OBJECTIVES: To compare success and safety of endotracheal tube (ETT) exchanges with primary intubations and identify factors associated with ETT exchange outcomes. DESIGN: Retrospective observational study of prospectively collected National Emergency Airway Registry for Neonates data. ETT exchanges are the placement of a new ETT when one is already in place, whereas primary intubations do not have a pre-existing ETT. The primary outcome was first-attempt success. Secondary outcomes included number of attempts, adverse tracheal intubation-associated events (TIAEs), severe TIAEs, desaturation and bradycardia. Descriptive statistics compared characteristics for ETT exchanges and primary intubations. Univariable and multivariable analyses compared primary and secondary outcomes and identified factors independently associated with ETT exchange outcomes. RESULTS: A total of 1572 ETT exchanges and 9999 primary intubations across 21 sites were included from October 2014 to September 2022. ETT exchanges represented 2.3%-31.2% (mean 13.6%) of intubations across sites. Patient, provider and practice characteristics varied significantly between ETT exchanges and primary intubations. In univariable analyses, ETT exchanges were associated with higher first-attempt success (70.5% vs 53.6%
p<
0.001) and fewer safety events. In multivariable analyses, ETT exchanges were associated with an increased adjusted OR (aOR) of first-attempt success (1.71
95% CI 1.57 to 1.86
p<
0.001). ETT exchanges were associated with lower aOR of all safety outcomes except severe TIAEs. Factors independently associated with ETT exchange first-attempt success included video laryngoscopy and paralytic premedication. CONCLUSION: Compared with primary intubations, ETT exchanges were associated with higher first-attempt success and fewer safety events. Video laryngoscope and paralytic premedication were associated with improved ETT exchange outcomes.