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Success and safety of neonatal endotracheal tube exchanges: a NEAR4NEOS multicentre retrospective cohort study
  1. Kathleen Miller1,
  2. Nicole Pouppirt2,3,
  3. Paul Wildenhain4,
  4. Ayman Abou Mehrem5,
  5. Ivana Brajkovic6,
  6. Cassandra DeMartino7,
  7. Kristen Glass8,
  8. Kate Alison Hodgson9,10,
  9. Philipp Jung11,
  10. Ahmed Moussa12,
  11. Mihai Puia-Dumitrescu13,
  12. Binhuey Quek14,
  13. Jennifer Rumpel15,
  14. Rebecca Shay16,
  15. David Tingay17,18,
  16. Michelle D Tyler19,
  17. Jennifer Unrau5,20,
  18. Michael Wagner21,
  19. Justine Shults1,22,
  20. Akira Nishisaki23,
  21. Elizabeth E Foglia24,25,
  22. Heidi M Herrick24,25
  1. 1Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2Division of Neonatology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
  3. 3Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  5. 5Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  6. 6Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
  7. 7Department of Pediatrics, Division of Neonatology, Yale University School of Medicine, New Haven, Connecticut, USA
  8. 8Department of Pediatrics, Division of Neonatology, Penn State Health Children’s Hospital/Penn State College of Medicine, Hershey, Pennsylvania, USA
  9. 9Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
  10. 10Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
  11. 11Department of Pediatrics, University Hospital Schleswig-Holstein, Luebeck, Germany
  12. 12Department of Pediatrics, Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
  13. 13Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital, Seattle, Washington, USA
  14. 14Division of Neonatology, KK Women's and Children's Hospital, Singapore
  15. 15Department of Pediatrics, Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
  16. 16Department of Pediatrics, Division of Neonatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
  17. 17Royal Children’s Hospital, Melbourne, Victoria, Australia
  18. 18Neonatology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  19. 19Department of Pediatrics, Division of Neonatology, Dartmouth Health Children's, Lebanon, New Hampshire, USA
  20. 20Department of Pediatrics, Division of Neonatology, Alberta Children's Hospital, Calgary, Alberta, Canada
  21. 21Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Intensive Care, and Pediatric Neurology, Medical University Vienna, Vienna, Austria
  22. 22Division of Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  23. 23Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  24. 24Department of Pediatrics, Division of Neonatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  25. 25Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Kathleen Miller; millerk26{at}chop.edu

Abstract

Objectives To compare success and safety of endotracheal tube (ETT) exchanges with primary intubations and identify factors associated with ETT exchange outcomes.

Design Retrospective observational study of prospectively collected National Emergency Airway Registry for Neonates data. ETT exchanges are the placement of a new ETT when one is already in place, whereas primary intubations do not have a pre-existing ETT. The primary outcome was first-attempt success. Secondary outcomes included number of attempts, adverse tracheal intubation-associated events (TIAEs), severe TIAEs, desaturation and bradycardia. Descriptive statistics compared characteristics for ETT exchanges and primary intubations. Univariable and multivariable analyses compared primary and secondary outcomes and identified factors independently associated with ETT exchange outcomes.

Results A total of 1572 ETT exchanges and 9999 primary intubations across 21 sites were included from October 2014 to September 2022. ETT exchanges represented 2.3%–31.2% (mean 13.6%) of intubations across sites. Patient, provider and practice characteristics varied significantly between ETT exchanges and primary intubations. In univariable analyses, ETT exchanges were associated with higher first-attempt success (70.5% vs 53.6%; p<0.001) and fewer safety events. In multivariable analyses, ETT exchanges were associated with an increased adjusted OR (aOR) of first-attempt success (1.71; 95% CI 1.57 to 1.86; p<0.001). ETT exchanges were associated with lower aOR of all safety outcomes except severe TIAEs. Factors independently associated with ETT exchange first-attempt success included video laryngoscopy and paralytic premedication.

Conclusion Compared with primary intubations, ETT exchanges were associated with higher first-attempt success and fewer safety events. Video laryngoscope and paralytic premedication were associated with improved ETT exchange outcomes.

  • Intensive Care Units, Neonatal
  • Neonatology
  • Resuscitation

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/archdischild-2024-328287

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • X @AymanAbouMehrem, @katehodg18

    • Correction notice This paper has been updated since it was first published. An author's surname was incorrect.

    • Contributors KM, EEF and HMH conceptualised and designed this research study. NP, PW, AAM, IB, CD, KG, KAH, PJ, AM, MP-D, BQ, JR, RS, DT, MDT, JU, MW, JS, AN, EEF and HMH coordinated and supervised data collection. KM, PW, JS, AN, EEF and HMH analysed and interpreted the data. KM and HMH drafted the initial manuscript, while all authors (NP, PW, AAM, IB, CD, KG, KAH, PJ, AM, MP-D, BQ, JR, RS, DT, MDT, JU, MW, JS, AN and EEF) critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. HMH is the guarantor.

    • Funding AN and EEF are supported through NICHD R01HD106996, DGT is supported by a NHMRC L1 Grant (2008212) and the Victorian Government Operational Infrastructure Support Program (Melbourne, Australia), and HMH is supported through an AHRQ Career Development Grant (K08HS029029).

    • Competing interests None declared.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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