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Do Extremes of Weight in Children Mean High-Risk Intubation?

March 28, 2024

Written by Aaron Lacy

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Underweight (less than 5th percentile) and obese (over 95th percentile) children are more likely to suffer hypoxemia and adverse events during tracheal intubation.

FYI, BMI is important in ETI
24,342 children (age 0-17) who underwent endotracheal intubation (ETI) from the NEAR4KIDS database were reviewed for ETI adverse events in relation to weight. 27.5% and 8.2% of these children were classified as underweight (<5th percentile) and obese (>95% percentile), respectively. Notably, one-third of those classified as underweight were <1 year of age and noted to have high rates of history of difficult intubation (16.7%) or difficult airway features (33.7). The most common indications for ETI of underweight children were oxygenation failure (34%) and ventilation failure (36.2%).

Underweight children were more likely to suffer adverse ETI events, aOR 1.09 (95%CI 1.02-1.18, p<0.001), and severe hypoxemia, aOR 1.11 (95%CI 1.03-1.21, p<0.001), than those of normal weight. Apneic oxygenation was used significantly less often in this population (14.1%) than in normal (17.1%) and obese (19.6%) patients (P<0.001).

Obese children were more likely to suffer severe hypoxemia, aOR 1.22 (95%CI 1.08-1.38, p<0.001) than those of normal weight.  

How will this change my practice?
During ETI of children in the ED or ICU one cannot just hope for the best; one must prepare for adverse outcomes and maximize their chance of success. As I said in a previous JF post, the rate of apneic oxygenation in this study was too low, especially knowing it prevents desaturation. I will continue to utilize all the tools available to me, including apneic oxygenation, to try and get the best outcome.

Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020). Pediatr Crit Care Med. 2024 Feb 1;25(2):147-158. Doi: 10.1097/PCC.0000000000003387.

What are your thoughts?