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Updated: May 26, 2025
A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
Interventions to Reduce Risk in the Physiologically Difficult Pediatric Airway: A Descriptive Study and Exploratory
Tanner Heckle1, Benjamin T Kerrey1,2, Yin Zhang3
1Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Insights
Preintubation interventions in pediatric emergency departments are highly variable and not associated with reduced cardiac arrest risk. Further research is needed to improve patient safety during intubation for difficult airways.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care
- Airway Management
Background:
- Physiologically difficult airways in pediatric emergency departments (PEDs) pose a high risk for peri-intubation cardiac arrest.
- Preintubation interventions aim to stabilize patients but their use and effectiveness are unclear.
Purpose of the Study:
- To describe the utilization of preintubation interventions in pediatric patients with physiologically difficult airways.
- To determine if these interventions are associated with a reduction in peri-intubation cardiac arrest.
Main Methods:
- Secondary analysis of a multicenter, retrospective cohort of 332 patients (<21 years) undergoing rapid sequence intubation in 8 academic PEDs.
- Patients met criteria for a physiologically difficult airway.
- Examined administration rates of IV fluids, vasoactive medications, and sodium bicarbonate; assessed association with cardiac arrest using propensity scores.
Main Results:
- 80% of patients received at least one intervention; IV fluids (77%), vasoactive medications (26%), and sodium bicarbonate (6%).
- Significant site-to-site variability in intervention administration rates was observed.
- Preintubation interventions were not significantly associated with a reduction in peri-intubation cardiac arrest (OR 1.59).
Conclusions:
- Wide variability exists in preintubation intervention use for pediatric patients with difficult airways.
- Current preintubation interventions were not linked to decreased peri-intubation cardiac arrest.
- Prospective studies are necessary to evaluate interventions for preventing cardiac arrest during pediatric intubation.
Objectives:
Patients with physiologically difficult airways are at high risk for peri-intubation cardiac arrest in the pediatric emergency department (PED). We sought to describe how preintubation interventions designed to improve physiologic status are used and if they are associated with a reduction in peri-intubation cardiac arrest.
Methods:
We completed a secondary analysis of a multicenter, retrospective cohort of patients <21 years old requiring tracheal intubation in 8 academic PEDs. Included patients underwent rapid sequence intubation and met at least 1 of 6 criteria for a physiologically difficult airway. We examined administration rates of preintubation interventions (intravenous [IV] fluids, vasoactive medications, and sodium bicarbonate) overall and by high-risk criteria. In an exploratory analysis, we assessed the relationship of preintubation interventions with peri-intubation cardiac arrest using weighted propensity scores and generalized linear mixed models.
Results:
Of 332 included patients, 264 patients (80%) received at least 1 intervention. A total of 257 (77%) patients received IV fluids, 87 (26%) received vasoactive medications, and 20 (6%) received sodium bicarbonate. Across sites, there were wide ranges of administration of IV fluids (59%-98%), vasoactive medications (10%-58%), and sodium bicarbonate (0%-36%). Preintubation interventions were not associated with peri-intubation cardiac arrest (odds ratio, 1.59; 95% CI 0.50 to 5.05).
Conclusion:
In PED patients with physiologically difficult airways, there is wide variability in the use of preintubation interventions. Receiving preintubation interventions was not associated with peri-intubation cardiac arrest. Future video-based prospective studies are needed to further evaluate interventions designed to prevent peri-intubation cardiac arrest.
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