Failed Endotracheal Intubation and Adverse Outcomes Among Extremely Low Birth Weight Infants

MB Wallenstein; KL Birnie; YH Arain; W Yang; NK Yamada; LC Huffman; JP Palma; VY Chock; GM Shaw; DK Stevenson


J Perinatol. 2016;36(2):112-115. 

In This Article

Abstract and Introduction


Objective: To quantify the importance of successful endotracheal intubation on the first attempt among extremely low birth weight (ELBW) infants who require resuscitation after delivery.

Study Design: A retrospective chart review was conducted for all ELBW infants ≤1000 g born between January 2007 and May 2014 at a level IV neonatal intensive care unit. Infants were included if intubation was attempted during the first 5 min of life or if intubation was attempted during the first 10 min of life with heart rate <100. The primary outcome was death or neurodevelopmental impairment. The association between successful intubation on the first attempt and the primary outcome was assessed using multivariable logistic regression with adjustment for birth weight, gestational age, gender and antenatal steroids.

Results: The study sample included 88 ELBW infants. Forty percent were intubated on the first attempt and 60% required multiple intubation attempts. Death or neurodevelopmental impairment occurred in 29% of infants intubated on the first attempt, compared with 53% of infants that required multiple attempts, adjusted odds ratio 0.4 (95% confidence interval 0.1 to 1.0), P<0.05.

Conclusion: Successful intubation on the first attempt is associated with improved neurodevelopmental outcomes among ELBW infants. This study confirms the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation after birth and has implications for personnel selection and role assignment in the delivery room.


Endotracheal intubation can be a lifesaving procedure for newborn infants with inadequate ventilation after birth.[1,2] The process of intubation itself is associated with adverse physiologic changes, including increased intracranial pressure and rapid deterioration of heart rate and oxygen saturation.[3–8] Failed or prolonged intubation attempts lead to persistence of these physiologic changes and persistence of inadequate ventilation and oxygenation.

Rapid and effective intubation is ideal. However, in a recent study of delivery room resuscitation, only 30% of infants were successfully intubated on the first attempt and 40% required three or more attempts,[9] primarily due to failed attempts by inexperienced trainees.[3,9,10]

Extremely low birth weight (ELBW) infants who receive cardiopulmonary resuscitation have increased risk of mortality and neurological injury.[11–13] However, extensive resuscitative measures often occur before establishing adequate ventilation.[14] We hypothesize that rapid intubation may obviate the need for cardiopulmonary resuscitation and, in turn, improve neonatal morbidity and mortality.

Our objective was to investigate whether intubation on the first attempt compared with failed first attempt was associated with less death or neurodevelopmental impairment among ELBW infants who required resuscitation after delivery.