Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training

Mizue Kishida¹, Robert A Berg², Natalie Napolitano³, John Berkenbosch^{4

5}, Andrea Talukdar⁶, Philipp Jung⁷, Matthew P Malone⁸, Simon J Parsons⁹, Ilana Harwayne-Gidansky¹⁰, Sholeen Nett¹¹, Lily Glater¹², Conrad Krawiec¹³, Asha Shenoi¹⁴, Awni Al-Subu¹⁵, Lee Polikoff¹⁶, Serena P Kelly¹⁷, Carolyn K Adams¹⁸, John S Giuliano Jr¹⁹, Shashikanth Ambati²⁰, David Tellez²¹, Rebecca J Martin⁸, Anthony Lee²², Ryan K Breuer²³, Katherine V Biagas²⁴, Palen P Mallory²⁵, Kelly L Corbett²⁶, G Kris Bysani²⁷, Laurence Ducharme-Crevier²⁸, Samantha Wirkowski²⁹, Matthew Pinto³⁰, Megan Toal³¹, Rachel K Marlow³², Michelle Adu-Darko³³, Justine Shults³⁴, Vinay Nadkarni³⁵, Akira Nishisaki³⁵; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Affiliations

¹ Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan.
² Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
⁴ Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville, Louisville, KY.
⁵ Division of Critical Care Medicine, "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY.
⁶ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Nebraska and University of Nebraska Medical Center, Omaha, NE.
⁷ Paediatric Department, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
⁸ Division of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.
⁹ Section of Critical Care, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada.
¹⁰ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Med, Albany, NY.
¹¹ Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, NH.
¹² Division of Pediatric Critical Care Medicine, Steven & Alexandra Cohen Children's Medical Center of New York, Zucker School of Medicine/Northwell, New Hyde Park, NY.
¹³ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA.
¹⁴ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Kentucky Children's Hospital, Lexington, KY.
¹⁵ Department of Pediatrics, University of Wisconsin-Madison, Madison, WI.
¹⁶ Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI.
¹⁷ Division of Critical Care Medicine, Department of Pediatrics, OHSU Doernbecher Children's Hospital, Portland, OR.
¹⁸ Pediatric Intensive Care Unit, UW Health-American Family Children's Hospital, Madison, WI.
¹⁹ Department of Pediatrics, Critical Care Medicine, Yale University School of Medicine, New Haven, CT.
²⁰ Division of Pediatric Critical Care, Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Med, Albany, NY.
²¹ Department of Critical Care, Phoenix Childrens Hospital, Phoenix, AZ.
²² Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH.
²³ Department of Pediatrics, Division of Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, NY.
²⁴ Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY.
²⁵ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital & Health Center, Duke University, Durham, NC.
²⁶ Section of Pediatric Critical Care Medicine, Department of Pediatrics, Dartmouth Health Children's, Geisel School of Medicine at Dartmouth, Lebanon, NH.
²⁷ Medical City Children's Hospital, Pediatric Acute Care Associates of North Texas, Dallas, TX.
²⁸ Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada.
²⁹ Division of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY.
³⁰ Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY.
³¹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY.
³² Pediatric Critical Care, Phoenix Children's Hospital, Phoenix, AZ.
³³ Department of Pediatrics, University of Virginia Medical Center, Charlottesville, VA.
³⁴ Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³⁵ Department of Anesthesiology, Critical Care Medicine, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

PMID: 39982154
PMCID: PMC11850027 (available on 2026-02-06)
DOI: 10.1097/PCC.0000000000003646

Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training

Mizue Kishida et al. Pediatr Crit Care Med. 2025.

. 2025 Feb 1;26(2):e166-e176.

doi: 10.1097/PCC.0000000000003646. Epub 2025 Feb 6.

