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Validating the performance of the modified LEMON criteria in predicting difficult intubation among pediatric

Shima Ohnishi1, Yusuke Hagiwara2, Shunsuke Amagasa1

  • 1Department of Emergency and Transport Medicine, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo 157-8535, Japan.

The American Journal of Emergency Medicine
|April 4, 2025
PubMed

Insights

The modified LEMON criteria are not sensitive or specific enough for predicting difficult pediatric intubation in the emergency department. New, individualized standards are needed for pediatric patients.

Area of Science:

  • Emergency Medicine
  • Anesthesiology
  • Pediatric Critical Care

Background:

  • Difficult tracheal intubation in pediatric patients presents a significant challenge in emergency settings.
  • Predictive tools are crucial for optimizing airway management and patient outcomes.
  • The modified LEMON criteria (Look externally, Evaluate the 3-3-2 rule, Obstructed airway, and Neck mobility) are used to assess airway difficulty.

Purpose of the Study:

  • To evaluate the effectiveness of the modified LEMON criteria in predicting difficult tracheal intubation in pediatric patients within the emergency department.
  • To determine the sensitivity, specificity, and predictive values of the modified LEMON criteria in this population.

Main Methods:

  • An observational, multicenter analysis of data from the 4th Japanese Emergency Airway Network (JEAN-4) study.
  • Included pediatric patients (<18 years) who underwent tracheal intubation between October 2018 and September 2022.
  • Difficult intubation was defined as requiring three or more attempts by attending physicians or fellows.

Main Results:

  • A total of 546 pediatric patients were analyzed, with 34 (6%) experiencing difficult intubation.
  • The modified LEMON criteria demonstrated a sensitivity of 41% and a specificity of 73% for predicting difficult intubation.
  • Positive predictive value was 9%, and negative predictive value was 95%.

Conclusions:

  • The modified LEMON criteria exhibit insufficient sensitivity and specificity for accurately predicting difficult tracheal intubation in pediatric emergency department patients.
  • Current criteria may not be adequate for the unique anatomical and physiological characteristics of children.
  • Development of age- and size-specific predictive standards is recommended for improved pediatric airway management.
Abstract

Keywords:
Airway managementChildrenDifficult intubationPediatric emergency departmentTracheal intubation

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