Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes*

Parker, Margaret M. MD, MCCM; Nuthall, Gabrielle MB ChB, FRACP, FCICM; Brown, Calvin III MD; Biagas, Katherine MD; Napolitano, Natalie MPH, RRT-NPS, FAARC; Polikoff, Lee A. MD; Simon, Dennis MD; Miksa, Michael MD, PhD, FAAP; Gradidge, Eleanor MD, FAAP; Lee, Jan Hau MBBS, MRCPCH, MCI; Krishna, Ashwin S. MD; Tellez, David MD, FCCM; Bird, Geoffrey L. MD, MSIS; Rehder, Kyle J. MD; Turner, David A. MD; Adu-Darko, Michelle MD, FAAP; Nett, Sholeen T. MD, PhD; Derbyshire, Ashley T. MSN, RN, PNP-AC; Meyer, Keith MD; Giuliano, John Jr MD; Owen, Erin B. MD; Sullivan, Janice E. MD; Tarquinio, Keiko MD, FAAP; Kamat, Pradip MD; Sanders, Ronald C. Jr MD, MS; Pinto, Matthew MD; Bysani, G. Kris MD, FAAP, FCCM; Emeriaud, Guillaume MD, PhD; Nagai, Yuki MD; McCarthy, Melissa A. RRT; Walson, Karen H. MD; Vanderford, Paula MD, FAAP; Lee, Anthony MD, FAAP; Bain, Jesse DO; Skippen, Peter MD; Breuer, Ryan MD; Tallent, Sarah MSN, RN, CPNP-AC; Nadkarni, Vinay MD, MS; Nishisaki, Akira MD, MSCE; for the National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Pediatric Critical Care Medicine: April 2017 - Volume 18 - Issue 4 - p 310–318
doi: 10.1097/PCC.0000000000001074
Feature Articles

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality.

Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%.

Setting: PICUs participating in NEAR4KIDS.

Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed.

Measurements and Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58–229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1–7 yr and 18% for 8–17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4–21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24–2.60; p = 0.002), after adjusted for patient confounders.

Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

1Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children’s Hospital, Stony Brook, NY.

2Department of Pediatrics, Pediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand.

3Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA.

4Department of Pediatrics, Columbia University/New York Presbyterian Hospital, New York, NY.

5Department of Respiratory Care, The Children’s Hospital of Philadelphia, Philadelphia, PA.

6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Providence, RI.

7Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

8Department of Pediatric Critical Care Medicine, The Children’s Hospital at Montefiore, Bronx, NY.

9Department of Pediatrics, Phoenix Children’s Hospital, Phoenix, AZ.

10Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore.

11Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children’s Hospital, University of Kentucky School of Medicine, Lexington, KY.

12Department of Child Health University of Arizona College of Medicine, Department of Critical Care Phoenix Children’s Hospital, Phoenix, AZ.

13Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA.

14Division of Critical Care, Department of Pediatrics, Duke Children’s Hospital, Durham, NC.

15Pediatric Critical Care Medicine, The University of Virginia Children’s Hospital, Charlottesville, VA.

16Division of Pediatric Critical Care, Children’s Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH.

17Pediatric Critical Care Medicine, Penn State Hershey Children’s Hospital, Hershey, PA.

18Pediatric Critical Care Medicine, Nicklaus Children’s Hospital, Miami Children’s Health System, Miami, FL.

19Critical Care Medicine, Department of Pediatrics, Yale Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT.

20Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Louisville, KY.

21Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.

22Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas College of Medicine, Little Rock, AR.

23Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children’s Hospital Westchester Medical Center, Valhalla, NY.

24Pediatric Critical Care Medicine, Medical City Children’s Hospital, Dallas, TX.

25Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada.

26Department of Emergency Medicine, Tokyo Metropolitan Children’s Medical Centre, Tokyo, Japan.

27Department of Critical Care Medicine, Children’s Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA.

28Division of Pediatric Critical Care Medicine, Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, GA.

29Division of Pediatric Critical Care Medicine, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR.

30Division of Critical Care, Nationwide Children’s Hospital, Columbus, OH.

31Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Richmond at VCU, Richmond, VA.

32Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada.

33Division of Critical Care, Department of Pediatrics, Women & Children’s Hospital of Buffalo, Buffalo, NY.

34Division of Pediatric Cardiac Intensive Care, Department of Pediatric Critical Care Medicine, Duke Children’s Hospital & Health Center, Durham, NC.

*See also p. 381.

