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


Among ELBW infants who required resuscitation at birth, successful intubation on the first attempt was associated with reduced risk of death or neurodevelopmental impairment compared with infants requiring multiple intubation attempts. Our results emphasize the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation in the delivery room, which is consistent with prior studies.[3]

Our stringent inclusion criteria selected for the most critically ill ELBW infants at birth—a group that has been shown to have an increased risk of morbidity and mortality compared with other ELBW cohorts.[11–13] However, the frequency of adverse outcomes was low among infants who were intubated on the first attempt. Likewise, higher frequencies of adverse outcomes were associated with failed intubation. For example, almost 1/3 of infants who required multiple intubation attempts also received chest compressions or epinephrine in the delivery room. Based on these results, it appears that rapid establishment of an effective airway may mitigate some of the risks associated with extensive resuscitation, especially if the primary cause of clinical instability is ineffective oxygenation and ventilation.

On the other hand, it is possible that ELBW infants who are predisposed to death or neurodevelopmental impairment are also more difficult to intubate at birth. This explanation seems unlikely, given similar baseline characteristics between the two groups of infants, with the exception of sex, and no biologically plausible mechanism.

In addition to neurodevelopmental outcomes, successful intubation was also associated with non-significant trends towards reduced risks of adverse delivery room and neonatal outcomes, including cardiopulmonary resuscitation, severe IVH, PVL, NEC and pneumothorax. The adverse physiologic changes associated with failed intubation, such as increased intracranial pressure or prolonged hypoxia, may contribute to these outcomes, which themselves may contribute to long-term neurodevelopmental impairment among infants requiring multiple intubation attempts.

We observed that male infants were less likely to be intubated on the first attempt. Analysis of the primary outcomes stratified by sex suggests that patient sex alone did not account for the risk reduction between infants intubated on the first attempt and those who were not. The lower likelihood of successful intubation among males may be due to chance, but there is some evidence that male sex is associated with poorer laryngoscopic view in children,[20] and that male infants require more extensive resuscitation than female infants.[21] Difficulty with airway management among males may contribute to overall sex differences in long-term outcomes among ELBW infants.[22] However, the present study was not designed to answer this question.

Our results lead us to speculate that airway management of ELBW infants in the delivery room should be reserved for experienced practitioners. Endotracheal intubation of ELBW infants by resident trainees, whose success rates are as low as 20%,[23] should be limited to controlled settings in the neonatal intensive care unit where effective bag-mask ventilation has already been established. Efforts to provide adequate intubation experience to residents, which is lacking at many institutions,[10] should focus on simulation training or more stable patient populations.

There are several major limitations of the present study. First, our sample size was small and not sufficiently powered to detect differences in secondary outcomes. Second, the generalizability of our results is unclear, given that our study population was derived from a single tertiary neonatal intensive care unit. Third, more detailed resuscitation information, including training level of the initial intubator and specific reason for initial intubation, was not available.