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Do We Need to Rethink NRP ETT Sizes?

April 30, 2024

Written by Aaron Lacy

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In a very specific subgroup of weights, using an ETT that is 0.5 mm smaller than the NRP recommended size was associated with reduced adverse events during tracheal intubation of neonates. 

Itsy bitsy teeny weenie ETTs
A multicenter neonatal intubation database (NEAR4NEOS) was used to retrospectively look for association of ETT size during intubation with tracheal intubation adverse events (TIAEs)*, severe hypoxia (>20% decrease in oxygen saturation), or need for ETT resizing within 7 days. The authors used predefined cohort groups stratified into 200g increments. Reviewing 7,293 intubations over a 7-year period they found:

  • For infants weighing 1.0 – 1.199 kg using a 2.5 mm ETT instead of a 3.0 mm ETT (NRP recommended) was associated with fewer TIAEs (20.8% vs 21.9%; aOR 0.62 95% CI 0.41-0.94) and fewer episodes of severe hypoxia (35.2% vs 52.9%; aOR 0.53 95% CI 0.38-0.75).
  • For infants weighing 2.0 – 2.199kg, using a 3.0 mm ETT instead of a 3.5 mm ETT (NRP recommended) was associated with fewer episodes of severe hypoxemia (41% vs 56%; aOR 0.55 95% CI 0.34-0.89).

ETT downsizing within 7 days occurred more frequently in the above two groups (1.0-1.199 kg, 12.6%; 2.0-2.199 kg, 17.1%) than any other subgroup.

How will this change my practice?
This research focuses on a very specific subgroup of patients. For someone who rarely sees critically ill neonates I rely heavily on NRP training and recommendations to guide my practice. If I had to intubate a child weighing 1-3 kg I still probably would follow NRP guidelines to cognitively offload during a likely stressful situation. However, I will be curious to see how this research potentially impacts future iterations of NRP guidelines, and this information will be intriguing for those who frequently intubate neonates.

Another Spoonful
If you need an NRP refresher, you might want to check out our NRP in 5 minutes video and NRP equipment and drug dosing cheat sheet!

Endotracheal tube size adjustments within 7 day of neonatal intubation. Pediatrics. 2024 Mar 12:e2023062925. Online Ahead of Print.


  • Severe TIAEs: cardiac arrest, esophageal intubation with delayed recognition, hypotension requiring therapy, cardiac compressions <1 minute, laryngospasm, vomit with aspiration, gum or dental trauma, pneumothorax and/or pneumomediastinum, and direct airway injury.
  • Nonsevere TIAEs: esophageal intubation with immediate recognition, dysrhythmia (including any duration of bradycardia <60 beats per minute without chest compressions performed), medication error, mainstem bronchial intubation, vomit without aspiration, hypertension requiring therapy, pain and/or agitation requiring additional medications causing a delay in intubation, epistaxis, and lip trauma.

What are your thoughts?