The PALISI Executive Committee are as follows: Ann Thompson, MD; Ira Cheifetz, MD; Martha Curley, PhD; Jacques Lacroix, MD; Dan Levin, MD; Neal Thomas, MD; Adrienne Randolph, MD; Marissa Tucci, MD; Douglas Willson, MD.

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).

Dr. Nuthall’s institution received funding from the A+ Trust Grant (to contribute to research nurses salary who helped collect data). Dr. Brown III disclosed receiving support from the Airway Management Education Center, LLC (partner). Ms. Napolitano’s institution received funding from AHRQ (R03HS021583 and R18HS022464), Draeger Medical, Aerogen, and Nihon Kohden, and she disclosed receiving support in the form of consulting relationships with Actuated Medical Incorporated, Allergy and Asthma Network, being on the board of directors for American Association for Respiratory Care and Asthma and Allergy Network, and a program grant to CHOP from CVS Health. Dr. Gradidge received funding from Pfizer. Dr. Sullivan received support for article research from the National Institutes of Health. Dr. Emeriaud’s institution received funding from GE's research program (supported by a clinical research scholarship from the Fonds de la Recherche du Québec - Santé). Dr. Nagai disclosed work for hire. Dr. Nadkarni was supported by AHRQ R03HS021583 and AHRQ R18HS022464, and holds the Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia. Dr. Nishisaki received support for article research from the Agency for Healthcare Research and Quality (AHRQ); his institution received funding from AHRQ R03HS021583 and R18HS022464; and he disclosed receiving support from holding the Endowed Chair, Critical Care Medicine, the Children's Hospital of Philadelphia. 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

Article Outline

Tracheal intubation (TI) is one of the most common procedures in the PICU and can lead to severe hypoxemia and other life-threatening complications (1, 2). Adverse TI associated events (TIAEs) and hypoxemia below 80% during TI occur in approximately 15% and 13% of TIs, respectively (2, 3). Compared with healthy patients undergoing TI (e.g., during anesthesia for elective surgery), critically ill patients are at a much higher risk for adverse events during TI (4). Adverse TIAEs may lead to increased morbidity and mortality in critically ill children and have been used as quality improvement (QI) and patient safety indicators (5).

Previous studies have demonstrated that airway events might be associated with ICU outcomes such as length of stay in critically ill children. Extubation failure in infants after cardiac surgery is associated with a significantly longer ICU stay (6). Children experiencing an unplanned extubation during their PICU course have increased length of stay in both the PICU and the hospital (7). What remains unclear is whether factors around the time of intubation itself contribute to these clinical outcomes: length of PICU stay or mechanical ventilation (MV), and mortality in the critically ill children.

To date, no studies have shown an association between immediate events such as TIAEs or peri-intubation oxygen desaturation and important clinical outcomes in critically ill children. We hypothesized that the occurrence of TIAEs or peri-intubation oxygen desaturations is associated with ICU outcomes: PICU mortality, longer length of PICU stay, and longer length of MV. We also hypothesized that the occurrence of any TIAE alone is associated with these ICU outcomes. Finally, we hypothesized the occurrence of severe TIAE alone is associated with these ICU outcomes. We used data from the National Emergency Airway Registry for Children (NEAR4KIDS) Network, a prospective multicenter QI intubation safety registry, to investigate the impact of TIAEs and oxygen desaturations on clinical outcomes.

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METHODS

Study Design and Setting

We performed a retrospective analysis of prospectively collected observational data on TIs from 35 PICUs in the NEAR4KIDS Network. Participating sites were enrolled through the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (8). Institutional Review Board approval was obtained at each participating site.

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Study Participants

Patients under 18 years old admitted to a participating PICU from January 2013 to June 2015 were included in the analysis if they underwent primary TI in the PICU and had documented ICU outcomes. TIs to replace an existing tracheal tube (tracheal tube change) were excluded.

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Data Collection

Data were extracted from the multicenter NEAR4KIDS database for all TIs occurring in participating PICUs. The NEAR4KIDS database was developed by members of the PALISI Network in collaboration with NEAR4KIDS and the National Emergency Airway Registry investigators to improve advanced-airway management for critically ill children (9, 10). The data collection form was developed and piloted in a single tertiary care PICU and adapted by NEAR4KIDS Network investigators for the multicenter investigation (2, 9).

