Background:The emergency department is a stressful workplace environment with environmental stimuli and distractions, including noise. This has potential effects on perceived stress for providers and critical procedure performance.Objective: This study aimed to characterize the impact of environmental noise levels on the time to intubate, the quality of intubation, and physiologic stress response in pediatric emergency department providers.Methods: This was a randomized control simulation-based study in which experienced pediatric providers intubated an adult manikin 3 times while experiencing 3 different ambient noise levels (60, 75, 80 dB) in random order. Participants' times to intubate were measured, as was the endotracheal tube depth. The quality of each intubation attempt was assessed via video review against a standardized checklist. Lastly, participants' heart rates were monitored in real time to assess for physiologic stress response. Differences in performance were analyzed using a repeated-measures analysis of variance.Results: No significant difference was found between noise levels and time to intubate (P = 0.19), although each subsequent attempt shortened the time to intubate (P = 0.01). Physiological heart rate changes did not differ by noise level (P = 0.35). Subjectively, "time and economy of motion" and "overall performance" did not differ by noise level but did improve for each subsequent attempt number (P < 0.046).Conclusions: Intubation performance improved with attempt number, but no differences in performance were seen between noise levels. This suggests that rehearsing and practice impacts performance more than environmental noise levels.