Endotracheal intubation is used to provide mechanical ventilation (MV) to patients with respiratory failure in PICUs. It may be accomplished via either the orotracheal or nasotracheal routes. These two routes of intubation are associated with differing degrees of difficulty and their own perceived advantages and disadvantages (1).
In adults, the Centers for Disease Control and Prevention recommends the orotracheal route as the preferred mode of intubation to provide MV in the ICU because of the higher rate of ventilator-associated pneumonia (VAP) reported with the use of the nasotracheal route (2). Esteban et al (3) performed an international review of MV in adult ICUs and found that 4% of the endotracheal tubes studied were passed through the nose.
A previous neonatal study found no significant difference in risk or complications between the two routes, but that orotracheal intubation was preferred due to relative ease and speed of intubation (1,4). However, the use, prevalence, and associated factors of nasotracheal intubation to provide MV have not been properly studied in the pediatric critical care population, and data comparing outcomes between those intubated via the orotracheal and nasotracheal route are lacking (5). Therefore, the main purpose of this study is to describe the use (and associated factors) of nasotracheal intubation in pediatric patients requiring MV; a secondary objective is to compare outcomes between those intubated via the orotracheal and nasotracheal routes. The main outcome analyzed will be the rates of unplanned extubation; secondary outcomes will be rates of sinusitis and VAP.
MATERIALS AND METHODS
We conducted a retrospective cohort study using deidentified patient data from the Virtual Pediatric Systems (VPS, LLC) database. VPS is an international, multisite, voluntary clinical PICU database established to collect clinical data with the goal of improving quality and establishing best practices. One-hundred thirty-five PICUs report data, and the database has an inter-rater reliability of greater than 96% (personal communication via VPS). No protected patient health information was used in this study. This study was determined by the Children’s Hospital of Wisconsin Human Research Protection Program to be exempt from Institutional Review Board review.
Data were obtained on patients who required endotracheal intubation for MV while admitted to U.S. PICUs between January 1, 2015, and December 31, 2016. Patients with a tracheostomy present at admission were excluded, and we did not analyze data from PICUs located outside of the United States.
Study variables collected included age group, gender, Pediatric Index of Mortality 2 (PIM2) score, operative status, trauma status, primary diagnosis category, the presence of sinusitis, and VAP as secondary diagnosis and duration of intubation, reason for endotracheal tube removal, length of ICU stay, and survival to PICU discharge. An admission was considered postsurgical if he/she had surgery within 24 hours before or after admission to the PICU (cardiac catheterizations, diagnostic or interventional, did not qualify as operations for this field). A patient was considered cardiac if admitted to the ICU for diagnosis and/or treatment of an active cardiac disorder; and postoperative cardiac surgery if he/she had a cardiac procedure within 24 hours before or at any point during their PICU admission (cardiac catheterizations, diagnostic or interventional, did not qualify as operations for this field). Trauma status was selected as yes if the principal cause of the patient’s injury or illness that created the need for the ICU admission was due to a physical trauma.
Statistical analysis for this retrospective study was performed using IBM SPSS software version 21 (Chicago, IL). Only the first intubation event for each patient was included in analysis. As none of the continuous variables were normally distributed, they were treated as nonparametric and were analyzed utilizing the Mann–Whitney U test. Chi-square test was used for categorical variable analysis with Fisher exact test used for those with low occurrence rates. A p value of less than 0.05 was considered significant throughout all analyses.
There were 121 PICUs analyzed in this study (all of the PICUs within the United States participating in VPS were represented). Of the PICUs analyzed, 53% (64 PICUs) had zero nasotracheal intubations during the 2 years analyzed. There were 29,865 intubation events compared with 12,088 unique patients. Of these, there were 680 nasotracheal intubations (5.6% of total) compared with 11,408 orotracheal intubations (94.4% of total). The variation in nasotracheal intubation use across the studied PICUs is shown in Figure 1. Nasotracheal intubation was used mostly in the cardiac patient population under the age of 2 years, with a majority of patients in the group less than 1 month old (Table 1). Nasotracheally intubated patients had longer duration of intubation, longer length of ICU stay, and a slightly better survival; the PIM2 risk of mortality (ROM) was similar between the groups (Table 1).
Table 2 shows outcomes possibly associated with the intubation route. There was no statistically significant difference in rate of occurrence of sinusitis or VAP between the nasotracheal and orotracheal groups. The nasotracheal group had a statistically significant lower rate of unplanned extubation. This difference persisted when adjusted to ventilator days (0.14/100 ventilator days in the nasotracheal group vs 0.51/100 ventilator days in orotracheal group, p < 0.001).
A subgroup analysis of cardiac patients under age 2 (Table 3) was performed and showed that patients in the nasotracheal group were slightly younger (and smaller), had a higher percentage of patients in the postoperative cardiac patient category (89.5% vs 55.6%; p < 0.001), and had a slight but statistically significant lower PIM2 ROM (1.6 vs 1.8; p = 0.017). Both groups had similar lengths of intubation (3.6 vs 3.2 d; p = 0.58), and there was no statistically significant difference in rate of sinusitis or VAP occurrence between the groups. The nasotracheal group had a statistically significant lower rate of unplanned removals (unplanned extubations) than the orotracheal group (0 vs 2.1 %; p < 0.001).
Our analysis of 121 U.S. PICUs found that nasotracheal intubation was used in a minority of the studied PICUs, and when used, it was in a small percentage of patients, mainly the young cardiac patient population. To our knowledge, this is the largest study focusing on the prevalence of use of nasotracheal intubation for patients requiring MV in U.S. PICUs.
