Luebeck, Germany
  15. 15 Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
  16. 16 Department of Pediatrics, Division of Neonatology, University of Colorado, Aurora, Colorado, USA
  17. 17 Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  18. 18 Newborn Critical Care, Alberta Children's Hospital, Calgary, Alberta, Canada
  19. 19 Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
  20. 20 CHU Sainte-Justine Research Centre, Université de Montréal, Montreal, Quebec, Canada
  21. 21 Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Mitchell David Johnson, Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia; mitchell.johnson{at}rch.org.au

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.

  • Intensive Care Units, Neonatal
  • Neonatology
  • Resuscitation

Data availability statement

Data are available upon reasonable request. Individual subject data collected during the study and statistical analysis will be available beginning at 12 months and ending 5 years after article publication to researchers who provide a methodologically sound proposal with approval by the NEAR4NEOS Manuscript Oversight Committee. Data will be available for analysis to achieve aims in the approved proposal. Proposals should be directed to buffmanH@chop.edu; to gain access, data requestors will need to sign a data access agreement approved by the Children’s Hospital of Philadelphia.

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Data availability statement

Data are available upon reasonable request. Individual subject data collected during the study and statistical analysis will be available beginning at 12 months and ending 5 years after article publication to researchers who provide a methodologically sound proposal with approval by the NEAR4NEOS Manuscript Oversight Committee. Data will be available for analysis to achieve aims in the approved proposal. Proposals should be directed to buffmanH@chop.edu; to gain access, data requestors will need to sign a data access agreement approved by the Children’s Hospital of Philadelphia.

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Footnotes

  • Presented at Preliminary results of this work were presented at the Perinatal Society of Australia and New Zealand (PSANZ) 2023 Congress and the conference abstract was published under the title ‘Factors that increase neonatal endotracheal intubation success on the second attempt: changing people or toys?’ (PSANZ 2023 - Oral, Journal of Paediatrics and Child Health, 2023;59(S1):4–54).

  • Contributors MDJ contributed to the conception and design of the study, analysed and interpreted the data, drafted the initial manuscript, and reviewed and revised the manuscript. MDJ is the guarantor. DGT, JKC, AS, EEF and AN contributed to the conception and design of the study, contributed to the analysis and interpretation of the data, and critically reviewed and revised the manuscript for important intellectual content. EJP, BD, ED, PW, JR, MW, VN, LJ, HMH, TH, KG, PJ, SDD, RS, JHK, JU and AM contributed to the acquisition of the data and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript and agree to be accountable for all aspects of the work.

  • Funding MDJ, AS, EJP, BD and DGT are supported by the Victorian Government Operational Infrastructure Support Program (Melbourne, Australia). DGT is supported by a National Health and Medical Research Council Level 1 Leadership Investigator Grant (ID 2008212). EJP and BD are supported by a Royal Children’s Hospital Foundation Grant (ID 2019-1155). NEAR4NEOS is supported by an NIH funding (1R01HD106996-01A1 to EEF). HMH is supported by an AHRQ career development award (K08HS029029). VN receives unrestricted research grants to his institution from the National Institutes of Health, AHRQ, US Department of Defence, American Heart Association, Laerdal Foundation and Zoll Medical.

  • Competing interests VN serves as the President of the Society of Critical Care Medicine (SCCM) 2023–2024. The views expressed in this manuscript are his and not intended to represent the opinions of the SCCM.

  • Provenance and peer review Not commissioned; externally peer reviewed.