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Trend and Outcomes of Video Laryngoscope Use Across PICUs*

Grunwell, Jocelyn R. MD, PhD1; Kamat, Pradip P. MD, MBA, FCCM1; Miksa, Michael MD, PhD, FAAP2; Krishna, Ashwin MD3; Walson, Karen MD4; Simon, Dennis MD5; Krawiec, Conrad MD6; Breuer, Ryan MD7; Lee, Jan Hau MBBS, MRCPCH, MCI8; Gradidge, Eleanor MD9; Tarquinio, Keiko MD, FAAP1; Shenoi, Asha MD, DCH, FAAP3; Shults, Justine PhD10; Nadkarni, Vinay MD, MS11; Nishisaki, Akira MD, MSCE11; for the National Emergency Airway Registry for Children (NEAR4KIDS) and the Pediatric Acute Lung Injury and Sepsis (PALISI) Network

Pediatric Critical Care Medicine: August 2017 - Volume 18 - Issue 8 - p 741-749
doi: 10.1097/PCC.0000000000001175
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Objective: Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs.

Design: Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015.

Setting: Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore.

Patients: Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation.

Interventions: Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation.

Measurements and Main Results: There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0–55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7–26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2–38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42–0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56–1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71–1.22; p = 0.59).

Conclusions: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.

1Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, GA.

2Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.

3Division of Critical Care Medicine, Department of Pediatrics, Kentucky Children’s Hospital, University of Kentucky School of Medicine, Lexington, KY.

4Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, GA.

5Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Pittsburgh, Pittsburgh, PA.

6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Pennsylvania State University College of Medicine, Hershey, PA.

7Division of Critical Care Medicine, Department of Pediatrics, Women and Children’s Hospital of Buffalo, Buffalo, NY.

8Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore.

9Division of Critical Care Medicine, Department of Pediatrics, Phoenix Children’s Hospital, Phoenix, AZ.

10Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

11Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA.

*See also p. 801.

A full list of the National Emergency Airway Registry for Children (NEAR4KIDS) Network is supplied in eTable 1 (Supplemental Digital Content 1, http://links.lww.com/PCC/A421).

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. Grunwell is supported by National Institute of Health (NIH) T32GM095442. The NIH had no role in the design, collection, analysis, and interpretation of data, writing of the article, or the decision to submit this article for publication. Dr. Lee’s institution received funding from Covidien, and he received funding from KK Women’s and Children’s Hospital. Dr. Shults was supported by Agency for Healthcare and Research Quality (AHRQ) R18HS022464, AHRQ R18HS024511. Drs. Nadkarni and Nishisaki were supported by AHRQ R03HS021583, AHRQ R18HS022464, AHRQ R18HS024511, and the Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia. Dr. Nishisaki’s institution received funding from AHRQ R03HS021583, AHRQ R18HS022464, and AHRQ R18HS024511. 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

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