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. 2024 Feb 14:69:102461.
doi: 10.1016/j.eclinm.2024.102461. eCollection 2024 Mar.

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

Mary Lyn Stein  1 , Lina Andrea Sarmiento Argüello  2 , Steven J Staffa  1 , Julia Heunis  3 , Chinyere Egbuta  1 , Stephen G Flynn  1 , Sabina A Khan  4 , Stefano Sabato  5 , Brad M Taicher  6 , Franklin Chiao  7 , Adrian Bosenberg  8 , Angela C Lee  9 , H Daniel Adams  10 , Britta S von Ungern-Sternberg  11 , Raymond S Park  1 , James M Peyton  1 , Patrick N Olomu  12 , Agnes I Hunyady  8 , Annery Garcia-Marcinkiewicz  13 , John E Fiadjoe  1 , Pete G Kovatsis  1 ; PeDI Collaborative Investigators
Collaborators, Affiliations

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

Mary Lyn Stein et al. EClinicalMedicine. .

Abstract

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications.

Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications.

Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications.

Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety.

Funding: None.

Keywords: Complications; Difficult airway; Intubation; Outcomes; Paediatric airway; Video laryngoscopy.

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Conflict of interest statement

Dr. von Ungern-Sternberg’s work is supported by the Stan Perron Charitable Foundation (00058) and through a National Health and Medical Research Council Investigator Grant (2009322) as well as Perth Children’s Hospital Foundation, WA Health Department, Telethon Trust, Australian and New Zeland College of Anaesthetists, Society of Paediatric Anaesthesia NZ/AUS, Thrasher Research Fund, University of Western Australia. Dr. Kovatsis was a medical advisor to Verathon, Inc to December 2020 and Dr. Hunyady is a medical advisor to Verathon, Inc. Dr. Fiadjoe serves in a leadership or fiduciary role for the American Board and Anesthesiology and the Society for Paediatric Anaesthesia. He reports payment or honoraria from Children’s National Hospital and expert testimony for Nemours Foundation. No other external funding or other competing interests declared.

Figures

Fig. 1
Fig. 1
Successful technique for tracheal intubation in early and current cohorts. The frequency of successful use of different techniques for tracheal intubation in the early and current cohorts are provided with percentages as well as numerators and denominators. The successful use of standard Macintosh or Miller blade video laryngoscopy increased significantly from 4% of cases (39/783) in the early cohort to 31.2% of cases (1224/3922) in the current cohort and the successful use of direct laryngoscopy, hyperangulated blade video laryngoscopy, flexible intubation, and combination techniques decreased from the early cohort to the current cohort.
Fig. 2
Fig. 2
Incidence of complications increases with number of attempts in full current cohort. The incidence of all complications and severe complications during each intubation attempt in the full unmatched current cohort are provided. The incidence of complications and severe complications increased with each additional intubation attempt.
See this image and copyright information in PMC

References

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