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

Authors

Mary Lyn Stein, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Lina Andrea Sarmiento Argüello, Instituto Nacional de Pediatría, Fundación Kardias A.C, Ciudad de México, Mexico.
Steven J. Staffa, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Julia Heunis, Department of Pediatrics, Boston Children's Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Chinyere Egbuta, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Stephen G. Flynn, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Sabina A. Khan, Department of Anesthesiology, UTHealth - McGovern Medical School, Houston, TX, USA.
Stefano Sabato, Department of Anaesthesia and Pain Management, Royal Children's Hospital, and Anaesthesia Research Group, Murdoch Children's Research Institute, Parkville, Australia.
Brad M. Taicher, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA.
Franklin Chiao, Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, USA.
Adrian Bosenberg, Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
Angela C. Lee, Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
H Daniel Adams, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
Britta S. von Ungern-Sternberg, Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Institute for Paediatric Perioperative Excellence, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perioperative Medicine Team, Perioperative Care Program, and Telethon Kids Institute, Perth, Australia.
Raymond S. Park, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
James M. Peyton, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Patrick N. Olomu, Department of Pediatric Anesthesiology and Pain Management, Children's Health System of Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Agnes I. Hunyady, Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
Annery Garcia-Marcinkiewicz, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
John E. Fiadjoe, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Pete G. Kovatsis, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.

Document Type

Journal Article

Publication Date

3-1-2024

Journal

EClinicalMedicine

Volume

69

DOI

10.1016/j.eclinm.2024.102461

Keywords

Complications; Difficult airway; Intubation; Outcomes; Paediatric airway; Video laryngoscopy

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.

APA Citation

Stein, Mary Lyn; Sarmiento Argüello, Lina Andrea; Staffa, Steven J.; Heunis, Julia; Egbuta, Chinyere; Flynn, Stephen G.; Khan, Sabina A.; Sabato, Stefano; Taicher, Brad M.; Chiao, Franklin; Bosenberg, Adrian; Lee, Angela C.; Adams, H Daniel; von Ungern-Sternberg, Britta S.; Park, Raymond S.; Peyton, James M.; Olomu, Patrick N.; Hunyady, Agnes I.; Garcia-Marcinkiewicz, Annery; Fiadjoe, John E.; and Kovatsis, Pete G., "Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time" (2024). GW Authored Works. Paper 4280.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/4280

Department

Anesthesiology and Critical Care Medicine