Outcomes of Nasotracheal Versus Orotracheal Intubation in Neonates After Cardiopulmonary Bypass Surgery: A Retrospective Cross-Sectional Analysis.

Abstract

Background: Institutions variably utilize oral (OI) versus nasal intubation (NI) for neonatal cardiac surgery. The proposed advantages of NI include a lower rate of endotracheal tube (ETT) dislodgement, decreased sedation requirements, and improved oral feeding. However, NI carries an additional risk of pressure injury and increased technical difficulty.

Aims: The goal of this study was to evaluate whether NI was associated with decreased risk of ETT dislodgement or improved feeding outcomes versus OI.

Methods: We performed a single center, retrospective, cross-sectional study of neonates intubated in the operating room undergoing cardiopulmonary bypass surgery from 2018 to 2020. Primary outcomes were unplanned extubation and oral feeding at discharge. Secondary outcomes included hospital length of stay, duration of intubation, otolaryngology (ENT) consult, skin breakdown related to the ETT, postoperative sedation medications, and adverse anesthesia induction events. Chi-squared and Fisher's exact tests were used for categorical data and Wilcoxon rank-sum tests for continuous data. Unadjusted results were calculated using univariate regressions. Adjusted results were calculated using linear mixed effect models and logistic regressions. Continuous outcomes were log transformed, and results adjusted for weight and surgeon. p < 0.05 was statistically significant.

Results: Of the 179 patients, 49.8% (n = 89) were OI and 50.2% (n = 90) were NI. There was no difference in unplanned extubation, length of hospital stay, length of intubation, complications during induction, or percentage of exclusively oral feeding at the time of transfer from the intensive care unit or discharge from the hospital. There was a statistically significant difference in skin breakdown related to the ETT, where 89% of breakdown occurred in the NI group (p = 0.045, OR = 0.12, 95% CI [0.01, 0.65]). Sedation administration between the groups was similar.

Conclusions: NI was not associated with improved exclusive oral feeding at discharge for neonatal cardiac surgical patients and may be associated with an increased risk of pressure injury in this single center, retrospective, cross-sectional study.

Clinical implications: Several studies have investigated practice patterns and potential benefits of nasal intubation (NI) versus oral intubation (OI) in neonates undergoing cardiac surgical procedures; however, there is wide variation in national practice standards and unclear effects on postoperative feeding outcomes. At our high-volume cardiac center, we implemented a nasal intubation program for neonates as a quality improvement initiative. We found that NI was not associated with decreased risk of peri-operative unplanned extubation nor improved oral feeding outcomes at the time of hospital discharge.