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Tracheal Intubation Practice and Safety Across International PICUs

A Report From National Emergency Airway Registry for Children*

Lee, Jan Hau, MBBS, MRCPCH, MCI1,2; Nuthall, Gabrielle, MBBS3; Ikeyama, Takanari, MD4; Saito, Osamu, MD5; Mok, Yee Hui, MBBS, MRCPCH1,2; Shepherd, Michael, MBBS6; Jung, Philipp, MD7; Shetty, Rakshay, MD8; Thyagarajan, Sujatha, FRCPCH8; Nett, Sholeen, MD, PhD9; Napolitano, Natalie, MPH, RRT-NPS, FAARC10; Nadkarni, Vinay, MD11; Nishisaki, Akira, MD, MSCE11 for the National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)

Pediatric Critical Care Medicine: January 2019 - Volume 20 - Issue 1 - p 1–8
doi: 10.1097/PCC.0000000000001782
Feature Article

Objectives: It is unknown if variation in tracheal intubation practice and outcomes exist across PICUs in different geographical regions. We hypothesized there would be differences in the process of care and adverse outcomes for tracheal intubation across PICUs in six different geographical regions (New Zealand, Japan, Singapore, Germany, India, and North America).

Design: Prospective multicenter pediatric tracheal intubation database (National Emergency Airway Registry for Children)

Setting: Six non-North American (International) and 36 North American PICUs.

Events: All PICU tracheal intubation encounters from July 2014 to June 2017

Measurements and Main Results: Adverse tracheal intubation–associated events and desaturation occurrence (oxygen saturation < 80%) were evaluated. A total of 1,134 and 9,376 TIs from International and North American PICUs were reported, respectively: primary tracheal intubation 9,060, endotracheal tube change 1,450. The proportion of tracheal intubations for endotracheal tube change was greater in International PICUs (37% vs 11%; p < 0.001). Median age for International tracheal intubations was younger compared with North America (0 yr [interquartile range, 0–2 yr] vs 1 yr (0–7 yr); p < 0.001). Among primary tracheal intubations, the most common indication was respiratory (International 67%, North American 63%; p = 0.049). Direct laryngoscopy was the most common device in both International (86%) and North American (74%) tracheal intubations. Occurrence of any adverse tracheal intubation–associated event was New Zealand 8%, Japan 17%, Singapore 9%, Germany 17%, and India 6%; International 11% versus North American 14%; p value equals to 0.003. Desaturation was reported less commonly in International PICUs: 13% versus North American 17%; p equals to 0.001. International PICUs used cuffed endotracheal tube less often (52% vs 95%; p < 0.001). Proportion of cuffed endotracheal tube use per PICU was inversely correlated with the rate of tube change (r = –0.67; p < 0.001).

Conclusions: There were both similarities and differences in tracheal intubation practice and outcomes across international PICUs. Fewer adverse tracheal intubation–associated events were reported from International versus North American PICUs. International PICUs used cuffed endotracheal tube less often and had higher proportion of endotracheal tube change.

1Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore.

2Duke-NUS Graduate School of Medicine, Singapore.

3Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand.

4Division of Pediatric Critical Care Medicine, Aichi Children’s Health and Medical Center, Aichi, Japan.

5Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan.

6Department of Children’s Emergency, Starship Children’s Hospital, Auckland, New Zealand

7Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany.

8Division of Critical Care, Rainbow Children’s Hospital, Marathahalli, Bangalore, India.

9Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

10Department of Respiratory Care, The Children’s Hospital of Philadelphia, Philadelphia, PA.

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

*See also p. 79.

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Supported, in part, by Agency for Healthcare Research and Quality (AHRQ) grants: AHRQ R03HS021583, AHRQ R18 HS022464, AHRQ R18HS024511; and the Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia held by Dr. Nadkarni.

Dr. Lee received funding from KK Women’s and Children’s Hospital. Dr. Nuthall’s institution received funding from A+ Trust (money was paid to a research nurse who did some of the data collection). Ms. Napolitano’s and Dr. Nishisaki’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ) R03HS021583 and AHRQ R18HS024511. Ms. Napolitano’s institution also received funding from research relationships with Draeger, Aerogen, Vero Biotech, Smith Medical, Actuated Medical, Nihon Kohden, CVS Health, and Philips Respironics. Dr. Nishisaki’s institution received funding from AHRQ R18 HS022464, 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.

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©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies