OBJECTIVE To determine the causes of failed extubation in the Neonatal Intensive Care Unit (NICU) and the need for airway intervention. METHODS Retrospective chart review. METHODS Tertiary care children's hospital. METHODS We identified all premature infants (gestational age <37 weeks) admitted to the NICU of a tertiary care children's hospital from January 1998 until December 2006 who underwent direct laryngoscopy and bronchoscopy (DLB) in the operating room (OR) for failed extubation. Data was collected on weight, gestational age, co-morbid conditions, number of failed extubations, findings at DLB and whether or not a tracheostomy was performed. RESULTS DLBs were performed on 63 patients to evaluate the cause of failed extubation. Group A comprised of 50 patients who underwent tracheostomy. They had an average gestational age of 30.0 weeks, birth weight of 1457g and number of failed extubations 2.68. Group B consisted of 13 patients who did not undergo tracheostomy. They had an average gestational age of 34.5 weeks, birth weight of 2309g and number of failed extubations 1.33. 56.0% of the tracheostomy group and 38.5% of the non-tracheostomy group had chronic lung disease (CLD). At endoscopy, 44% of Group A and 23.1% of Group B had some degree of subglottic stenosis. CONCLUSIONS Abnormal laryngotracheal findings are common in neonates who fail extubation. When compared to their counterparts with similar co-morbidities, neonates with CLD, gestational age of 30 weeks or below and low birth weight are twice as likely to have subglottic edema and fail extubation. They are also likely to be candidates for a tracheostomy.