Nasal versus oral intubation in the neonatal intensive care unit: associations with procedural success and safety in a retrospective cohort study from the National Emergency Airway Registry for Neonates (NEAR4NEOS)

Objective To evaluate the frequency and safety of nasal versus oral endotracheal intubation procedures in infants admitted to a neonatal intensive care unit (NICU). Design Retrospective cohort study. Setting 29 centres across seven countries from April 2017 to March 2025. Patients Infants <1 year of age undergoing endotracheal intubation. Main outcome measures Primary outcome was first course success, with course defined as all intubation attempts without a change in equipment, premedication or route. Secondary outcomes were first attempt success, adverse tracheal intubation-associated events (TIAEs), severe TIAEs and severe desaturations. Adjusted relative risks (aRR) were estimated using Poisson regression accounting for centre, patient, provider and procedural variables. Results Among 20 350 intubation courses (nasal 1057 (5.2%); oral 19 293 (94.8%)), nasal intubations occurred at 17 of 29 centres, with site-level use ranging from 0% to 99.2%. In fully adjusted models, nasal compared with oral intubation was associated with decreased course success (aRR 0.89; 95% CI 0.84 to 0.94, p<0.001), first attempt success and increased risk for severe desaturation. There were no significant differences in TIAEs. In a post-hoc analysis, these associations were not present at sites where intubations were predominantly performed via nasal route. Conclusions Nasal intubation may not be the preferred approach for infants in settings where it is infrequently performed but may achieve comparable or improved intubation-related outcomes in centres with established expertise.