Our results are consistent with the findings from two previous studies done with data from the national airway registry (3,6,7). These studies include data from 15 North American PICUs and revealed that nasotracheal intubation was used on a minority of patients (3.2–4.0%); however, these studies did not describe or analyze the factors associated with nasotracheal intubations. One of these studies compared tracheal intubation practice across six different geographical regions and found that rates of nasotracheal intubation varied significantly among the regions studied (7).
Given the differences in patients’ characteristics between the intubation route groups, it would be inappropriate to associate any outcome differences solely on the patient’s intubation route. In order to have a more homogeneous population, we performed a subgroup analysis among cardiac patients younger than 2 years old. This analysis showed that among these cardiac patients, patients using a nasotracheal route were still younger (and smaller) and had a significantly higher percentage of postoperative cardiac patients. This could be explained by the belief that using the nasotracheal route (vs an orotracheal one) facilitates performing transesophageal echocardiogram (which is a common procedure during congenital heart disease surgery). This analysis also showed that the nasotracheal intubated patients had a slightly lower PIM2 ROM which would explain the slightly better survival and lower PICU length of stay observed in this group. We also found that nasotracheal intubation use was associated with a significantly lower rate of unplanned extubations and no significant difference in the rate of sinusitis or VAP.
Unplanned extubation is noted to be one of the most common airway adverse events in the ICU (8). Although there is a historical belief that nasotracheal tubes are less likely to be accidentally removed (9), previous studies have had conflicting results regarding unplanned extubation and a possible correlation to the route of endotracheal intubation. One single pediatric center study revealed that patients who experienced an unplanned extubation were less likely to have received a nasal endotracheal tube (10). In addition, there have been multiple studies of adult ICU patients revealing that unplanned extubation occurred more frequently in patients intubated orally, although these studies acknowledge that there may be significant variations in technique of securing the tube that may affect the results (11–13). Conversely, Piva et al (14) in a single-center PICU study found that the pathway of intubation (orotracheal or nasotracheal) did not carry any additional risk for accidental extubation. Our study evaluated more units and intubation events than the previously mentioned studies and did find a significant difference in rate of unplanned extubation between those intubated via the nasotracheal or orotracheal routes.
Studies conducted in the adult population have shown that the use of nasotracheal intubation is associated with increased rates of sinusitis. A prospective study in adult ICU patients revealed that long-term orotracheal intubation reduced the incidence of maxillary sinusitis compared with those intubated via the nasotracheal route (15). Similarly, in another prospective study by Michelson et al (16), they concluded that nasotracheal intubation was an additional risk factor for sinusitis in the critically ill patient, and they concluded orotracheal intubation was preferred. In a later study again by Michelson et al (17), they performed daily ultrasounds of the maxillary sinuses of ICU patients requiring prolonged intubation and found that those intubated via the nasotracheal route had higher incidence of sinusitis with earlier onset. It is believed that occlusion of the sinus openings blocks drainage of the sinuses, causing edema, and promoting local infection of the nasal mucosa which leads to increased rates of sinusitis (16,18). It is well known in the adult ICU population that sinusitis can evolve into bacteremia, sepsis, and VAP (19,20).
Conversely, in an adult prospective study by Holzapfel et al (21) they found no statistically significant difference in rate of sinusitis or VAP between patients intubated via the nasal or oral route (of note, they did report a trend of decreased sinusitis in those intubated orally; p = 0.08). In a PICU study by Moore et al (22), when reviewing patients who had a head CT during their admission, the presence of an endotracheal tube increased the risk for incidental sinusitis, but the location of the tube (oral vs nasal) did not impact the frequency of sinusitis. Although our study similarly did not find a difference in rate of sinusitis between the two modes of intubation, the majority of patients with a nasotracheal tube in our study were very young and would not have complete sinus development at the time the tube was in place.
Our study is limited by its retrospective cohort design. Data availability is restricted by standardized data elements collected and entered to VPS. Although other studies cited above used strict criteria for the diagnosis of sinusitis and VAP, our study is limited to data listed as a diagnosis abstracted from the medical record and entered in the database but without further detail as to when it was diagnosed or how it was determined. Additionally, we are unable to analyze the setting in which the endotracheal tube was placed and which type of provider placed the tube. Although this likely increased the total number of tubes analyzed in our study, it also introduces further variability in outcomes due to tubes being placed in different settings by different types of providers. Another significant limitation, especially pertinent to the analysis of unplanned extubations, is the lack of data regarding sedation practices and the use of tube taping/securing techniques.
Although the American Board of Pediatrics content specifications for Pediatric Critical Care Medicine includes recognizing the relationship between nasotracheal intubation and sinusitis, knowing indications/contraindications for nasotracheal intubation and understanding the advantages and risks, it does not specify this as a required procedural skill (23). Our study supports that with how few nasotracheal tubes are used, it is reasonable to not require this skill in a general pediatric critical care fellowship. With that said, as most of these tubes are placed in the young cardiac population, it may be beneficial for those completing a fourth year in cardiac focused intensive care training to be properly trained in this procedure.
Future studies should further identify potential advantages and disadvantages to nasotracheal intubation in the PICU patient to determine if this route of intubation should be used more than is currently being done. These studies should focus on the patient population most receiving nasal tubes (young cardiac population). These studies should include analysis of oral-motor skills (notably feeding and phonation), rates of epistaxis, and amount of sedation required. If future studies were to identify advantages to the nasotracheal route, then a change in practice for pediatric patients requiring MV may be warranted.
Our study found that nasotracheal intubation was used in a minority of the PICUs analyzed. When used, it was mostly in the cardiac patient population under the age of 2 years, with the majority of patients being in the group less than 1 month old. Among these young cardiac patients, the use of nasotracheal intubation was associated with a significantly lower rate of unplanned extubation and no significant difference in the rate of sinusitis or VAP between the two groups.
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