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Identifying the Risky Pediatric Airway

October 14, 2020

Written by Aaron Lacy

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In children who met high-risk criteria (hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus, and post ROSC) there was significantly higher risk of peri-intubation cardiac arrest.

Why does this matter?
While we can maximize our positioning, equipment, and technique for intubation in critically ill children, this only corrects the anatomically difficult airway. It is important to recognize factors that may predispose children to a physiologically difficult airway and peri-intubation arrest.  We know hypoxia and age under 1 year increase the risk of peri-intubation arrest. Are other factors in play as well?

From bad to worse
This retrospective cohort study at a large single center included patients ≤ 21 years who had tracheal intubation in the shock trauma suite of the emergency department.  Using literature review, expert opinion, and review of institutional cases of peri-intubation cardiac arrest, high-risk criteria were identified: hypotension, persistent hypoxemia, SpO2 <90%), severe metabolic acidosis (pH <7.1), concern for cardiac dysfunction, status asthmaticus, and post-ROSC.

A total of 213 patients were included. The primary outcome, peri-intubation cardiac arrest within 10 minutes of tracheal intubation, occurred in 5.6% (2/36) of patients who met 1 or more of the high-risk criteria versus 0% (0/177) of those who did not (difference 5.6%; 95%CI 1.0-18.1).  There were also significant differences in secondary outcomes including in-hospital mortality (25% vs 2.3%, 95%CI 11.0-38.9), ECMO activation (8.3% vs 0%, 95%CI 2.5-21.8), and lower likelihood of first-pass intubation success (47.2% vs 66.1%, 95%CI -35.5 to -1.5). These criteria offer a good starting point to identify patients at risk for physiologic decompensation after intubation.

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department. Acad Emerg Med. 2020 Sep 7. doi: 10.1111/acem.14128. Online ahead of print.

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Reviewed by Clay Smith

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