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End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

Langhan, Melissa L. MD, MHS, FAAP; Emerson, Beth L. MD; Nett, Sholeen MD, PhD; Pinto, Matthew MD; Harwayne-Gidansky, Ilana MD; Rehder, Kyle J. MD; Krawiec, Conrad MD; Meyer, Keith MD; Giuliano, John S. Jr MD; Owen, Erin B. MD; Tarquinio, Keiko M. MD; Sanders, Ron C. Jr MD, MS; Shepherd, Michael MD; Bysani, Gokul Kris MD, FAAP, FCCM; Shenoi, Asha N. MD, FAAP; Napolitano, Natalie MPH, RRT-NPS, FAARC; Gangadharan, Sandeep MD; Parsons, Simon J. MD; Simon, Dennis W. MD; Nadkarni, Vinay M. MD, MS; Nishisaki, Akira MD, MSCE; for Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) and National Emergency Airway Registry for Children (NEAR4KIDS) Investigators
Pediatric Critical Care Medicine: Post Author Corrections: November 14, 2017
doi: 10.1097/PCC.0000000000001372
Feature Article: PDF Only

Objective:

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation–associated events.

Design:

A multicenter retrospective cohort study.

Setting:

Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

Patients:

Primary tracheal intubation in children younger than 18 years.

Interventions:

None.

Measurements and Main Results:

Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25–85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

Conclusions:

Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

The full list of National Emergency Airway Registry for Children Investigators (PALISI) and National Emergency Airway Registry for Children (NEAR4KIDS) Investigators are as follows: Michelle A. Adu-Darko, MD, Division of Critical Care, Department of Pediatrics, University of Virginia Children’s Hospital; Lee A. Polikoff, MD, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine a Brown University; Joy D. Howell, MD, FAAP, FCCM, Department of Pediatric Critical Care Medicine, Cornell University; Guillaume Emeriaud, MD, PhD, Department of Pediatrics, Sainte Justine Hospital, University of Montreal; Osamu Saito, MD, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children’s Medical Center; Jan Hau Lee, MBBS, MRCPCH, MCI, Children’s Intensive Care, KK Women’s and Children’s Hospital; Alberto Orioles, MD, Children’s Hospitals and Clinics of Minnesota, Children’s Respiratory and Critical Care; Karen Walson, MD, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta at Scottish Rite; Paula A. Vanderford, MD Division of Pediatric Critical Care Medicine, Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and Science University; Anthony Y. Lee, MD Division of Critical Care, Department of Pediatrics, Nationwide Children’s Hospital; Michael Miksa, MD, Pediatric Critical Care. Children’s Hospital at Montefiore, Pediatric Critical Care; Ana L. Graciano, MD, Department of Pediatric Critical Care Medicine, University of Maryland Children’s Hospital Baltimore; Jesse Bain, DO, Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University; Peter W. Skippen, MD, Intensive Care Unit, Department of Pediatrics, BC Children’s Hospital; Ryan K. Breuer, MD, Division of Pediatric Critical Care, Department of Pediatrics, University of Buffalo, Women and Children’s Hospital of Buffalo; Iris Toedt-Pingel, MD, Division of Pediatric Critical Care, Department of Pediatrics, University of Vermont College of Medicine; and David Tellez, MD, FCCM, Department of Critical Care, Phoenix Children’s Hospital.

Supported by Agency for Healthcare Research and Quality: AHRQ R03HS021583, AHRQ R18HS022464, and AHRQ R18HS024511.

Dr. Langhan’s institution received funding from a Medtronic research grant, and she received funding the American Academy of Pediatrics (editorial board honoraria). Dr. Napolitano’s institution received funding from Draeger, Philips/Respironics, Aerogen, CVS Health, Actuated Medical, GeNO, Nihon Kodhen, and an Agency for Healthcare Research and Quality (AHRQ) grant, and she received funding from the AAN and AARC (voluntary board membership; only travel was reimbursed for meetings). Dr. Nishisaki’s institution received funding from AHRQ R03HS021583, AHRQ R18HS022464, and AHRQ R18HS024511, and he received support for article research from the AHRQ. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: nishisaki@email.chop.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies