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. 2025 Feb 4;6(2):100052.
doi: 10.1016/j.acepjo.2025.100052. eCollection 2025 Apr.

Interventions to Reduce Risk in the Physiologically Difficult Pediatric Airway: A Descriptive Study and Exploratory Analysis

Tanner Heckle  1 , Benjamin T Kerrey  1   2 , Yin Zhang  3 , Preston Dean  1   2
Affiliations

Interventions to Reduce Risk in the Physiologically Difficult Pediatric Airway: A Descriptive Study and Exploratory Analysis

Tanner Heckle et al. J Am Coll Emerg Physicians Open. .

Abstract

Objectives: Patients with physiologically difficult airways are at high risk for peri-intubation cardiac arrest in the pediatric emergency department (PED). We sought to describe how preintubation interventions designed to improve physiologic status are used and if they are associated with a reduction in peri-intubation cardiac arrest.

Methods: We completed a secondary analysis of a multicenter, retrospective cohort of patients <21 years old requiring tracheal intubation in 8 academic PEDs. Included patients underwent rapid sequence intubation and met at least 1 of 6 criteria for a physiologically difficult airway. We examined administration rates of preintubation interventions (intravenous [IV] fluids, vasoactive medications, and sodium bicarbonate) overall and by high-risk criteria. In an exploratory analysis, we assessed the relationship of preintubation interventions with peri-intubation cardiac arrest using weighted propensity scores and generalized linear mixed models.

Results: Of 332 included patients, 264 patients (80%) received at least 1 intervention. A total of 257 (77%) patients received IV fluids, 87 (26%) received vasoactive medications, and 20 (6%) received sodium bicarbonate. Across sites, there were wide ranges of administration of IV fluids (59%-98%), vasoactive medications (10%-58%), and sodium bicarbonate (0%-36%). Preintubation interventions were not associated with peri-intubation cardiac arrest (odds ratio, 1.59; 95% CI 0.50 to 5.05).

Conclusion: In PED patients with physiologically difficult airways, there is wide variability in the use of preintubation interventions. Receiving preintubation interventions was not associated with peri-intubation cardiac arrest. Future video-based prospective studies are needed to further evaluate interventions designed to prevent peri-intubation cardiac arrest.

Keywords: emergency department; pediatrics; peri-intubation cardiac arrest; physiologically difficult airway; tracheal intubation.

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Conflict of interest statement

All authors have affirmed they have no conflicts of interest to declare.

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