Collected data included patient demographics (age, weight, sex), patient severity of illness (Pediatric Index of Mortality 2 [PIM2]), patient history (illness category, cyanotic heart disease), patient assessment (indication for TI, airway examination), airway management approach and medications, and adverse events. Each site leader developed a site-specific compliance plan to ensure greater than 95% capture rate for intubation encounters performed in the PICU. Two NEAR4KIDS compliance officers were responsible for review and approval for each site’s plan prior to the start of data collection. Site leaders subsequently reviewed their PICU intubation encounters and recorded PICU mortality, duration of PICU stay, and duration of MV for each patient.

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Definitions and Outcome Measures

The NEAR4KIDS operational definition team defined adverse TIAEs a priori with two categories: nonsevere TIAEs and severe TIAEs (2, 9, 11). Severe TIAEs included cardiac arrest, esophageal intubation with delayed recognition, emesis with witnessed aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax, pneumomediastinum, or direct airway injury. Nonsevere TIAEs included mainstem bronchial intubation, esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring therapy, epistaxis, dental or lip trauma, medication error, arrhythmia, and pain or agitation requiring additional medication and causing a delay in intubation. Emesis was coded when gastric content was noticed in the oropharynx during airway management. Peri-intubation oxygen desaturation was defined as SpO2 less than 80% during an intubation attempt, when the highest documented SpO2 was greater than 90% after preoxygenation.

An airway management encounter, course, and attempt were defined a priori to improve reporting of intubation events (2). “Encounter” was defined as one completed advanced-airway management event, including intubation, for a patient. “Course” was defined as one method of TI and one set of medications. “Attempt” was defined as a single advanced airway maneuver and ending when the device is removed.

Primary outcomes were PICU mortality, duration of PICU stay, and duration of MV. Duration of PICU stay and MV were reported as number of days with 0–24 hours = 0, 25–48 hours = 1, 49–72 hours = 2, etc. If a patient failed extubation within 24 hours, it was not considered a successful extubation. Duration of MV was determined by time (in days) between TI and successful extubation.

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Statistical Analysis

Statistical analysis was performed using STATA 11.2 and 14.0 (StataCorp, College Station, TX). Data are presented as mean ± SD or median (interquartile range [IQR]) where appropriate. Univariate analysis for categorical variables was performed using chi-square test. Wilcoxon signed rank test was used for comparison of nonparametric variables. For multivariate analysis, logistic regression was used to identify independent associations between PICU outcomes and categorical variables. Linear regression was similarly used to identify independent associations between PICU outcomes and continuous variables. Natural log transformation was performed to ensure normality.

A multivariable regression model with the occurrence of any TIAEs or desaturation to SpO2 less than 80% as an exposure variable included patient-level covariates associated with occurrence of any TIAEs or desaturation to SpO2 less than 80% (age, PIM2, diagnosis, indication for respiratory failure, shock, procedural, upper airway obstruction, pulmonary toilet [suctioning and clearance of secretions], history of difficult airway, and symptom of upper airway obstruction). p value of less than or equal to 0.1 was used for inclusion criteria except for PIM2.

A multivariable regression model with any adverse TIAE included patient-level covariates associated with occurrence of any TIAE (diagnosis, indication for respiratory failure, shock, procedural, indication for therapeutic hyperventilation, history of difficult airway, and symptom of upper airway obstruction), age and PIM2 score. p value of less than or equal to 0.1 was used for inclusion criteria except age and PIM2 which were decided a priori.

A multivariable regression model with severe TIAE included covariates associated with occurrence of severe TIAE (age, diagnosis, indication for respiratory failure, shock, procedural, loss of airway protection, and symptom of upper airway obstruction) and PIM2 score; p value of less than or equal to 0.1 was used for inclusion criteria. Finally, sensitivity analyses were performed by repeating the above multivariable regression with a limited TI dataset from the sites that reported greater than 95% of PICU outcome data (i.e., missing data < 5%).

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RESULTS

Site and Patient Characteristics

A total of 5,504 primary TI encounters were entered in to the NEAR4KIDS database by 35 participating PICUs during the study period (January 2013 to June 2015). A median of 108 (IQR, 58–229) TIs per site was reported during that time period. At least one TIAE was reported in 892 TIs (16.2%), whereas severe TIAEs were reported in 364 TIs (6.6%). TIAE or desaturation to SpO2 less than 80 % was reported in 1,617 (29%) of TIs (Table 1). The completeness of outcomes data (PICU mortality, PICU length of stay, duration of MV) ranged from 78% to 81% for all TI encounters.

