Resident Childrens Hospital of Philadelphia Philadelphia, Pennsylvania, United States
Background: Infants in the neonatal intensive care unit (NICU) are often intubated for prolonged durations and may require an endotracheal tube (ETT) exchange for many reasons including air leak, obstruction, or inadequate ventilation or oxygenation. ETT exchanges are the placement of a new ETT when one is already in place, and can be compared to primary intubations, where an ETT is not yet in place. Limited data exist about the prevalence and outcomes of neonatal ETT exchanges. Objective: To compare the success and safety of neonatal ETT exchanges vs primary intubations in the NICU Design/Methods: Retrospective cohort study using prospectively collected data from the National Emergency Airway Registry for Neonates (NEAR4NEOS) from 10/2014-09/2022. Exclusion criteria included non-NICU intubations, first attempts by non-NICU providers, and patients with airway anomalies. We evaluated the association between ETT exchanges vs primary intubations on success and safety outcomes. Our primary outcome was first attempt success, and secondary outcomes were number of attempts, course success, adverse tracheal intubation associated events (TIAEs), severe TIAEs, severe desaturation, and bradycardia. Patient, provider, and practice characteristics were compared between ETT exchanges and primary intubations. Univariable and multivariable analyses compared primary and secondary outcomes of ETT exchanges and primary intubations. Characteristics that varied between types of intubation with a p-value < 0.2 were included in multivariable analyses. A p-value < 0.05 was considered significant. Results: There were 1572 ETT exchanges and 9999 primary intubations across 21 sites; site-specific ETT exchange prevalence ranged from 2.3 to 31.2% (Figure 1). Patient, provider, and practice characteristics varied significantly between ETT exchanges and primary intubations (Table 1). In univariable analyses, ETT exchanges were associated with significantly higher first-attempt success (70.5% vs 53.6%; p< 0.001) and fewer adverse safety events (Table 2). After adjusting for patient, provider, and practice characteristics, ETT exchanges were independently associated with an increased adjusted odds ratio (aOR) of first-attempt success (aOR 1.71; 95% CI 1.57-1.86; p< 0.001; Table 2). ETT exchanges were independently associated with lower odds of all secondary safety outcomes except severe TIAEs.
Conclusion(s): Almost all patient, provider, and practice characteristics differed between ETT exchanges and primary intubations. Compared to primary intubations, ETT exchanges were associated with higher first-attempt success and fewer adverse safety events.
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