Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study

Objectives

This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes.

Methods

We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients' clinical status and extubation readiness criteria.

Results

In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38-36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2-48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001).

Conclusion

A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.