Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey

Abstract

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey

“…

We would like to comment on, and correct some misunderstandings in, the paper by Foy et al, which suggests that there are major gaps in optimal airway management in neonatal intensive care units (NICUs) in the UK, particularly lack of continuous waveform capnography and/or videolarygoscopy [1]. We are in full agreement with the NHS Improvement recommendation that undetected oesophageal intubation should be a 'Never Event', but note that detection of this event relates mostly to the use of capnography at intubation, rather than during ongoing ventilatory support.It is well recognised that detection of exhaled CO 2 using a colorimetric device facilitates confirmation of tracheal tube placement in newborn babies, despite being subject to both false-positive and false-negative results, and this is recommended by international guidelines [2].

…”

“…We would like to comment on, and correct some misunderstandings in, the paper by Foy et al, which suggests that there are major gaps in optimal airway management in neonatal intensive care units (NICUs) in the UK, particularly lack of continuous waveform capnography and/or videolarygoscopy [1]. We are in full agreement with the NHS Improvement recommendation that undetected oesophageal intubation should be a 'Never Event', but note that detection of this event relates mostly to the use of capnography at intubation, rather than during ongoing ventilatory support.…”

Results from capnography studies in adults may not apply to neonates

“…In response to the editorial by Cook and Harrop-Griffiths on capnography,1 we reiterate the British Association of Perinatal Medicine’s position statement on waveform capnography in newborn infants2 published in response to the article by Foy et al in Anaesthesia 3…”

Capnography prevents avoidable deaths

“…Waveform capnography is currently available in only 50% of neonatal intensive care units and is often not used even when available 7. Efficacy and practicality remain controversial, but national guidance8 and research9 support the use of capnography in neonates.…”

“…We welcome the British Association of Perinatal Medicine’s development of a framework for difficult airway management in this high risk group of patients,3 and hope that the guidance will be extended to all routine airway management. One quarter of neonatal intensive care units have reported cases of serious harm or death from airway management difficulties in the past five years,7 and reports of infant deaths after delayed identification of tracheal tube dislodgement suggest that there is a pressing need for guidance and risk management in this area.…”