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


A retrospective chart review was conducted for all ELBW infants ≤1000 g born at Lucile Packard Children's Hospital at Stanford between January 2007 and May 2014. This study population was a convenience sample of available electronic data from our institution. This study was approved by our institutional review board, and all research components adhered to institutional ethical human research guidelines.

Medical record numbers were identified using the Stanford Translational Research Integrated Database Environment (STRIDE) with the following search criteria: (1) birth weight≤1000 g, and (2) date of birth within the study period.[15] Chart reviews were conducted for all infants identified by STRIDE. Infants were included in the final analysis 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. These inclusion criteria were developed to identify unstable ELBW infants requiring resuscitation after birth—a group that may benefit from rapid establishment of effective ventilation. Intubation attempt was defined as insertion of laryngoscope blade into the airway. There is no standard policy at our institution for routine intubation of ELBW infants in the delivery room. Intubation was performed at the discretion of the individual provider and was based on the clinical status of the infant. Surfactant is not administered in the delivery room at our institution.

Infants were excluded if birth occurred at an outside hospital, if delivery record details were insufficient to establish number of intubation attempts, or if long-term follow-up data were unavailable.

Demographic, maternal and postnatal information was collected. Number of attempts until successful intubation was recorded. Infants intubated on the first attempt were compared with infants who required multiple intubation attempts. The primary outcome was a composite of death or neurodevelopmental impairment at 18 to 22 months of age, which was defined as any one of the following: cognitive composite score≤70 on the Bayley Scales of Infant and Toddler Development, third edition,[16] moderate or severe cerebral palsy, severe hearing impairment, or bilateral visual impairment. Cerebral palsy was defined as non-progressive abnormality of muscle tone in one or more extremities.[17] Hearing impairment was defined as severe impairment indicated by formal audiology evaluation. Visual impairment was defined as vision worse than 20/200. Similar criteria for neurodevelopmental impairment have been used in prior studies of ELBW infants.[18] Scores from the Capute Scales (a norm-referenced developmental assessment tool that is highly correlated with the Bayley Scales) were used if Bayley Scales of Infant and Toddler Development, third edition scores were not available, with neurodevelopmental impairment defined by adjusted full scale Capute developmental quotient ≤70. The Capute full scale developmental quotient is a composite of the cognitive adaptive test for visual-motor development and the Clinical Linguistic and Auditory Scale for language development.

Delivery room outcomes included 5 min Apgar score, chest compressions initiated after first intubation attempt, and use of epinephrine (either intravenous or endotracheal). Neonatal outcomes included severe intraventricular hemorrhage (IVH, grade 3 or 4), bronchopulmonary dysplasia, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC, Bell stage II or greater), severe retinopathy of prematurity (ROP), pneumothorax and patent ductus arteriosus. Bronchopulmonary dysplasia was defined as use of supplemental oxygen at 36 weeks postmenstrual age. Severe retinopathy of prematurity was defined as threshold retinopathy or the need for ophthalmologic intervention.[19]

Statistical analysis was performed using the Statistical Analysis Software, version 4.1 (SAS Institute, Cary, NC, USA, 2003). Measures of central tendency were used to describe data, including mean, s.d., median and interquartile range for continuous variables. Binary and categorical variables were described using frequencies and percentages. Infants successfully intubated on the first attempt were compared with infants who required multiple attempts using Student's t-test, the χ 2 test, Fisher's exact test and the Wald test as appropriate. Multivariable logistic regression was used to adjust for potential confounding variables, including birth weight, gestational age, sex and antenatal steroid administration. Statistical significance was set as a P-value of <0.05.