706 - Nasotracheal or Orotracheal? Rethinking Intubation Routes to Reduce Unplanned Extubations in Neonates

Publication Number: 1683.706

Pavani Chitamanni, Columbia University Vagelos College of Physicians and Surgeons, Brooklyn, NY, United States; Thomas Hays, Columbia University Irving Medical Center, New York, NY, United States; Diana Vargas chaves, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Rakesh Sahni, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Gloria Lush, NewYork-Presbyterian Morgan Stanley Children's Hospital, Englewood, NJ, United States; Takeya Patterson, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Alex J. Lyford, Middlebury College, WEYBRIDGE, VT, United States; Faith Kim, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States

Background: Tracheal intubation (TI) is a common procedure performed in neonates who are critically ill or require perioperative anesthesia. It can be performed via the nasotracheal or orotracheal route. Previous studies comparing the two routes have been inconclusive due to small sample sizes and variable patient populations. Unplanned extubations (UEs) are a significant complication of TI, which can sometimes lead to rapid cardiorespiratory deterioration.

Objective: Our objective is to evaluate the association between intubation route and UE risk in our NICU population.

Design/Methods: This retrospective cohort study analyzed all TI episodes for neonates admitted to a level IV NICU from January 2022 to December 2024, regardless of the location of initial TI (e.g., NICU, delivery room, operating room, outside hospital). We collected TI-related data including age, route, and duration using standardized automated reports from our electronic medical record, as part of our quality improvement initiative to reduce UEs. Additional information on UEs and adverse events associated with the route of intubation were collected by reviewing provider-documented reports. The baseline characteristics between the orotracheal intubation (OTI) and nasotracheal intubation (NTI) cohorts were compared using Chi square test for categorical variables and Mann-Whitney U test for continuous variables. The risk of UEs was compared between the two groups by Kaplan-Meier survival analysis.

Results: A total of 1,160 TI events were analyzed, of which 602 (51.9%) were NTIs and 558 (48.1%) were OTIs. Among the baseline characteristics, gestational age, normalized birth weight and age at endotracheal tube placement were statistically different between the two groups (Table 1). There were a total of 23 UEs: 9 (39.1%) in the NTI group and 14 (60.9%) in the OTI group. The probability of a UE was significantly higher in the OTI group compared to the NTI group (p = 0.03) (Figure 1). Furthermore, the Cox multivariable models consistently demonstrated increased risk of UE in OTIs compared to NTIs, which was robust even after adjustment for individual covariates.

Conclusion(s): Our findings demonstrate that NTI is associated with lower UE risk in neonates. These data support unbiased evaluation of NTI as a possible means to lower the incidence of UE and improve clinical outcomes in these infants. Although our findings are compelling within our institution, further multicenter studies are necessary to account for practice variability and assess generalizability to broader populations.

Table 1: Baseline Characteristics of Infants with Nasotracheal and Orotracheal Intubations
1 Data are shown as median (interquartile range), or n (%)
2 Chi square or Mann-Whitney U test as indicated
3 Z-score normalized by sex and gestational age by Fenton curve

Figure 1: Probability of Infants Remaining Intubated Stratified by Intubation Route
• p-value determined by Kaplan-Meier analysis is 0.03
• Censoring events, represented by small vertical lines on the curve, indicate planned extubations, death while intubated, or transfer out of NICU while intubated