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Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS



To determine the relationship between number of attempts and adverse events during neonatal intubation.

Study design

A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation).


Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt.


The risk of adverse safety events during intubation increases with the number of intubation attempts.

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Fig. 1
Fig. 2: Number of intubation attempts and outcome.


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This research was supported by NICHD R21 HD089151. Akira Nishisaki was supported by NICHD R21 HD089151 and AHRQ R18HS024511. EEF was supported by NICHD K23HD084727 and is a consultant for Medtronic. Natalie Napolitano was supported by NICHD R21 HD 089151 and AHRQ R18HS024511 and have research and/or consulting relationships with Drager, Actuated Medical, Smiths Medical, and VERO-Biotech. DGT is supported by a National Health and Medical Research Council (Australia) Investigator (Grant ID 2008212) and the Victorian Government Operational Infrastructure Support Program (Melbourne, Australia).

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Authors and Affiliations




NS conceptualized and designed the study, analyzed the data, drafted the initial manuscript, and reviewed and revised the manuscript. All authors except JS coordinated and supervised data collection. JS and AN performed statistical analyses. All authors participated in data collection in their respective sites, interpreted the data and critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Neetu Singh.

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The authors have no conflicts of interest to declare. JB and NS are the site principal investigator for aerosolized surfactant clinical trial phase 2b sponsored by Aerogen.

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Singh, N., Sawyer, T., Johnston, L.C. et al. Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 42, 1221–1227 (2022).

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