78 - Identifying Optimal Endotracheal Tube Size for Neonatal Intubation in the International NEAR4NEOS Database

Poster Number: 78
Publication Number: 78.437

Patrick J. Peebles, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Erik A. Jensen, Children's Hospital of Philadelphia, haddonfield, NJ, United States; Heidi M. Herrick, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Paul Wildenhain, Childrens Hospital of Philadelphia, Wilmington, DE, United States; Jennifer Rumpel, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Ahmed Moussa, CHU Sainte-Justine, Université de Montréal, Westmount, PQ, Canada; Neetu Singh, DHMC, Lebanon, NH, United States; Ayman Abou Mehrem, University of Calgary, Calgary, AB, Canada; Bin Huey Quek, KK Women's and Children's Hospital, Singapore, N/A, Singapore; Michael Wagner, Medical University of Vienna, Vienna, Wien, Austria; Kristen M. Glass, Penn State Health Milton S Hershey Medical Center, Hershey, PA, United States; David Tingay, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Taylor L. Sawyer, University of Washington, Seattle, WA, United States; Brianna K. Brei, University of Nebraska College of Medicine, Omaha, NE, United States; Philipp Jung, University Children's Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Schleswig-Holstein, Germany; Jennifer Unrau, University of Calgary, Calgary, AB, Canada; Jae H. Kim, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; James S. Barry, University of Colorado, centennial, CO, United States; Stephen D. DeMeo, WakeMed Children's Hospital WakeMed Health and Hospitals, Raleigh, NC, United States; Lindsay Johnston, Yale School of Medicine, New Haven, CT, United States; Akira Nishisaki, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Elizabeth Foglia, Perelman School of Medicine at the University of Pennsylvania, Swarthmore, PA, United States

Background: Tracheal intubation (TI) is an essential procedure for critically ill infants. Limited data inform the empiric endotracheal tube (ETT) size selection for neonatal TI. Improper ETT size leads to harm from ETTs that are too large (airway injury, failure of the TI procedure) or too small (inaccurate ventilator measurements or need to upsize the ETT due to leak). The Neonatal Resuscitation Program (NRP) provides expert-based ETT size recommendations based on patient weight: 2.5mm for < 1000g, 3.0mm for 1000-2000g, and 3.5mm for >2000g.

Objective: To characterize initial ETT size selection for neonatal TI based on patient weight, and to compare data-driven ETT size thresholds with NRP recommendations.

Design/Methods: Retrospective multicenter cohort study using prospectively collected TI practice and outcome data in the National Emergency Airway Registry for Neonates (NEAR4NEOS). Infants with airway or cranial anomalies and cuffed ETTs were excluded. We included the first eligible TI encounter per infant (in the NICU or delivery room) from 6/2016-3/2021. The initial ETT size selection was classified according to patient weight subgroups (rounded down to nearest 100g). The frequency of ETT downsizing and upsizing was summarized across subgroups. Downsizing was defined as an encounter when the final successful attempt was performed using a smaller ETT than the initially selected size. Upsizing was defined as an encounter followed by placement of a larger ETT within one week. NRP ETT size recommendations with a suboptimal (>10%) frequency of upsizing or downsizing for patient weight subgroups were identified.

Results: There were 5433 infants across 17 NICUs included (Table 1). The initially selected ETT size based on patient weight varied substantially (Figure 1). Among infants with ETT sizes that corresponded with NRP recommendations, downsizing occurred in >10% of infants in weight subgroups 1000-1200g with an initial 3.0mm ETT and in >10% of infants in subgroups 2000-2600g with an initial 3.5mm ETT. Upsizing did not exceed 10% for any subgroup following NRP recommendations (Figure 2).Conclusion(s): There is substantial variation in the initial ETT size selection for neonatal TI based on patient weight. A suboptimal frequency of downsizing occurs for several patient weight subgroups following NRP ETT size recommendations, with infrequent upsizing when 0.5mm smaller ETTs are used. These data suggest that higher weight thresholds for transitioning between ETT sizes may be more appropriate.
Table 1Patient and tracheal intubation characteristics for 5433 included infants
Figure 1Distribution of patient weight for 2.5, 3.0 and 3.5 mm endotracheal tube size selection for the first attempt of the first tracheal intubation encounter. A 2.0 or 4.0 mm endotracheal tube was selected in 111 (2.0%) of tracheal intubations (data not displayed). The Neonatal Resuscitation Program recommended endotracheal tube sizes thresholds are shown in vertical reference lines.