title: The 30-second rule: the effects of prolonged intubation attempts on oxygen saturation and heart rate in preterm infants in the delivery room.
abstract: BACKGROUND
  A duration of 30 seconds has been shown to improve the success rate of intubation attempts without any decompensation. There is limited data regarding the detrimental effects of prolonged intubation attempts in preterm infants. The aim was to determine the effect of prolonged intubation attempts on heart rate and oxygen saturation in preterm infants.
  
  
  METHODS
  We retrospectively reviewed videos and physiologic data collected during delivery room (DR) resuscitations. Infants who had a functioning pulse oximeter at the time of intubation in the delivery room were analyzed using video and analog recordings. The duration of the intubation attempt was defined as the time the laryngoscope blade was in the infant's mouth. Prolonged intubations were defined as intubations over 30 seconds. Baseline heart rate and saturations were defined as the heart rate and saturation immediately prior to the intubation attempt. Video recording was used to determine time laryngoscope was in the mouth, what other procedures were performed, and whether there was recovery between attempts. Analog data including heart rate, airway pressure and saturation was also recorded.
  
  
  RESULTS
  There were 52 intubation attempts in 28 infants. The median (IQR) birth weight and gestational age were 795 (705, 972) grams and 25 (25, 27) weeks. The duration of an intubation attempt was 35 (27, 46) seconds with number of attempts 2 (1, 2). There were 34 intubation attempts greater than 30 seconds (prolonged group) and 18 attempts less than or equal to 30 seconds (short group). Longer attempts did not affect intubation success (successful 34 [25,37] seconds vs. unsuccessful 41[29, 53] seconds; P=0.05). Infants in the prolonged group had a greater decrease in oxygen saturation percentage from baseline (5±8 percent, short intubation group and 13±27 prolonged intubation group; P=0.004). There was also a significant decrease in heart rate beats per minute between the two groups (6±9 in the short intubation group and 23±29 prolonged group; P=0.004).
  
  
  CONCLUSIONS
  The currently recommended guideline by the Neonatal Resuscitation Program limiting intubation attempts to less than 30 seconds is supported by stable oxygen saturations and heart rate. Prolonging the intubation more than 30 seconds leads to greater hypoxia and may contribute to increased neonatal morbidity, with no effect on success rate.
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Madeline
authors.initials: M
authors.lastname: Wozniak
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Kathy
authors.initials: K
authors.lastname: Arnell
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Brown
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gonzales
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Danielle
authors.initials: D
authors.lastname: Lazarus
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA.
authors.forename: Wade
authors.initials: W
authors.lastname: Rich
authors.affiliation: Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA - Anup.katheria@sharp.com.
authors.forename: Anup
authors.initials: A
authors.lastname: Katheria
mesh_terms: D003696:Delivery Rooms; D005260:Female; D005865:Gestational Age; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D000860:Hypoxia / Q000209:etiology; D007231:Infant, Newborn; D007234:Infant, Premature; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D010092:Oximetry; D010100:Oxygen / Q000378:metabolism*; D017410:Practice Guidelines as Topic; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D014741:Video Recording
chemical_list: D010100:Oxygen