The majority of TIs (46%) were performed in infants less than 1 year of age, followed by children 1–7 years old (33%) and older children (21%). Demographics and clinical factors associated with TIAEs are outlined in Table 1. There were statistically significant differences in age, diagnostic category, indication for TI, and upper airway obstruction between the group with TIAE or desaturation to SpO2 less than 80% and no event group (Table 1). Infants had a higher frequency of TIAE or desaturation to SpO2 less than 80%, as did children with a respiratory indication for TI. There were no significant differences in the PIM2 scores between event and nonevent groups.

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Outcomes

The PICU mortality data were available in 4,471 (81%) of all 5,504 entered TI encounters. Among those reported, the PICU mortality was 9.6% (430/4,471 encounters). The overall median duration of PICU stay after TI was 12 days (IQR, 6–16 d) in 4,318 (78%) TI encounters. Data on duration of MV after TI encounter were available in 4,349 (79%) of TI encounters. The overall median MV duration was 4 days (IQR, 1–8 d).

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Univariate Analyses

The occurrence of TIAE or desaturation to SpO2 less than 80% was associated with longer duration of MV (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.0001) but not with ICU mortality. The occurrence of TIAE was significantly associated with longer duration of MV (4 d [IQR, 2–9 d] vs 4 d [IQR, 1–8 d]; p < 0.0005) but not with duration of PICU stay or PICU mortality (Table 2). Only the occurrence of severe TIAEs was associated with longer duration of MV (5 vs 4 d; p = 0.003), longer PICU stay (15 vs 12 d; p = 0.035), and PICU mortality (17.9% vs 9.6%; p < 0.0001) (Table 2). The association between each severe TIAE and ICU outcomes is shown in Supplemental Table A (Supplemental Digital Content 1, http://links.lww.com/PCC/A380).

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Multivariable Analyses

A multivariable analysis for individual ICU outcomes (PICU mortality, duration of PICU stay, and duration of MV) was performed, in which we accounted for patient-level factors associated with the occurrence of TIAEs as described in Table 1 and outlined in the legend of Table 3. In this regression model, only the occurrence of severe TIAEs was independently associated with increased PICU mortality (odds ratio = 1.80; 95% CI, 1.24–2.60; p = 0.002). The occurrence of any TIAE or desaturation to SpO2 less than 80% was not associated with an increase in PICU mortality.

The occurrence of TIAE or desaturation to SpO2 less than 80% was associated with an increase in the duration of MV (12% above baseline; p = 0.004). None of the immediate events (any TIAEs, severe TIAEs, or desaturation to SpO2 < 80%) were independently associated with the duration of PICU stay.

Sensitivity analyses with a limited TI dataset from sites that reported greater than 95% of PICU outcome data revealed similar results except that severe TIAEs were independently associated with duration of PICU stay (16% increase, p = 0.049), as shown in Supplemental Table B (Supplemental Digital Content 2, http://links.lww.com/PCC/A381).

Table 4 demonstrates the result of multivariable analyses for duration of MV. The occurrence of TIAE or desaturation to SpO2 less than 80% was independently associated with an increase in duration of MV. The PIM2 score, PICU admission diagnosis as respiratory disease, respiratory failure, or pulmonary toileting (suctioning and clearance of secretions) as an indication for TI were associated with longer duration of MV. Procedural indication or indication for upper airway obstruction was both associated with shorter duration of MV.

Table 5 demonstrates the result of multivariable analyses with severe TIAE as an exposure variable and PICU mortality as an outcome variable. The occurrence of severe TIAE was independently associated with higher PICU mortality. Older age, PIM2 score, cardiac disease, and hemodynamic instability as a TI indication were also associated with higher PICU mortality. Upper airway obstruction or procedural indication as a TI indication was independently associated with lower PICU mortality.

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DISCUSSION

Using data from the NEAR4KIDS Registry database, we have shown that adverse events at the time of TI in the PICU, including oxygen desaturation to SpO2 less than 80%, are associated with important clinical outcomes. On univariate analysis, the combined event of TIAE or desaturation to SpO2 less than 80%, as well as any TIAE (severe or nonsevere), is associated with duration of MV, whereas severe TIAEs are associated with duration of MV and PICU stay as well as mortality. On multivariable analysis, TIAE or desaturation to SpO2 less than 80% is associated with duration of MV and severe TIAEs are associated with mortality even after we adjusted for patient-level confounders including severity of illness.

