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Prolonged Apnea in Pediatric Intubation – Who’s At Risk?

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Written by Aaron Lacy

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In this ED/PICU-based cohort, infants < 12 months were more likely to have longer periods of apnea than older children. Apneic oxygenation was protective against desaturation in all ages.

Breathe, baby, breathe!
Intubating children is risky, but it’s a necessary evil. This study analyzed 204 children <18 years of age who underwent intubation in the PICU or ED. The authors looked at apneic time, categorized it into “long” or “short” periods, and tracked desaturation (SpO2 <90%) events. The study used 54 seconds as the cutoff for prolonged vs. short apnea, which was the median apneic time observed in the dataset. This feels long to me, as studies show laryngoscopy in children exceeding 30 seconds have an increased risk of desaturation.

They found that long apneic times were more common in infants (<12 months) than in younger (age 1–7 years, aOR 0.88) or older (8–17 years, aOR 0.07) children. There was no association of apnea time with provider, laryngoscope, airway characteristics, or the use of apneic oxygenation. They found that apneic oxygenation significantly reduced desaturation risk (aOR 0.17; 95%CI 0.07-0.43).

How will this change my practice?
Intubating critically ill children is very dangerous—we should always prepare as much as possible. I treat all my pediatric intubations as if the worst is going to happen. My big takeaway here is that despite this being yet another study showing that apneic oxygenation prevents desaturation in children, there’s still low uptake of this practice. Give the kids some O’s, people!

Source
Apneic time during intubation in critically ill children. Pediatr Res. 2026 Jan 13. doi: 10.1038/s41390-026-04773-3. Epub ahead of print. PMID: 41530490.

View JournalFeed Critical Appraisal

Critical Appraisal

Study Identification

Title: Apneic time during intubation in critically ill children
Authors: Theerapon Jariyasakoolroj, Taiki Kojima, Shefali Godara, Priyanka Kharayat, Natalie Napolitano, Kathryn Graham, Lindsay Shepard, Vinay Nadkarni, Aaron Donoghue, Akira Nishisaki
Journal: Pediatric research
Year: 2026
DOI: https://doi.org/10.1038/s41390-026-04773-3
Trial Registration: Not reported
Country / Region: United States
Setting: Pediatric intensive care unit and emergency department at Children's Hospital of Philadelphia

Background

Prolonged apneic time during tracheal intubation may increase the risk of oxygen desaturation in critically ill children.

Study Question

What factors are associated with long apneic times, and how do they relate to oxygen desaturation in critically ill children during tracheal intubation?

Study Design & Conduct

Study Design: Prospective observational study
Prospective / Retrospective: Prospective
Multicenter: No
Unit of Allocation: Not applicable
Unit of Analysis: Tracheal intubations
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: Not reported

Population

Inclusion Criteria:
  • Children under 18 years
  • Undergoing primary oral tracheal intubation in PICU or ED
Exclusion Criteria:
  • Missing data on apneic time or oxygen saturation
  • Nasal intubations
  • Pre-existing tracheostomies
  • Emergency resuscitation cases with unreliable data
Number Screened: 3568
Number Enrolled: 204
Number Analyzed: 204
Key Baseline Characteristics
Age: Median age varied by group
Sex: Not reported
Disease Severity: Not reported
Care Setting Distribution: PICU and ED
Additional Baseline Characteristics
  • Infants more likely to have long apneic times

Exposures / Interventions

Primary Exposure / Intervention
Description: Measurement of apneic time during tracheal intubation
Definition / Dose: 54-second cutoff for long apneic time
Timing: During tracheal intubation
Classification Method: Direct observation and video review
Protocolized / Discretionary: Protocolized
Comparator / Reference
Description: Short apneic time and no apneic oxygenation
Definition: Apneic time ≤54 seconds and absence of apneic oxygenation

Outcomes & Results

Primary Outcomes
Oxygen desaturation
Definition: SpO₂ <90% during the apneic period
Time Point: During tracheal intubation
Measurement Method: SpO₂ measurement
Results: No significant association with long apneic time
Secondary Outcomes
Degree of oxygen desaturation
Definition: Drop in SpO₂ from highest to lowest during apneic period
Time Point: During tracheal intubation
Measurement Method: SpO₂ measurement
Results: Median degree of desaturation was 0% in both groups

Risk of Bias

Risk of Bias - ROBINS-I
  • Confounding (Some concerns): Potential confounders like comorbidities and preparation before intubation were not fully accounted for.
  • Selection of participants (Low): Participants were selected based on clear inclusion criteria.
  • Classification of interventions (Low): Interventions were clearly defined and consistently applied.
  • Deviations from intended interventions (Low): Interventions were applied as intended without deviations.
  • Missing data (Some concerns): Exclusions due to missing data could introduce bias.
  • Measurement of outcomes (Low): Outcomes were measured using standardized methods.
  • Selection of the reported result (Low): All relevant outcomes were reported.
Transparency
Funding Disclosed: TRUE
COI Statement Present: TRUE
This critical appraisal is generated using a structured framework applied to the full text of the original article and is presented separately from the physician’s commentary.

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