A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching

Abstract

BACKGROUND: Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS: We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children’s hospitals. We categorized the attending anesthesiologist’s ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS: Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%–20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = −2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = −1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36–3.15; P = .001). CONCLUSIONS: Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications.

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

“…Nevertheless, the results of the present study are more informative than those reported by the registries that are voluntary based and are subject to underreporting. 5,29 The second limitation is attributable to the nature of the study itself as information was gathered from 165 centres that were willing to participate, and thus, a selection bias may be perceived as most centres are specialised and the overall incidence of difficult intubation could be underestimated for non-participating or non-dedicated paediatric centres. 6,9 The (non-)availability of videolaryngoscopes or fibreoptic endoscopes in the participating centres may also have affected the final results.…”

Normal and difficult airways in children: “What’s New”—Current evidence

“…Neuromuscular blockade agents have traditionally been avoided in patients with difficult airways. An observational study from the aforementioned Pedi Registry found an association between spontaneous ventilation technique (versus controlled ventilation with or without neuromuscular blockade) and increased nonsevere complications . Light anesthesia was the likely cause of these complications as patients in the spontaneous group had more reported airway reactivity.…”

Emerging trends, techniques, and equipment for airway management in pediatric patients

“…A randomized controlled trial of 160 adult patients with anticipated difficult airways demonstrated the use of this combined technique of VL with a flexible scope as stylet resulted in higher first‐pass success rates, shorter time to successful intubation, and lower rates of airway injury when compared with hyperangulated VL alone . This technique has also been used successfully in children who are difficult to intubate . It provides improved maneuverability and visualization over either technique alone; however, it does require multiple practitioners to operate the two devices and likely performs better in situations of anticipated difficulty rather than as a rescue technique.…”

“…The ETT is connected to the anesthesia circuit, again reconfirming oxygenation and ventilation (Figure A). Following successful SGA placement, the provider may maintain spontaneous ventilation or choose to control ventilation with or without the use of neuromuscular blocking drugs as dictated by the clinical situation . A triple port, swivel adapter is connected to the ETT, which, in turn, is connected to the anesthesia circuit to allow oxygenation and ventilation throughout the period of flexible laryngotracheobronchoscopy.…”