Pediatric airway management in the emergency department: in urgent need of CPR

Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department

BACKGROUND AND OBJECTIVES

There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital.

METHODS

All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children <18 years were identified by querying our perioperative clinical information system. Medical records were comprehensively reviewed to describe the emergency intubation process and outcomes.

RESULTS

One hundred and thirty-two intubations from 120 children (median age 3.3 years) were eligible. The majority of emergency tracheal intubations were successful with 1-2 laryngoscopy attempts, while 14 (10.6%) were difficult. Despite grade 3 view in 3/14 cases, the airway was secured after multiple direct laryngoscopy attempts. Eleven required use of an alternative airway device to secure the airway. A preexisting airway abnormality or craniofacial abnormality was present in 57% of cases with difficult intubation including half with micrognathia or retrognathia. Major intubation-related adverse events such as aspiration, occurred in 5 (3.8%) emergency tracheal intubations. Mild-to-moderate intubation-related adverse events occurred in 23 (17.4%) emergency tracheal intubations including mainstem bronchus intubation (13.6%).

CONCLUSION

A significant rate of difficult intubation and mild-to-moderate intubation-related adverse events were found in emergency tracheal intubations on inpatient units and the emergency department in children performed by a pediatric anesthesiology emergency airway team. Difficult intubation was observed frequently in children with preexisting airway and craniofacial abnormalities and often required the use of an alternative airway device to successfully secure the airway.

Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department

Introduction

The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED).

Methods

We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient’s age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator’s level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years.

Results

A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI [54%–66%]). In the multivariable model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23–4.87]), use of RSI (aOR, 2.17; 95% CI [1.31–3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78–5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63–5.70]), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI [1.92–8.63]) were significantly associated with a higher chance of first-pass success.

Conclusion

Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.