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Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study



We examined the association between the number of tracheal intubation (TI) attempts and clinical outcomes in extremely preterm infants.


This is a single-center retrospective cohort study examining infants born at ≤28 weeks gestation intubated within the first four postnatal days. We analyzed infant, provider, and practice characteristics and clinical outcomes by exposure groups (1 vs. 2 vs. ≥3 TI attempts). Primary outcomes were death prior to NICU discharge or severe intraventricular hemorrhage (IVH).


Ninety-nine infants were included. 46.5% required one TI attempt, 29.3% required two, and 24.2% required three or more. Increasing attempts was significantly associated with death (p = 0.004), adverse tracheal intubation-associated events (TIAEs; p = 0.004), and the training level of the first attempt provider (p = 0.002). No association was found with severe IVH or complications of prematurity.


Increasing attempts was associated with death and adverse TIAEs. Careful selection of providers could decrease adverse TIAEs and improve outcomes.

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Data availability

The data supporting the findings of this study are available from the corresponding author upon request.


  1. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, te Pas A, et al. European consensus guidelines on the management of respiratory distress syndrome–2019 update. Neonatology 2019;115:432–50.

    Article  Google Scholar 

  2. Sawyer T, Foglia E, Hatch LD, Moussa A, Ades A, Johnston L, et al. Improving neonatal intubation safety: a journey of a thousand miles. J Neonatal-Perinat Med. 2017;10:125–31.

    CAS  Article  Google Scholar 

  3. Gleiβner M, Jorch G, Avenarius S. Risk factors for intraventricular hemorrhage in a birth cohort of 3721 premature infants. J Perinat Med. 2000;28. Available from:

  4. Ballabh P. Intraventricular hemorrhage in premature infants: mechanism of disease. Pediatr Res. 2010;67:1–8.

    Article  Google Scholar 

  5. Bassan H. Intracranial hemorrhage in the preterm infant: understanding it, preventing it. Clin Perinatol. 2009;36:737–62.

    Article  Google Scholar 

  6. Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, et al. Neonatal intubation practice and outcomes: an international registry study. Pediatrics 2019;143:e20180902.

    Article  Google Scholar 

  7. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60:749–754.e2.

    Article  Google Scholar 

  8. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20:71–8.

  9. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts: Anesth Analg. 2004;99:607–13.

  10. Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatr Anesth. 2014;24:1204–11.

  11. Choi HJ, Je SM, Kim JH, Kim E. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study. Resuscitation 2012;83:1363–8.

    Article  Google Scholar 

  12. Wallenstein MB, Birnie KL, Arain YH, Yang W, Yamada NK, Huffman LC, et al. Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants. J Perinatol. 2016;36:112–5.

    CAS  Article  Google Scholar 

  13. Debay A, Patel S, Wintermark P, Claveau M, Olivier F, Beltempo M. Association of delivery room and neonatal intensive care unit intubation, and number of tracheal intubation attempts with death or severe neurological injury among preterm infants. Am J Perinatol. 2020;19:s-0040–1718577.

    Google Scholar 

  14. Sauer CW, Kong JY, Vaucher YE, Finer N, Proudfoot JA, Boutin MA, et al. Intubation attempts increase the risk for severe intraventricular hemorrhage in preterm infants—a retrospective cohort study. J Pediatr. 2016;177:108–13.

    Article  Google Scholar 

  15. Papile L-A, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92:529–34.

    CAS  Article  Google Scholar 

  16. Vermont Oxford Network. Available from:

  17. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39:1376–80.

    CAS  Article  Google Scholar 

  18. Lee JH, Turner DA, Kamat P, Nett S, Shults J, Nadkarni VM, et al. The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study. BMC Pediatr. 2016;16:58.

    Article  Google Scholar 

  19. Haubner LY, Barry JS, Johnston LC, Soghier L, Tatum PM, Kessler D, et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation 2013;84:1359–64.

    Article  Google Scholar 

  20. Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr. 2005;146:638–41.

    Article  Google Scholar 

  21. Johnston L, Sawyer T, Ades A, Moussa A, Zenge J, Jung P, et al. Impact of physician training level on neonatal tracheal intubation success rates and adverse events: a report from National emergency airway registry for neonates (NEAR4NEOS). Neonatology 2021;118:434–42.

    Article  Google Scholar 

  22. Johnston LC, Chen R, Whitfill TM, Bruno CJ, Levit OL, Auerbach MA. Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation. BMJ Simul Technol Enhanc Learn. 2015;1:12–8.

    Article  Google Scholar 

  23. Xiao X, Zhao S, Meng Y, Soghier L, Zhang X, Hahn J A Physics-based Virtual Reality Simulation Framework for Neonatal Endotracheal Intubation. In: 2020 IEEE Conference on Virtual Reality and 3D User Interfaces (VR) [Internet]. Atlanta, GA, USA: IEEE; 2020 [cited 2021 Oct 6]. p. 557–65. Available from:

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The authors are grateful to the National Emergency Airway Registry for Neonates (Near4Neos) for the intubation database and the respiratory therapists and nursing staff for recording the intubation and airway events.

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Authors and Affiliations



KEM assisted with the design of the study, organized the data, carried out the analysis, drafted the initial manuscript, and reviewed and revised the manuscript for intellectual content. NS conceptualized and designed the study, collected data, assisted with the analysis, and reviewed and revised the manuscript for intellectual content. Both authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Kathleen E. Miller.

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The authors declare no competing interests.

Ethics approval

All components of this research project adhered to the intuition’s research guidelines and ethical standards. The institutional review board (IRB) approved this study.

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Miller, K.E., Singh, N. Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study. J Perinatol (2022).

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