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

• Published in: EClinicalMedicine Vol. 69; p. 102461
• Main Authors: Mary Lyn Stein, Lina Andrea Sarmiento Argüello, Steven J. Staffa, Julia Heunis, Chinyere Egbuta, Stephen G. Flynn, Sabina A. Khan, Stefano Sabato, Brad M. Taicher, Franklin Chiao, Adrian Bosenberg, Angela C. Lee, H. Daniel Adams, Britta S. von Ungern-Sternberg, Raymond S. Park, James M. Peyton, Patrick N. Olomu, Agnes I. Hunyady, Annery Garcia-Marcinkiewicz, John E. Fiadjoe, Pete G. Kovatsis, Benjamin Bruins, Paul Stricker, Elizabeth Laverriere, Justin L. Lockman, Brian Struyk, Christopher Ward, Akira Nishisaki, Ramesh Kodavatiganti, Rodrigo Daly Guris, Luis Sequera-Ramos, Mark Teen, Ayodele Oke, Grace Hsu, Arul Lingappan, Rhae Battles, Ashley Bocanegra, Tally Goldfarb, Edgar Kiss, Peter Szmuk, Sam Mireles, Andrea Murray, Simon Whyte, Ranu Jain, Maria Matuszczak, Christopher Holmes, Alexander McCann, Clyde Matava, Nicholas Dalesio, Robert Greenberg, Angela Lucero, Sapna Desai, Sondra Rosander, Sindhu Samba, Charles Schrock, Sydney Nykiel-Bailey, Jennifer Marsh, Melissa Brooks Peterson, Amy Lee, Somaletha Bhattacharya, Nicholas Burjek, Narasimhan Jagannathan, David Lardner, Christy Crockett, Sara Robetson, Jasmine Patel, Aarti Sharma, Thomas Templeton, Piedad Echeverry Marín, Carolina Pérez-Pradilla, Neeta Singh, David Sommerfield, Neil Hauser, Emily Hesselink, Hilana Lewkowitz-Shpuntoff, Pilar Castro, N. Ricardo Riveros Perez, Eduardo Vega, Alejandro González, Paola Ostermann, Kasia Rubin, Jonathan Meserve, Charles Lord, Angela Lee, Songyos Valairucha, Priti Dalal, Thanh Tran, Taylor Anspach, Lisa K. Lee, Ihab Ayad, Mohamed Rehman, Allison Fernandez, Lillian Zamora, Niroop Ravula, Sadiq Shaik, Judit Szolnoki, Preethy Mathew, Sandhya Yaddanapudi, Indu Sen, Aakriti Gupta
• Format: Journal Article
• Language: English
• Published: Elsevier 01.03.2024
• Subjects: Complications; Difficult airway; Intubation; Outcomes; Paediatric airway; Video laryngoscopy
• ISSN: 2589-5370

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.