Download PDF
Am J Perinatol 2022; 39(07): 776-785
DOI: 10.1055/s-0040-1718577
Original Article

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

Anthony Debay
1   Faculty of Medicine, McGill University, Montreal, Quebec, Canada
,
Sharina Patel
2   McGill University Health Center Research Institute, Montreal, Quebec, Canada
,
Pia Wintermark
2   McGill University Health Center Research Institute, Montreal, Quebec, Canada
3   Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
,
Martine Claveau
3   Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
,
François Olivier
3   Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
,
Marc Beltempo
3   Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
› Author Affiliations Funding M.B. holds an Early Career Investigator Grant from the CIHR Institute of Human Development, Child and Youth Health. A.D. received a scholarship from Dr. Clarke K. McLeod Memorial Scholarship, McGill University, Montreal, QC, Canada; Michael B. and Mary Elizabeth Wood Summer Research Bursary, McGill University, Montreal, QC, Canada.
› Further Information
    Permissions and Reprints

Abstract

Objective The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants.

Study Design Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3–4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders.

Results Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1–2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21–28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21–10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17–6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47–2.03).

Conclusion The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI.

Key Points

  • Delivery room intubation correlates with morbidity.

  • Less than 2 intubation attempts are not associated with IVH.

  • Provider training reduces intubation attempts.

Keywords

prematurity - brain injury - intraventricular hemorrhage - periventricular leukomalacia - delivery room - premedication

