Factors that impact second attempt success for neonatal intubation following first attempt failure: A report from the National Emergency Airway Registry for Neonates

Objective To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. Design Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Setting Eighteen academic NICUs in NEAR4NEOS. Patients Neonates requiring two or more attempts at intubation between October 2014 and December 2021. Main outcome measures The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. Results 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. Conclusions Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.