Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department

  1. Edir S Abid1,
  2. Kelsey A Miller1,2,
  3. Michael C Monuteaux1,2,
  4. Joshua Nagler1,2
  1. Correspondence to Dr Joshua Nagler, Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA; [email protected]


Background Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting.

Objective We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations.

Design and methods We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors.

Results During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy.

Conclusion Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All included data were abstracted from an internal quality assurance database and the electronic health record, and are deidentified for the purpose of analyses and reporting.

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