Consequences of NICU Intubations: Incidence, Identifications, and Interventions

Introduction: Prolonged intubation often leads to laryngeal injuries such as subglottic stenosis, especially in neonates with prematurity, sepsis, and congenital defects key for tissue healing. However, literature is sparse regarding which Neonatal Intensive Care Unit (NICU) patients are at risk for adverse effects. The study’s goals were to determine intubation risk factors, characterize laryngeal injuries, and calculate the incidence of intervention.

Methods: This retrospective study targeted all intubated NICU patients at a quaternary care pediatric hospital from April 1, 2020 to 2023. Electronic records were reviewed for demographics such as gestational age, size impression, and genetic syndromes as well as intubation details. Patients were divided into intubation only or intervention groups, those with direct laryngoscopy and bronchoscopy (DLB) history.

Results: Of 441 patients, 94 (21.3%) neonates had a DLB history. Characteristics significantly impacting intervention included older gestational age (p=0.03), genetic syndromes (p < 0.0001), and congenital heart disease (p=0.003). Significant risk factors were older age at first intubation (p=0.03), more intubation events (p < 0.0001), longer intubation duration (p < 0.0001), and larger endotracheal tube diameter (p < 0.0001). Birth weight and intubation attempts were not significant. ENT was more likely to intubate the Intervention cohort (p < 0.0001). DLB demonstrated granulation tissue (29.8%), tracheomalacia (21.3%), laryngomalacia (9.6%), subglottic ulceration (6.4%), complete tracheal rings (3.2%), and vocal fold paralysis (1.1%). Subglottic stenosis incidence was 13.8% with balloon dilation in 6.4%. Two thirds of neonates with DLB ultimately required tracheostomy.

Conclusions: At this institution, most NICU patients undergoing DLB evaluation ultimately required further procedures including but not limited to tracheostomy. Identifying which neonates are more likely to experience post-intubation laryngeal pathologies may help minimize future injuries and guide decision making.