738 - Comparison of Neonatal Tracheal Intubation Adverse Events and Severe Desaturations between Level III and Level IV NICUs in infants <1500g: A Multicenter Analysis from the NEAR4NEOS Network

Publication Number: 1715.738

Josh J. Daniel, Yale School of Medicine, New haven, CT, United States; Cassandra DeMartino, Yale School of Medicine, New Haven, CT, United States; Veronika Shabanova, Yale School of Medicine, New Haven, CT, United States; Lindsay Johnston, Yale-New Haven Children's Hospital, New Haven, CT, United States

Background: Tracheal intubation is a high-risk procedure in very low birth weight (VLBW) infants. While NICU level designations reflect increasing complexity of care, their association with procedural outcomes remains unclear.

Objective: To compare risk of tracheal intubation-associated events (TIAEs), severe desaturations, and intubation attempts in VLBW infants between level III and IV NICUs. We hypothesized that level III NICUs would experience more TIAES and severe desaturations due to more limited access to video laryngoscopy (VL), premedication, and subspecialty support; and that level III NICUs would have lower first-attempt success and more attempts overall.

Design/Methods: A retrospective cohort study of intubations in VLBW infants ( < 1500g) across 15 U.S. NICUs (8 level III, 7 level IV) in the NEAR4NEOS registry (2019–2024). Poisson regression adjusted for infant-, site-, and intubation-level covariates, with NICU site as a random effect, estimated rate- and risk- ratios (RR) with 95% Confidence Interval (95%CI).

Results: Compared to level IV NICUs (2022 intubations in 1314 VLBW infants), level III NICUs (2200 intubations in 1413 VLBW infants) more frequently used VL (VL: 28.6% vs. 24.1%, p< 0.001), premedication with sedation and paralysis (33.6% vs. 26.7%, p< 0.001), and had greater attending presence (70% vs. 55.5%, p< 0.001). Level IV NICUs had a higher adjusted risk of any TIAEs, driven by significantly more non-severe TIAEs (RR 1.47, 95% CI 1.08–2.02) but fewer severe TIAEs (Table 2). Severe desaturation rates (p=0.85) and number of intubation attempts (p=0.82) did not differ by NICU levels. VL and premedication were associated with fewer attempts, while resident-performed intubations and lack of attending supervision were associated with more attempts.

Conclusion(s): While level IV NICUs on average had more non-severe TIAEs, the similarity in severe desaturation rates and number of intubation attempts across NICU levels suggests that some aspects of procedural success can be maintained regardless of NICU level. This finding challenges the assumption that higher-level NICUs inherently achieve superior procedural outcomes. Adverse event rates differed by device group, premedication use and attending presence-which underscores the importance of standardized practices and training across all NICU sites to improve intubation safety.

Table 1: Covariates of Interest by NICU Level
Table 1 PDF.pdf

Table 2. Unadjusted Associations between NICU Level and Outcomes of Interest
Table 2 PDF.pdf