Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities

OBJECTIVE

Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement.

METHODS

All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored.

RESULTS

A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt.

CONCLUSION

In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.

Evaluation of tracheal intubations in a paediatric intensive care unit

INTRODUCTION

Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality.

PATIENTS AND METHODS

Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events.

RESULTS

The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events.

CONCLUSIONS

In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.

Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review

Endotracheal intubation is associated with an increased risk of cardiorespiratory arrest. Various factors modulate the risk of peri-intubation cardiorespiratory arrest. The primary objective of this study was to determine the risk of peri-intubation cardiorespiratory arrest in pediatric patients in a hospital setting, and the secondary objective was to determine the effect of various factors on the peri-intubation cardiorespiratory arrest risk. A systematic review was performed to identify eligible manuscripts. Studies were deemed appropriate if they included pediatric patients in a hospital setting not exclusively intubated for an indication of cardiorespiratory arrest. Data were extracted from studies deemed eligible for inclusion. A pooled risk of cardiorespiratory arrest was determined. A Bayesian linear regression was conducted to model the risk of cardiorespiratory arrest. All data used in this were study-level data. A total of 11 studies with 14,424 intubations were included in the final analyses. The setting for six (54.5%) studies was the emergency department. The baseline adjusted risk for peri-intubation cardiorespiratory arrest in pediatric patients was 3.78%. The mean coefficient for a respiratory indication for intubation was −0.06, indicating that a respiratory indication for intubation reduced the per-intubation cardiorespiratory arrest risk by 0.06%. The mean coefficient for use of ketamine was 0.07, the mean coefficient for use of a benzodiazepine was −0.14, the mean coefficient for use of a vagolytic was −0.01, and the mean coefficient for use of neuromuscular blockade was −0.40. Pediatric patients during the peri-intubation period have the risk of developing cardiorespiratory arrest. The pooled findings demonstrate associations that seem to highlight the importance of maintaining adequate systemic oxygen delivery to limit this risk.

Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study

Aim

Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics-particularly the location, patient, and provider factors-in the pediatric ED.

Methods

We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre-ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors.

Results

Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre-ED setting and 177 were intubated in the ED. The overall first-attempt success rate was 72%, with the rate varying by location, patient, and provider factors-for example, 68% at the pre-ED setting, 67% for children <2 years, 56% for children with airway-related anatomical anomalies, and 61% with intubation by a resident physician. Intubation-related adverse events were observed in 17%, most of which were hypoxemia (14%).

Conclusions

Based on data from a multicenter prospective study, the overall first-attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.

Tracheal Tube Misplacement after Emergency Intubation in Pediatric Trauma Patients: A Retrospective, Exploratory Study

Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76–0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04–0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians’ expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.

Lung Ultrasound for Detecting Tracheal and Mainstem Intubation: A Systematic Review and Meta-Analysis

Precise positioning of the left or right main bronchus is a prerequisite for effective lung isolation in thoracic surgeries. This study aimed to clarify the ability of lung ultrasound to detect tracheal and mainstem intubation. Studies that investigated the ability of lung ultrasound to detect tracheal and mainstem intubation were searched from PubMed and ScienceDirect databases from their inception to March 2021. The pooled accuracy of this method and its sensitivity and specificity were computed with a fixed-effects model using Stata 14.0. Nine eligible articles that involved a total of 617 participants were included in this systematic review and meta-analysis. Overall, the accuracy of lung ultrasound in detecting tracheal and mainstem intubation was 86.7%, with a sensitivity of 93.0% and a specificity of 75.0%. Subgroup analysis revealed that the accuracy remained high regardless of patient age, ultrasonic method, sample size, study design or ultrasonic skills training. Sensitivity analysis indicated that the results were stable. Deeks' test showed no publication bias. These findings imply that lung ultrasound is an effective method for detecting tracheal and mainstem intubation.