Failure of Invasive Airway Placement on the First Attempt Is Associated With Progression to Cardiac Arrest in Pediatric Acute Respiratory Compromise*

Abstract

Objectives: The aim of this study was to describe the proportion of acute respiratory compromise events in hospitalized pediatric patients progressing to cardiopulmonary arrest, and the clinical factors associated with progression of acute respiratory compromise to cardiopulmonary arrest. We hypothesized that failure of invasive airway placement on the first attempt (defined as multiple attempts at tracheal intubation, and/or laryngeal mask airway placement, and/or the creation of a new tracheostomy or cricothyrotomy) is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest. Design: Multicenter, international registry of pediatric in-hospital acute respiratory compromise. Setting: American Heart Association’s Get with the Guidelines-Resuscitation registry (2000–2014). Patients: Children younger than 18 years with an index (first) acute respiratory compromise event. Interventions: None. Measurements and Main Results: Of the 2,210 index acute respiratory compromise events, 64% required controlled ventilation, 26% had return of spontaneous ventilation, and 10% progressed to cardiopulmonary arrest. There were 762 acute respiratory compromise events (34%) that did not require an invasive airway, 1,185 acute respiratory compromise events (54%) with successful invasive airway placement on the first attempt, and 263 acute respiratory compromise events (12%) with failure of invasive airway placement on the first attempt. After adjusting for confounding variables, failure of invasive airway placement on the first attempt was independently associated with progression of acute respiratory compromise to cardiopulmonary arrest (adjusted odds ratio 1.8 [95% CIs, 1.2–2.6]). Conclusions: More than 1 in 10 hospitalized pediatric patients who experienced an acute respiratory compromise event progressed to cardiopulmonary arrest. Failure of invasive airway placement on the first attempt is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest. (Pediatr Crit Care Med 2017; XX:00–00)

Airway management in paediatric anaesthesia in Europe—insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe

“…16,17 Importantly, this finding also requires incorporation of future updates of current paediatric airway rescue algorithms for anaesthesia, intensive care, and emergency medicine. 18,19 The choice of the airway device needs to be considered in the context of patient's respiratory risk factors and planned surgical procedures. In line with previous reports, the use of tracheal intubation was associated with higher incidence of critical respiratory events when compared with the use of face masks.…”

Respiratory Therapist Intubation Practice in Pediatric ICUs: A Multicenter Registry Study

“…5 More than one intubation attempt has been associated with progression to cardiac arrest. 6 Tracheal intubation by respiratory therapists (RTs) has been described in several case series with success rates and complication rates similar to physicians. [7][8][9][10][11][12] However, recent data are limited and the existing literature consists of small, single-center studies of varying quality.…”

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees

“…During PCCM Fellowship training a median of 26 tracheal intubations outside of the operating room were needed to achieve 90% competency within four attempts ( 11 ). However, in allowing for up to four attempts there are likely an increased patient safety events in pediatric patients ( 4 , 7 ). Finally, while we saw no decline in intubations performed over the past decade the number performed is still less than was experienced in our institution in the past.…”

“…Many Residents are performing few procedures ( 2 , 3 ) and therefore the subsequent years of Fellowship training are a finite period to obtain competence. Failure to complete a procedure is associated with increased risk of patient safety events ( 4 – 7 ). PCCM and similar medical specialties, such as Anesthesiology and Emergency Medicine, have determined a minimum number of procedures before an expected competency (success for completing a given procedure) for a given procedure would be obtained ( 8 – 11 ).…”