Authors

Affiliations

¹ Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan.
² Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA.
⁴ Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville, Louisville, KY.
⁵ Division of Critical Care Medicine, "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY.
⁶ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Nebraska and University of Nebraska Medical Center, Omaha, NE.
⁷ Paediatric Department, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
⁸ Division of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.
⁹ Section of Critical Care, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada.
¹⁰ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Med, Albany, NY.
¹¹ Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, NH.
¹² Division of Pediatric Critical Care Medicine, Steven & Alexandra Cohen Children's Medical Center of New York, Zucker School of Medicine/Northwell, New Hyde Park, NY.
¹³ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA.
¹⁴ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Kentucky Children's Hospital, Lexington, KY.
¹⁵ Department of Pediatrics, University of Wisconsin-Madison, Madison, WI.
¹⁶ Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI.
¹⁷ Division of Critical Care Medicine, Department of Pediatrics, OHSU Doernbecher Children's Hospital, Portland, OR.
¹⁸ Pediatric Intensive Care Unit, UW Health-American Family Children's Hospital, Madison, WI.
¹⁹ Department of Pediatrics, Critical Care Medicine, Yale University School of Medicine, New Haven, CT.
²⁰ Division of Pediatric Critical Care, Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Med, Albany, NY.
²¹ Department of Critical Care, Phoenix Childrens Hospital, Phoenix, AZ.
²² Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH.
²³ Department of Pediatrics, Division of Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, NY.
²⁴ Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY.
²⁵ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital & Health Center, Duke University, Durham, NC.
²⁶ Section of Pediatric Critical Care Medicine, Department of Pediatrics, Dartmouth Health Children's, Geisel School of Medicine at Dartmouth, Lebanon, NH.
²⁷ Medical City Children's Hospital, Pediatric Acute Care Associates of North Texas, Dallas, TX.
²⁸ Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada.
²⁹ Division of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY.
³⁰ Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY.
³¹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY.
³² Pediatric Critical Care, Phoenix Children's Hospital, Phoenix, AZ.
³³ Department of Pediatrics, University of Virginia Medical Center, Charlottesville, VA.
³⁴ Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
³⁵ Department of Anesthesiology, Critical Care Medicine, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

PMID: 39982154
PMCID: PMC11850027 (available on 2026-02-06)
DOI: 10.1097/PCC.0000000000003646

Abstract

Objectives: Tracheal intubation (TI) is a critical skill for PICU attending physicians to maintain. We hypothesize that attendings perform fewer TIs and have lower success rate in PICU programs with a Pediatric Critical Care Medicine (PCCM) fellowship.

Design: Retrospective study using the National Emergency Airway Registry for Children (NEAR4KIDS) from July 2016 to June 2020. Exposures were presence of PCCM fellowship and attending TI skill maintenance program (SMP). The primary outcome was attending's first attempt success and the secondary outcome was adverse airway outcome in the first attempt.

Setting: Thirty-three PICUs in North America.

Patients: Children receiving TI.

Interventions: None.

Measurements and main results: Overall, 23 of 33 PICUs had a PCCM fellowship with three of 23 having an attending TI SMP. Attendings performed TI in 24.1% (2,728/11,323): 13.9% (13.8 TI/yr per PICU) in PICUs with a fellowship vs. 66.0% (36.6 TI/yr per PICU) without a fellowship (p < 0.001). Attending first attempt success in PICUs with vs. without fellowships was 70.5% vs. 81.3% (difference, 10.8% [95% CI, 7.6-14.0%]; p < 0.0001). After controlling for confounders, attendings in a PICU with a fellowship had lower odds for first attempt success (adjusted odds ratio [aOR], 0.65 [95% CI, 0.47-0.90]). We failed to find an association between attending first attempt success and PICU program type, with vs. without a TI SMP (74.0% vs. 69.5%; p = 0.146). The adverse airway outcome rate of the TI with attending's first attempt was lower in PICU programs with vs. without a TI SMP (32.8% vs. 40.3%; p = 0.020). However, after adjusting for confounders, we failed to exclude the possibility of near halving of odds of adverse outcome (aOR, 0.75 [95% CI, 0.55-1.01]; p = 0.058).

Conclusions: Attendings in PICU programs with a fellowship have fewer opportunities to perform TI and lower first attempt success rates. Opportunities exist for attending TI skill maintenance, especially in PICUs with a PCCM fellowship.

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Conflict of interest statement

Drs. Napolitano’s and Shults’s institution received funding from the Agency for Healthcare Research and Quality (AHRQ; R18HS024511). Dr. Napolitano’s institution received funding from Dräger, Actuated Medical, and Philips Respironics; they received support for article research from Timpel and VERO-Biotech. Dr. Krawiec received funding from New England Journal of Medicine Healer Cases and Carle Illinois School of Medicine Admissions Committee. Dr. Polikoff received funding from Novavax. Dr. Nishisaki’s institution received funding from Chiesi, AHRQ, and the National Institute of Child Health and Human Development. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

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Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training

Affiliations

Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training

Authors

Affiliations

Abstract

Conflict of interest statement

References

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources