Articles
Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

https://doi.org/10.1016/S2213-2600(15)00508-1Get rights and content

Summary

Background

Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications.

Methods

The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe.

Findings

Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication.

Interpretation

More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety.

Funding

None.

Introduction

Tracheal intubation is a potentially life-saving procedure done by many clinicians and is usually easily accomplished with conventional direct laryngoscopy. Difficult tracheal intubation requires unique expertise and methods such as extraglottic airway devices, fibre-optic bronchoscopy, and video laryngoscopy.1 Despite the widespread use of these indirect techniques by various clinicians (eg, emergency room physicians, neonatologists, intensivists, surgeons, and anaesthesiologists), little is known about related adverse events.2, 3, 4 Children under care of an anaesthetist have more airway-related adverse events than adults.5 Analysis of the American Society of Anesthesiologists (ASA) closed claims database showed that respiratory events were more common in children than in adults (43% vs 30% respectively; p≤ 0·01) with greater mortality in paediatric claims than in adult claims (50% vs 35%; p ≤0·01).5, 6 The Fourth National Audit Project (NAP4) of the UK Royal College of Anaesthetists and the Difficult Airway Society did a study7, 8 of major complications of airway management in their National Health Service hospitals during 1 year. They reported only ten events in children younger than 10 years, four of which were related to difficult intubation. Complications included subglottic narrowing, aspiration, and death. A knowledge gap exists about the efficacy of various indirect tracheal intubation methods in children, related complications, and their risk factors. We successfully designed and implemented a collaborative, multicentre web-based registry (the Pediatric Difficult Intubation (PeDI) registry) under the auspices of the Society for Pediatric Anesthesia to address these concerns and improve airway management in children with difficult tracheal intubation.

The goals of the present study were to define the type and incidence of complications that arise from airway management in children with difficult tracheal intubation; establish the success of various tracheal intubation techniques; identify associations between patient, clinician, and practice characteristics, and the occurrence of complications; and establish the effect of multiple tracheal intubation attempts (>2 attempts) on complications.

Research in context

Evidence before the study

Findings of single centre studies in adults have shown that repeated conventional tracheal intubation attempts in critically ill patients contribute to patient morbidity. Multicentre studies from paediatric intensive care units suggest that critically ill children are at high risk of complications during airway management in the intensive care unit. Little is known about the complications and associated risk factors of airway management in children with difficult tracheal intubation cared for by anaesthesiologists. Before undertaking this study we searched the scientific literature published between October, 1975, and October, 2011, with the terms “pediatric difficult intubation”, “difficult airway”, “difficult direct laryngoscopy”, “difficult tracheal intubation”, “complications and pediatric intubation”, “anesthesiology and pediatric difficult intubation” in various combinations. We filtered our results to exclude adult studies, case reports, and case series. We found no relevant large multicentre trials directly relating to this topic. The aim of our study was to establish the complications and their associated risk factors in children included in a prospective multicentre difficult tracheal intubation registry.

Added value of this study

This study is the first to assess the complications of children with difficult tracheal intubation as established by anaesthesiologists. This study establishes the complication rates in these patients, identifies the risk factors for complications, and estimates the incidence of difficult tracheal intubation in children under anaesthesia care. This study has identified a high complication rate. This finding should encourage further investigations and a change in clinical practice patterns to enhance patient safety.

Implications of all the available evidence

Children with difficult tracheal intubation are a high-risk group and multiple tracheal intubation attempts are a key risk factor for complications. Clinicians should treat every tracheal intubation attempt as a critical intervention and should limit the number of direct laryngoscopy and tracheal intubation attempts in this population. Future research should investigate interventions to reduce these complications such as checklists and care protocols. Additionally, the role and efficacy of passive oxygenation during tracheal intubation is unclear and should be investigated.

Section snippets

Study design

The PeDI Collaborative Group was created as a special interest group within the Society for Pediatric Anesthesia with the goal to make possible multicentre collaboration and quality improvement in patients with difficult tracheal intubation. In December, 2010, members of the Society for Pediatric Anesthesia were solicited via electronic mail to take part in the special interest group; known experts in the paediatric anaesthesia community were also invited to participate. 48 members of the

Results

The study period included data collected from our centres between Aug 6, 2012, and Jan 31, 2015. The 13 centres reported 1061 cases of tracheal intubation during this period. The four largest centres contributed most of the cases in the registry; table 1 reports the distribution of cases across centres. One centre was excluded because of lack of full compliance with data capture rates and audits, leaving 1018 cases for analysis (table 1). Three centres reported 112, 164, and 20 cases of

Discussion

This prospective multicentre study estimated that difficult tracheal intubation occurred in 2–5 per 1000 paediatric anaesthesia cases in large academic centres in the USA. Furthermore, this registry showed that 20% of children with difficult tracheal intubations had a complication. We identified the following associations with any complication (severe or non-severe): multiple tracheal intubation attempts (>2), weight less than 10 kg, short thyromental distance, abnormal airway physical

References (27)

  • JP Morray et al.

    A comparison of pediatric and adult anesthesia closed malpractice claims

    Anesthesiology

    (1993)
  • N Jimenez et al.

    An update on pediatric anesthesia liability: a closed claims analysis

    Anesth Analg

    (2007)
  • RS Cormack et al.

    Difficult tracheal intubation in obstetrics

    Anaesthesia

    (1984)
  • Cited by (297)

    View all citing articles on Scopus
    View full text