Tracheal Intubation Practice and Safety Across International PICUs: A Report From National Emergency Airway Registry for Children*

Lee, Jan Hau; Nuthall, Gabrielle; Ikeyama, Takanari; Saito, Osamu; Mok, Yee Hui; Shepherd, Michael; Jung, Philipp; Shetty, Rakshay; Thyagarajan, Sujatha; Nett, Sholeen; Napolitano, Natalie; Nishisaki, Akira; Investigators, Sepsis

doi:10.1097/pcc.0000000000001782

Cited by 41 publications

(13 citation statements)

References 25 publications

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“…First-pass success rates, frequency of TIAEs and desaturations and bradycardias are the hallmarks of intubation quality. When compared to older children and adults, neonatal intubations appear to be remarkably more difficult and associated with more TIAEs (12,13). This does not necessarily arise from anatomy and physiology.…”

Section: Resultsmentioning

confidence: 99%

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

et al. 2021

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Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations.Objective: Aim of this study was to determine the frequency of tracheal intubation–associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit.Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded.Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (<10 intubation encounters) (OR = 2.15; 95% CI, 1.257–3.685) and equipment problems (OR = 3.43; 95% CI, 1.12–10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06–0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25–0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08–4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265–2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04–2.46) were associated with unsuccessful intubation attempts.Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.

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Section: Resultsmentioning

confidence: 99%

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

et al. 2021

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“…The high rate of cardiac arrest prior to and during intubation should encourage both critical care and HCT physicians to critically examine NIPPV practice patterns. In large, international cohorts, the reported arrest rate during pediatric intubation ranges between 0.5%-1.7% ( 21 – 23 ). These data come from a variety of large, tertiary, pediatric hospitals that care for medically complex and fragile children with high acuity.…”

Section: Discussionmentioning

confidence: 99%

Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant

et al. 2021

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RationaleLittle is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients.ObjectiveWe sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement.MethodsThis is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016.Results97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p<0.001), and higher respiratory rate at multiple hours of NIPPV use (1hr p=0.02, 2hr p=0.04, 4hr p=0.008, 8hr p=0.002). Using respiratory rate at 4 hours a multivariable model was constructed. This model demonstrated high ability to discriminate NIPPV failure (AUC=0.794) with the following results: respiratory rate >40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p<0.001] and vasoactive use [aOR=4.9 (95% CI: 1.9, 13.1), p=0.001]. Of note, 11 patients had a cardiac arrest during intubation (11%) and 3 others arrested prior to intubation. These 14 patients were closer to HCT [14 days (IQR:4, 73) vs 54 (IQR:21,117), p<0.01] and there was a trend toward beginning NIPPV outside of the PICU and arrest during/prior to intubation (p=0.056).ConclusionsIn this cohort respiratory rate at 4 hours and vasoactive use are independent risk factors of NIPPV failure. An objective model to predict which children may benefit from a trial of NIPPV, may also inform the timing of both NIPPV initiation and uncomplicated intubation.

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“…The lower rate of PEAO could be due to the fact that we used micro-cuffed endotracheal tubes (high-volume-low-pressure) in all cases as these were routinely available from the hospital supply during the study period. The use of micro-cuffed ETT may had led to lesser movement of ETT, lesser chances of unplanned extubation or ETT change, lower risk of laryngeal edema, and hence lower rates of PEAO ( 15 , 30 , 31 ). None of the Pediatric studies looked into the impact of nasotracheal intubation on the rate of PEAO, time taken for intubation, unplanned extubation, extubation failure, and other important clinical outcomes (duration of PICU stay and mortality).…”

Section: Discussionmentioning

confidence: 99%

“…As nasotracheal intubation is technically challenging and associated with more complications, it is recommended that it should be performed by skilled healthcare providers (1,2). Due to these reasons, nasotracheal intubation is less commonly practiced (2-5.6% of all endotracheal intubations) among adults and children undergoing mechanical ventilation in ICUs (2,5,(11)(12)(13)(14)(15).…”

Section: Introductionmentioning

confidence: 99%

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

et al. 2021

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Background: The data on long-term nasotracheal intubation among mechanically ventilated critically ill children is limited. The purpose of this study was to compare the rate of post-extubation airway obstruction (PEAO) with nasotracheal and orotracheal intubation.Methods: This open-label randomized controlled trial was conducted in PICU of a tertiary care and teaching hospital in North India from January-December 2020 involving intubated children aged 3 months−12 years. After written informed consent, children were randomized into nasotracheal and orotracheal intubation groups. Post-extubation, modified Westley's croup score (mWCS) was used at 10-timepoints (0-min, 30 min, 1, 2, 3, 6, 12, 24, 36, and 48-h after extubation) to monitor for PEAO. The primary outcome was the rate of PEAO; and secondary outcomes were time taken for intubation, number of intubation attempts, complications during intubation, unplanned extubation, repeated intubations, tube malposition/displacement, endotracheal tube blockade, ventilator associated pneumonia, skin trauma, extubation failure/re-intubation, duration of PICU stay, and mortality.Results: Seventy children were randomized into nasotracheal (n = 30) and orotracheal (n = 40) groups. Both the groups were similar in baseline characteristics. The rate of PEAO was similar between nasotracheal and orotracheal groups (10 vs. 20%, p = 0.14). The maximum mWCS and mWCS at 10-timepoints were similar in two groups. The time taken for intubation was significantly longer (85 vs. 48 s, p < 0.001) in nasotracheal group, whereas other secondary outcomes were similar in two groups.Conclusion: The rate of PEAO was not different between nasotracheal and orotracheal groups.Clinical Trial Registration:http://ctri.nic.in, Identifier: CTRI/2020/01/022988.

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Tracheal Intubation Practice and Safety Across International PICUs: A Report From National Emergency Airway Registry for Children*

Cited by 41 publications

References 25 publications

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

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