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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.


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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.

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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 42, 1216–1220 (2022).

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