About this item:

376 Views | 343 Downloads

Author Notes:

Correspondence: lee.jan.hau@kkh.com.sg; lee.jan.hau@singhealth.com.sg

JHL and DT are co-first authors.

DT and JHL designed and led the project, collected and analyzed data, and drafted the manuscript.

AN and JS provided statistical analysis, and critically reviewed the manuscript.

PK, SN and VN helped with the study’s design and approach, critically reviewed and revised the manuscript.

AN and VN assisted with database creation and design.

AN aided in project design and implementation, provided mentorship throughout the project, and critically reviewed the manuscript.

AN had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

We would like to thank investigators from the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) and the National Emergency Airway Registry for Children (NEAR4KIDS) who have contributed data for this investigation [listed in Final Published Version].

The authors declare that they have no competing interests.


Research Funding:

This study was funded by Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia, Unrestricted Research funds from the Laerdal Foundation for Acute Care Medicine, Agency for Healthcare Research and Quality (AHRQ)1R03HS021583- 01, AHRQ 1 R18 HS022464-01.

Dr. Nishisaki was supported by AHRQ 1R03HS021583- 01, AHRQ 1 R18 HS022464-01.


  • Life Sciences & Biomedicine
  • Pediatrics
  • Acute respiratory failure
  • Child
  • Critical illness
  • Desaturation
  • Intubation
  • Mechanical ventilation
  • Pediatric intensive care unit
  • Registries

The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study


Journal Title:

BMC Pediatrics


Volume 16, Number 1


, Pages 58-58

Type of Work:

Article | Final Publisher PDF


Background: The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association between number of TI attempts and severe desaturation (SpO2 < 70%) and adverse TI associated events (TIAEs). Methods: We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80% during TI attempt), severe desaturation (<70%), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment). Results: Of 3382 TIs, 2080(65%) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60%), second attempt in 503/2080(24%), and ≥3 attempts in 321/2080(15%). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16%, 2 attempts:36%, ≥3 attempts:56%, p < 0.001; adjusted OR for 2 attempts: 2.9[95% CI:2.3-3.7]; ≥3 attempts: 6.5[95% CI: 5.0-8.5], adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12%, 2 attempts:30%, ≥3 attempts:44%, p < 0.001); adjusted OR for 2 attempts: 3.1[95% CI:2.4-4.0]; ≥3 attempts: 5.7[95% CI: 4.3-7.5] ). TIAE rates increased from 10 to 29to 38% with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.7[95% CI:2.9-4.9] ≥3 attempts: 5.5[95% CI: 4.1-7.4]. Severe TIAE rates went from 5 to 8 to 9% (p = 0.008); adjusted OR for 2 attempts: 1.6 [95% CI:1.1-2.4]; ≥3 attempts: 1.8[95% CI:1.1-2.8]. Conclusions: Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.

Copyright information:

© Lee et al. 2016. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).

Creative Commons License

Export to EndNote