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Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events
Curran Hunter Daigle1, John E Fiadjoe1, Elizabeth K Laverriere1
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Difficult bag-mask ventilation occurs in about 10% of pediatric intensive care unit patients undergoing tracheal intubation. This difficulty significantly increases the risk of adverse events and oxygen desaturation during the procedure.
Area of Science:
- Pediatric Critical Care Medicine
- Airway Management
- Intubation Procedures
Background:
- Bag-mask ventilation is a common pre-intubation procedure in pediatric intensive care units (PICUs).
- Limited data exists on the prevalence, risk factors, and consequences of difficult bag-mask ventilation in critically ill children.
- Understanding these factors is crucial for improving patient safety during tracheal intubation.
Purpose of the Study:
- To determine the prevalence of difficult bag-mask ventilation in pediatric intensive care unit patients.
- To identify risk factors associated with difficult bag-mask ventilation.
- To assess the association between difficult bag-mask ventilation and adverse tracheal intubation-associated events or oxygen desaturation.
Main Methods:
- Retrospective analysis of prospectively collected data from the National Emergency Airway Registry for Children (NEAR).
- Inclusion of data from 46 international PICUs between January 2013 and December 2018.
- Statistical analysis using univariate and multivariable logistic regression to identify risk factors and associations.
Main Results:
- Difficult bag-mask ventilation was reported in 9.5% of 15,810 pediatric patients undergoing tracheal intubation.
- Factors associated with difficulty included older age, respiratory diagnosis, difficult airway features, experienced providers, and lack of neuromuscular blockade.
- Adverse events or desaturation occurred in 40.2% of patients with difficult bag-mask ventilation versus 19.8% without (OR 2.28).
Conclusions:
- Approximately 1 in 10 pediatric intensive care unit patients experience difficult bag-mask ventilation during tracheal intubation.
- Difficult bag-mask ventilation is independently associated with a more than twofold increased risk of adverse events and oxygen desaturation.
- Further research is needed to enhance preprocedural planning and management strategies for difficult bag-mask ventilation.
Objectives:
Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.
Design:
A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.
Setting:
Forty-six international PICUs.
Patients:
Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.
Interventions:
None.
Measurements And Main Results:
The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).
Conclusions:
Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.
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