The association of TIAE or desaturation to SpO2 less than 80% with clinical outcomes raises several important questions. First, can future interventions reduce the occurrence of oxygen desaturations and TIAEs for critically ill children undergoing TI? Second, will these interventions reducing the occurrence of desaturation and TIAEs lead to better ICU outcomes?

In response to the first question, the NEAR4KIDS Network has developed and implemented a TI safety bundle checklist that is currently being evaluated. The bundle was developed by a multidisciplinary QI committee and includes risk factor assessment, TI plan generation, a preprocedure time-out to ensure appropriate preparation, and a postprocedure huddle to identify opportunities for QI (5). It has been recognized that difficult TIs are associated with a higher frequency of desaturations below 80% and adverse TIAEs; recognition prior to intubation may help the team be better prepared and potentially reduce TIAEs (12). The NEAR4KIDS Network is considering future QI interventions to decrease the frequency of TIAEs and oxygen desaturations in critically ill children. These interventions include apneic oxygenation and video laryngoscopy.

Apneic oxygenation, a method to provide oxygen during laryngoscopy, has been suggested as a possible intervention to decrease desaturation during TI. Adult study results are conflicting as to whether apneic oxygenation improves clinical outcomes (13–19). The adult studies that are supportive of apneic oxygenation to date have included high-risk patients but have been observational or had small numbers (13, 15, 17–19). Apneic oxygenation for TI in critically ill children has not yet been studied.

Video laryngoscopy is another technique which may be considered as a possible method to decrease TIAEs. Video laryngoscopy has been shown to be a reasonable alternative to direct laryngoscopy for pediatric patients (20, 21). However, a meta-analysis demonstrated that although video laryngoscopy improved glottic visualization in pediatric patients, the improved visualization was at the expense of a longer time to successful TI and an increase in the TI failure rate (22). The role of video laryngoscopy in TIs in the PICU requires further investigation.

The NEAR4KIDS collaborative has also implemented the checklist to ensure the skillset of the airway provider matches to the risk of TIs (5). Allowing a less-experienced trainee to attempt TI in an emergency situation places the child at increased risk of adverse TIAEs. Multiple attempts at intubation are also associated with increased risk of TIAEs (23). There is an increased frequency of adverse TIAEs when the initial person to attempt TI is a resident rather than a critical care fellow (24). Emergent TIs are a common occurrence in the PICU and are associated with TIAEs (25), in contrast to the operating room, where conditions are controlled, and the intubation is more often nonemergent. The safety of the child requires a more experienced physician to attempt TI initially, potentially leading to fewer opportunities for a trainee to obtain the necessary experience to perform the procedure skillfully. Alternative methods of training, including simulation and controlled settings for elective TI, may be necessary before allowing residents to perform TI in a critically ill child.

To answer the second question, well-thought QI intervention plans and diligent execution with apneic oxygenation, video laryngoscopy with an updated airway safety checklist, and a robust statistical analysis to evaluate the effect of these QI interventions on ICU outcomes are essential.

Our study has several limitations. Only about 80% of the TI reports included ICU mortality, length of PICU stay, and the duration of MV. The data were self-reported, which could introduce reporter bias. Although site-specific compliance plan was in place to ensure complete and accurate reporting, the individual data reported were not reviewed by persons outside each institution. Importantly, under-adjustment of risk factors as confounders may have biased our results. It is possible that the occurrence of desaturation or adverse TIAEs is simply an epiphenomenon in the association between a patient risk factor (e.g., severity of respiratory illness) and ICU outcomes. However, after we adjusted for patient-level confounders including severity of illness and indication for TIs (procedural vs urgent/emergent), the association between desaturation or TIAEs and the duration of MV remained significant. Because this was an observational study, unmeasured confounders may also have affected the results, and we were not able to control for them. Finally, we analyzed the data with composite TI events (i.e., any TIAE or desaturation, any TIAE, severe TIAE) as a priori decided. Each component of TIAEs, however, likely has a different weight in association with patient ICU outcomes, and we were not powered to delineate this difference.

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CONCLUSIONS

Oxygen desaturations and TIAEs are common with TI in the PICU and are associated with longer duration of MV. Severe TIAEs are also associated with mortality. Although implementing QI interventions to reduce desaturation and TIAEs has its own face value, given the association between these immediate TI events and worse ICU outcomes could be noncausal, the clinical impact of future QI interventions should be rigorously evaluated whether these interventions would actually improve patient ICU outcomes.

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adverse events; intensive care unit; intubation; outcomes; pediatric

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