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Updated: Jul 26, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to
Preston Dean1, Gary Geis1, Erin F Hoehn2
1Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
Insights
Identifying high-risk criteria in pediatric patients undergoing intubation can significantly reduce peri-intubation cardiac arrest and mortality. This multicenter study confirms these risk factors are associated with adverse outcomes.
Area of Science:
- Emergency Medicine
- Pediatric Critical Care
Background:
- Previous single-center studies identified risk factors for peri-intubation cardiac arrest in the emergency department (ED).
- A need existed to validate these findings in a more diverse, multicenter patient cohort.
Purpose of the Study:
- To validate previously identified risk factors for peri-intubation cardiac arrest in a multicenter pediatric emergency department cohort.
- To assess the association between high-risk criteria and peri-intubation cardiac arrest, extracorporeal membrane oxygenation (ECMO) cannulation, and in-hospital mortality.
Main Methods:
- Retrospective cohort study of 1200 pediatric patients undergoing tracheal intubation across eight academic pediatric EDs.
- Examined six high-risk criteria: persistent hypoxemia, persistent hypotension, cardiac dysfunction concern, post-return of spontaneous circulation (ROSC), severe metabolic acidosis, and status asthmaticus.
- Used generalized linear mixed models to compare outcomes between patients meeting one or more high-risk criteria versus none.
Main Results:
- 27.7% of patients met at least one high-risk criterion.
- Meeting any high-risk criterion was associated with significantly increased odds of peri-intubation arrest (AOR 75.7), ECMO (AOR 7.1), and mortality (AOR 3.4).
- Persistent hypoxemia, persistent hypotension, cardiac dysfunction concern, and post-ROSC were independently associated with peri-intubation arrest.
Conclusions:
- Meeting at least one high-risk criterion is strongly associated with peri-intubation cardiac arrest in pediatric patients.
- These findings confirm the predictive value of these risk factors in a broader, multicenter setting.
- Identifying and managing these high-risk criteria may mitigate adverse outcomes during pediatric intubation.
Background:
Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients.
Methods:
We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models.
Results:
Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC.
Conclusions:
In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.
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