Tracheal Intubation During CPR: First-Attempt Success and Association With Outcomes

Introduction: Previous studies have found that tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) is associated with decreased survival to hospital discharge, but key TI characteristics have not been evaluated. We aimed to describe TI practices during CPR and hypothesized that first attempt success would be associated with improved outcomes.


Methods: Single center, retrospective observational study of children with >=1 minute of CPR for IHCA without an airway at CPR onset (2017-2024). Data from local cardiac arrest and airway quality improvement databases were merged to obtain granular TI data. Fisher’s exact and Wilcoxon rank-sum tests compared patient and event characteristics. Among events with a TI attempt, the association between first attempt success and outcome was evaluated using logistic regression (a priori covariables: age, etiology, location, weekday/daytime). Primary outcome was survival to discharge with favorable neurologic outcome (pediatric cerebral performance category 1, 2 or no change); secondary outcomes were return of spontaneous circulation (ROSC) and survival to discharge.


Results: Among 197 children without an airway at CPR onset, TI was attempted during CPR in 99 (50%). Patients with a TI attempt had longer CPR duration (30 [13, 52] vs 2 [1.2, 4] minutes, p< 0.01) and less frequent ROSC (54% vs 100%, p< 0.01) than those without. Number of attempts was missing in 6%, who were excluded from further analyses. Among 93 patients with a TI attempt, 53% had success with first attempt, 38% with 2, 8% with >=3, and 2% were unsuccessful. Provider type (e.g., attending, fellow) was not associated with first attempt success (p=0.38). There was no difference in time to TI (9 [4, 15] vs 11 [8, 14] min, p=0.27) or CPR duration (34 [14, 52] vs 29 [14, 47] min, p=1.0) with first attempt success vs >=2 attempts. There was no association between first attempt success compared to >=2 attempts and favorable neurologic outcome (aOR 0.57, 95% CI: 0.22, 1.46), ROSC, or discharge survival.


Conclusions: During pediatric in-hospital CPR, the first TI attempt was successful in only 53% of patients. There was no association between first attempt success and outcomes. Further prospective work is needed to understand mechanisms by which TI during CPR may be harmful.