The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study

Jan Hau Lee, David A Turner, Pradip Kamat, Sholeen Nett, Justine Shults, Vinay M Nadkarni, Akira Nishisaki, Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), National Emergency Airway Registry for Children (NEAR4KIDS), Jan Hau Lee, David A Turner, Pradip Kamat, Sholeen Nett, Justine Shults, Vinay M Nadkarni, Akira Nishisaki, Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), National Emergency Airway Registry for Children (NEAR4KIDS)

Abstract

Background: The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association between number of TI attempts and severe desaturation (SpO2 < 70 %) and adverse TI associated events (TIAEs).

Methods: We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80 % during TI attempt), severe desaturation (<70 %), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment).

Results: Of 3382 TIs, 2080(65 %) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60 %), second attempt in 503/2080(24 %), and ≥3 attempts in 321/2080(15 %). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16 %, 2 attempts:36 %, ≥3 attempts:56 %, p < 0.001; adjusted OR for 2 attempts: 2.9[95 % CI:2.3-3.7]; ≥3 attempts: 6.5[95 % CI: 5.0-8.5], adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12 %, 2 attempts:30 %, ≥3 attempts:44 %, p < 0.001); adjusted OR for 2 attempts: 3.1[95 % CI:2.4-4.0]; ≥3 attempts: 5.7[95 % CI: 4.3-7.5] ). TIAE rates increased from 10 to 29 to 38 % with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.7[95 % CI:2.9-4.9] ; ≥3 attempts: 5.5[95 % CI: 4.1-7.4]. Severe TIAE rates went from 5 to 8 to 9 % (p = 0.008); adjusted OR for 2 attempts: 1.6 [95 % CI:1.1-2.4]; ≥3 attempts: 1.8[95 % CI:1.1-2.8].

Conclusions: Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.

Keywords: Acute respiratory failure; Child; Critical illness; Desaturation; Intubation; Mechanical ventilation; Pediatric intensive care unit; Registries.

Figures

Fig. 1
Fig. 1
Study inclusion diagram

References

    1. Khemani RG, Thomas NJ, Venkatachalam V, Scimeme JP, Berutti T, Schneider JB, et al. Comparison of SpO2 to PaO2 based markers of lung disease severity for children with acute lung injury. Crit Care Med. 2012;40(4):1309–16. doi: 10.1097/CCM.0b013e31823bc61b.
    1. Leclerc F, Duhamel A, Deken V, Le Reun C, Lacroix J, Leteurtre S. Nonrespiratory pediatric logistic organ dysfunction-2 score is a good predictor of mortality in children with acute respiratory failure. Pediatr Crit Care Med. 2014;15(7):590–3. doi: 10.1097/PCC.0000000000000184.
    1. Jeena PM, Wesley AG, Coovadia HM. Admission patterns and outcomes in a paediatric intensive care unit in South Africa over a 25-year period (1971-1995) Intensive Care Med. 1999;25(1):88–94. doi: 10.1007/s001340050792.
    1. Nishisaki A, Ferry S, Colborn S, DeFalco C, Dominguez T, Brown CA, 3rd, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med. 2012;13(1):e5–10. doi: 10.1097/PCC.0b013e3181fe472d.
    1. Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA, 3rd, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749–54. doi: 10.1016/j.annemergmed.2012.04.005.
    1. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71–8. doi: 10.1111/acem.12055.
    1. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607–13. doi: 10.1213/01.ANE.0000122825.04923.15.
    1. Lane B, Finer N, Rich W. Duration of intubation attempts during neonatal resuscitation. J Pediatr. 2004;145(1):67–70. doi: 10.1016/j.jpeds.2004.03.003.
    1. O’Donnell CP, Kamlin CO, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics. 2006;117(1):e16–21. doi: 10.1542/peds.2005-0901.
    1. Choi HJ, Je SM, Kim JH, Kim E. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study. Resuscitation. 2012;83(11):1363–8. doi: 10.1016/j.resuscitation.2012.03.010.
    1. Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Paediatr Anaesth. 2014
    1. Carroll CL, Spinella PC, Corsi JM, Stoltz P, Zucker AR. Emergent endotracheal intubations in children: be careful if it’s late when you intubate. Pediatr Crit Care Med. 2010;11(3):343–8. doi: 10.1097/PCC.0b013e3181ce6d19.
    1. Nishisaki A, Turner DA, Brown CA, 3rd, Walls RM, Nadkarni VM. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med. 2013;41(3):874–85. doi: 10.1097/CCM.0b013e3182746736.
    1. Sanders RC, Jr, Giuliano JS, Jr, Sullivan JE, Brown CA, 3rd, Walls RM, Nadkarni V, et al. Level of trainee and tracheal intubation outcomes. Pediatrics. 2013;131(3):e821–8. doi: 10.1542/peds.2012-2127.
    1. Tarquinio KM, Howell JD, Montgomery V, Turner DA, Hsing DD, Parker MM, et al. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015;16(3):210–8. doi: 10.1097/PCC.0000000000000319.
    1. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008;34(10):1835–42. doi: 10.1007/s00134-008-1205-6.
    1. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004;39(9):1376–80. doi: 10.1016/j.jpedsurg.2004.05.010.
    1. Haubner LY, Barry JS, Johnston LC, Soghier L, Tatum PM, Kessler D, et al. Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units. Resuscitation. 2013;84(10):1359–64. doi: 10.1016/j.resuscitation.2013.03.014.
    1. Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics. 2003;112(6 Pt 1):1242–7. doi: 10.1542/peds.112.6.1242.
    1. Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med. 2012;40(6):1808–13. doi: 10.1097/CCM.0b013e31824e0e67.
    1. Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34(9):2355–61. doi: 10.1097/01.CCM.0000233879.58720.87.
    1. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med. 2013;187(8):832–9. doi: 10.1164/rccm.201210-1851OC.
    1. Graciano AL, Tamburro R, Thompson AE, Fiadjoe J, Nadkarni VM, Nishisaki A. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med. 2014;40(11):1659–69. doi: 10.1007/s00134-014-3407-4.
    1. Li S, Rehder KJ, Giuliano JS, Jr, Apkon M, Kamat P, Nadkarni VM, et al. Development of a quality improvement bundle to reduce tracheal intubation-associated events in pediatric ICUs. Am J Med Qual. 2014
    1. Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med. 2014

Source: PubMed

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