Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates

Arch Dis Child Fetal Neonatal Ed. 2019 Sep;104(5):F461-F466. doi: 10.1136/archdischild-2018-316336. Epub 2019 Feb 22.


Objective: To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU).

Design: Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates.

Setting: Ten academic NICUs.

Patients: Neonates intubated in the NICU at each of the sites between October 2014 and March 2017.

Main outcome measures: Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation.

Results: Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53).

Conclusions: Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.

Keywords: difficult airway; difficult intubation; intubation failure; intubation success; neonatal intubation.

MeSH terms

  • Airway Management / methods
  • Clinical Competence*
  • Emergencies / epidemiology*
  • Female
  • Humans
  • Hypoxia* / etiology
  • Hypoxia* / prevention & control
  • Incidence
  • Infant, Newborn
  • Infant, Premature
  • Intensive Care Units, Neonatal* / standards
  • Intensive Care Units, Neonatal* / statistics & numerical data
  • Intubation, Intratracheal* / adverse effects
  • Intubation, Intratracheal* / methods
  • Intubation, Intratracheal* / standards
  • Intubation, Intratracheal* / statistics & numerical data
  • Male
  • Outcome Assessment, Health Care
  • Practice Patterns, Physicians' / standards
  • Quality Improvement / standards
  • Registries
  • Retrospective Studies
  • United States / epidemiology