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Published on: January 17, 2011
Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department
Preston N Dean1,2, Erin F Hoehn1,2,3, Gary L Geis1,2
1From the, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Insights
Critically ill children with specific high-risk criteria, including hypotension or severe acidosis, face a significantly higher risk of cardiac arrest during tracheal intubation. These findings aid in identifying vulnerable pediatric patients requiring closer monitoring during emergency procedures.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care
- Cardiology
Background:
- Peri-intubation cardiac arrest in critically ill children is a significant concern with incompletely understood risk factors.
- Tracheal intubation in a pediatric emergency department (PED) carries inherent risks for patient deterioration.
Purpose of the Study:
- To identify and derive specific physiologic risk factors associated with peri-intubation deterioration during tracheal intubation in a pediatric emergency department.
- To develop criteria for identifying children at high risk for adverse events during intubation.
Main Methods:
- A retrospective cohort study was conducted on patients undergoing emergency tracheal intubation in a PED.
- High-risk criteria for peri-intubation arrest were developed, including hypotension, concern for cardiac dysfunction, persistent hypoxemia, severe metabolic acidosis (pH < 7.1), post-return of spontaneous circulation (ROSC), and status asthmaticus.
- Electronic health records were reviewed to compare outcomes between patients meeting one or more high-risk criteria versus those meeting none.
Main Results:
- Patients meeting at least one high-risk criterion had a 5.6% incidence of peri-intubation cardiac arrest compared to 0% in those meeting none (p=0.028).
- These high-risk patients also showed increased rates of postintubation cardiac arrest (11.1%), in-hospital mortality (25%), and ECMO activation (8.3%), along with lower first-pass intubation success rates (47.2%).
- Significant differences in outcomes were observed between the high-risk group and the no-high-risk criterion group across all secondary outcomes.
Conclusions:
- Established criteria effectively identify physiologically challenging airways in the PED.
- Children presenting with hypotension, persistent hypoxemia, cardiac dysfunction concerns, severe metabolic acidosis, status asthmaticus, or post-ROSC are at elevated risk for peri-intubation cardiac arrest and mortality.
- Further multicenter studies are recommended to validate these findings and refine risk stratification for pediatric intubations.
Background:
The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED).
Methods:
This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria.
Results:
Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively.
Conclusions:
We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
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