Supplementary Material



Publication History

Received: 17 April 2020

Accepted: 07 September 2020

Article published online:
19 October 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Sweet DG, Carnielli V, Greisen G. et al; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants: 2013 update. Neonatology 2013; 103 (04) 353-368
    CrossrefPubMedGoogle Scholar
  • 2 Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL. Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care Med 1984; 12 (06) 501-503
    CrossrefPubMedGoogle Scholar
  • 3 Biniwale M, Wertheimer F. Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants. Resuscitation 2017; 116: 33-38
    CrossrefPubMedGoogle Scholar
  • 4 Beltempo M, Isayama T, Vento M. et al; on behalf of the International Network for Evaluating Outcomes of Neonates. Respiratory management of extremely preterm infants: an international survey. Neonatology 2018; 114 (01) 28-36
    CrossrefPubMedGoogle Scholar
  • 5 Beltempo M, Carson G, DaSilva O. et al. Canadian Neonatal Network 2018 Annual Report. Toronto, Ontario: . Accessed 2019 at: http://www.canadianneonatalnetwork.org/Portal/LinkClick.aspx?fileticket=PvniYH94zm0%3d&tabid=39
    PubMedGoogle Scholar
  • 6 Aly H, Massaro AN, Patel K, El-Mohandes AA. Is it safer to intubate premature infants in the delivery room?. Pediatrics 2005; 115 (06) 1660-1665
    CrossrefPubMedGoogle Scholar
  • 7 Beltempo M, Wintermark P, Lemyre B. et al; Canadian Neonatal Network Investigators. Predictors of severe neurologic injury on ultrasound scan of the head and risk factor-based screening for infants born preterm. J Pediatr 2019; 214: 27-33.e3
    CrossrefPubMedGoogle Scholar
  • 8 Carbajal R, Eble B, Anand KJS. Premedication for tracheal intubation in neonates: confusion or controversy?. Semin Perinatol 2007; 31 (05) 309-317
    CrossrefPubMedGoogle Scholar
  • 9 Synnes A, Luu TM, Moddemann D. et al; Canadian Neonatal Network and the Canadian Neonatal Follow-Up Network. Determinants of developmental outcomes in a very preterm Canadian cohort. Arch Dis Child Fetal Neonatal Ed 2017; 102 (03) F235-F234
    CrossrefPubMedGoogle Scholar
  • 10 Wallenstein MB, Birnie KL, Arain YH. et al. Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants. J Perinatol 2016; 36 (02) 112-115
    CrossrefPubMedGoogle Scholar
  • 11 Jarjour IT. Neurodevelopmental outcome after extreme prematurity: a review of the literature. Pediatr Neurol 2015; 52 (02) 143-152
    CrossrefPubMedGoogle Scholar
  • 12 Sauer CW, Kong JY, Vaucher YE. et al. Intubation attempts increase the risk for severe intraventricular hemorrhage in preterm infants: a retrospective cohort study. J Pediatr 2016; 177: 108-113
    CrossrefPubMedGoogle Scholar
  • 13 Committee on Fetus and Newborn, American Academy of Pediatrics. Respiratory support in preterm infants at birth. Pediatrics 2014; 133 (01) 171-174
    CrossrefPubMedGoogle Scholar
  • 14 Lee SK, Beltempo M, McMillan DD. et al; Evidence-based Practice for Improving Quality Investigators. Outcomes and care practices for preterm infants born at less than 33 weeks' gestation: a quality-improvement study. CMAJ 2020; 192 (04) E81-E91
    CrossrefPubMedGoogle Scholar
  • 15 Fleishman R, Mossabeb R, Menkiti O, Young M, Bains V, Cooperberg D. Transition to routine premedication for nonemergent intubations in a level IV neonatal intensive care unit. Am J Perinatol 2018; 35 (04) 336-344
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 McCrea HJ, Ment LR. The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clin Perinatol 2008; 35 (04) 777-792 , vii
    CrossrefPubMedGoogle Scholar
  • 17 Finan E, Campbell DM, Aziz K, McNamara PJ. Update for Canadian NRP providers: a case-based review. Paediatr Child Health 2017; 22 (06) 351-356
    CrossrefPubMedGoogle Scholar
  • 18 Barrington K. Premedication for endotracheal intubation in the newborn infant. Paediatr Child Health 2011; 16 (03) 159-171
    CrossrefPubMedGoogle Scholar
  • 19 Canadian Neonatal Network. Abstractor's Manual. Accessed 2014 at: http://www.capsnetwork.org/portal/Portals/0/CAPSNet/Manual/CAPSNet%20Manual%20-V5.1.0.1%20Feb%202014%20FINAL.pdf
    PubMedGoogle Scholar
  • 20 Kramer MS, Platt RW, Wen SW. et al; Fetal/Infant Health Study Group of the Canadian Perinatal Surveillance System. A new and improved population-based Canadian reference for birth weight for gestational age. Pediatrics 2001; 108 (02) E35
    CrossrefPubMedGoogle Scholar
  • 21 Papile LA, 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 (04) 529-534
    Google Scholar
  • 22 Beltempo M, Shah PS, Ye XY, Afifi J, Lee S, McMillan DD. Canadian Neonatal Network Investigators. SNAP-II for prediction of mortality and morbidity in extremely preterm infants. J Matern Fetal Neonatal Med 2019; 32 (16) 2694-2701
    CrossrefPubMedGoogle Scholar
  • 23 Salas AA, Carlo WA, Ambalavanan N. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Gestational age and birthweight for risk assessment of neurodevelopmental impairment or death in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101 (06) F494-F501
    CrossrefPubMedGoogle Scholar
  • 24 Handley SC, Passarella M, Lee HC, Lorch SA. Incidence trends and risk factor variation in severe intraventricular hemorrhage across a population based cohort. J Pediatr 2018; 200: 24-29.e3
    CrossrefPubMedGoogle Scholar
  • 25 Murthy P, Zein H, Thomas S. et al. Neuroprotection care bundle implementation to decrease acute brain injury in preterm infants. Pediatr Neurol 2020; 110: 42-48
    CrossrefPubMedGoogle Scholar
  • 26 Schmidt B, Davis P, Moddemann D. et al; Trial of Indomethacin Prophylaxis in Preterms Investigators. Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med 2001; 344 (26) 1966-1972
    CrossrefPubMedGoogle Scholar
  • 27 Kakkilaya V, Jubran I, Mashruwala V. et al. Quality improvement project to decrease delivery room intubations in preterm infants. Pediatrics 2019; 143 (02) e20180201
    CrossrefPubMedGoogle Scholar
  • 28 Herrick HM, Glass KM, Johnston LC. et al. Comparison of neonatal intubation practice and outcomes between the neonatal intensive care unit and delivery room. Neonatology 2019
    PubMedGoogle Scholar
  • 29 Haubner LY, Barry JS, Johnston LC. et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation 2013; 84 (10) 1359-1364
    CrossrefPubMedGoogle Scholar
  • 30 Foglia EE, Ades A, Sawyer T. et al; NEAR4NEOS Investigators. Neonatal intubation practice and outcomes: an international registry study. Pediatrics 2019; 143 (01) e20180902
    CrossrefPubMedGoogle Scholar
  • 31 Pearce N. Analysis of matched case-control studies. BMJ 2016; 352: i969
    CrossrefPubMedGoogle Scholar
  • 32 Maalouf EF, Duggan PJ, Counsell SJ. et al. Comparison of findings on cranial ultrasound and magnetic resonance imaging in preterm infants. Pediatrics 2001; 107 (04) 719-727
    CrossrefPubMedGoogle Scholar
  • 33 Miller SP, Cozzio CC, Goldstein RB. et al. Comparing the diagnosis of white matter injury in premature newborns with serial MR imaging and transfontanel ultrasonography findings. AJNR Am J Neuroradiol 2003; 24 (08) 1661-1669
    PubMedGoogle Scholar
  • 34 Leijser LM, de Bruïne FT, van der Grond J, Steggerda SJ, Walther FJ, van Wezel-Meijler G. Is sequential cranial ultrasound reliable for detection of white matter injury in very preterm infants?. Neuroradiology 2010; 52 (05) 397-406
    CrossrefPubMedGoogle Scholar
  • 35 Serenius F, Källén K, Blennow M. et al; EXPRESS Group. Neurodevelopmental outcome in extremely preterm infants at 2.5 years after active perinatal care in Sweden. JAMA 2013; 309 (17) 1810-1820
    CrossrefPubMedGoogle Scholar
  • 36 Stjernqvist K, Svenningsen NW. Ten-year follow-up of children born before 29 gestational weeks: health, cognitive development, behaviour and school achievement. Acta Paediatr 1999; 88 (05) 557-562
    CrossrefPubMedGoogle Scholar