Airway Registry Research Articles

Success and safety of neonatal endotracheal tube exchanges: a NEAR4NEOS multicentre retrospective cohort study

ObjectivesTo compare success and safety of endotracheal tube (ETT) exchanges with primary intubations and identify factors associated with ETT exchange outcomes.DesignRetrospective observational study of prospectively collected National Emergency Airway Registry...

Tracheal Intubation by Attending Physicians in a U.S. Registry, 2016-2020: Analysis by PICU Participation in a Skills Maintenance Program and Fellowship Training.

Tracheal intubation (TI) is a critical skill for PICU attending physicians to maintain. We hypothesize that attendings perform fewer TIs and have lower success rate in PICU programs with a Pediatric Critical Care Medicine (PCCM) fellowship. Retrospective study using the National Emergency Airway Registry for Children (NEAR4KIDS) from July 2016 to June 2020. Exposures were presence of PCCM fellowship and attending TI skill maintenance program (SMP). The primary outcome was attending's first attempt success and the secondary outcome was adverse airway outcome in the first attempt. Thirty-three PICUs in North America. Children receiving TI. None. Overall, 23 of 33 PICUs had a PCCM fellowship with three of 23 having an attending TI SMP. Attendings performed TI in 24.1% (2,728/11,323): 13.9% (13.8 TI/yr per PICU) in PICUs with a fellowship vs. 66.0% (36.6 TI/yr per PICU) without a fellowship (p < 0.001). Attending first attempt success in PICUs with vs. without fellowships was 70.5% vs. 81.3% (difference, 10.8% [95% CI, 7.6-14.0%]; p < 0.0001). After controlling for confounders, attendings in a PICU with a fellowship had lower odds for first attempt success (adjusted odds ratio [aOR], 0.65 [95% CI, 0.47-0.90]). We failed to find an association between attending first attempt success and PICU program type, with vs. without a TI SMP (74.0% vs. 69.5%; p = 0.146). The adverse airway outcome rate of the TI with attending's first attempt was lower in PICU programs with vs. without a TI SMP (32.8% vs. 40.3%; p = 0.020). However, after adjusting for confounders, we failed to exclude the possibility of near halving of odds of adverse outcome (aOR, 0.75 [95% CI, 0.55-1.01]; p = 0.058). Attendings in PICU programs with a fellowship have fewer opportunities to perform TI and lower first attempt success rates. Opportunities exist for attending TI skill maintenance, especially in PICUs with a PCCM fellowship.

Heidelberg Adult and Pediatric Airway Registry (HAPA-Registry)

Background: Advanced airway management is of fundamental importance in almost all areas of anesthesiology, emergency medicine, and critical care. Securing the airway is of the utmost importance, as this is a prerequisite for the oxygenation of the human organism. The clinical relevance of airway management is particularly evident in the fact that the primary cause of significant anesthesia-related complications can be attributed to this field. The need for the systematic recording of these procedures and their complications, as well as structured training in airway management and the evaluation of outcome parameters, is, therefore, evident. Methods: The HAPA-registry is a prospective and monocentric observational trial at the Department of Anesthesiology, Medical Faculty Heidelberg, University of Heidelberg, Germany. All patients requiring general anesthesia with consecutive advanced airway management during a surgical procedure were included. We, therefore, planned to include approximately 9000 patients in the first period. Following successful airway management, the anesthetist completed a case report form (CRF) in person. The intention was to record airway management cases on an annual basis for a period of several months, thus ensuring that the register remains up-to-date and that airway management procedures are continuously recorded. Discussion: The aim of this study was to establish an airway registry that enables the systematic recording and evaluation of different methods of airway management. The registry can be used to monitor and evaluate the implementation of current guidelines and recommendations for action, as well as the rates of success and complications.

Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI).

Small case series have described awake supraglottic airway placement in infants with significant airway obstruction and difficult intubations. We conducted this study to determine outcomes when supraglottic airways were placed in awake children enrolled in the international Pediatric Difficult Intubation Registry including success of ventilation, success of tracheal intubation, and complications. We reviewed the Pediatric Difficult Intubation Registry to identify all cases of awake supraglottic airway placement before planned tracheal intubation from August 2012 to September 2023 with subsequent review of details of awake supraglottic airway placement in the medical record. We present descriptive statistics of patient demographics, ventilation and intubation outcomes, and complications. A supraglottic airway was placed in an awake child in 95 of 8061 (1.2%) cases in the Pediatric Difficult Intubation Registry. Median age was 37 days (range 0-17.6 years) and median weight was 3.7 kg (1.6-46.7 kg). Sixteen (17%) cases were in patients older than 2 years and 7 (7%) were in adolescents. Adequate ventilation via a supraglottic airway was achieved in 81/95 (85%, 95% confidence interval [CI], 77%-93%) encounters. Inadequate (n = 13) or impossible (n = 1) ventilation occurred in 14/95 (15%). No complications were reported with supraglottic airway placement. For subsequent intubation, there was a 35% (33/95) first-attempt success rate and 99% (94/95) eventual success, with 1 patient awakened after failed attempts at tracheal intubation. Hypoxia occurred during the first intubation attempt in 9/95 (9%) encounters. The incidence of hypoxia was lower in encounters in which ventilation via the supraglottic airway was adequate (4/81, 5%) than in encounters in which ventilation via the supraglottic airway was inadequate or impossible (5/14, 36%). Although infrequently attempted, awake placement of a supraglottic airway in children with difficult airways achieved adequate ventilation and provided a conduit for oxygenation and ventilation after induction of anesthesia across a spectrum of ages.

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

ObjectiveTo determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.DesignRetrospective analysis of prospectively collected data on...

Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study

Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study

Usability Testing Via Simulation: Optimizing the NEAR4PEM Preintubation Checklist With a Human Factors Approach.

To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist. This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist. Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist. Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.

Harms Associated with Tracheal Reintubation After Unplanned Extubation: A Retrospective Cohort Study

Abstract Objective This study evaluates the clinical harm associated with tracheal intubation (TI) after unplanned extubation (UE) in the pediatric intensive care unit (ICU). We hypothesized that TI after UE is associated with a higher risk of adverse airway outcomes (AAOs), including peri-intubation hypoxia. Methods A total of 23,320 TIs from 59 ICUs in patients aged 0 to 17 years from 2014 to 2020 from the National Emergency Airway Registry for Children (NEAR4KIDS) database were evaluated. AAO was defined as any adverse TI-associated event and/or peri-intubation hypoxia (SpO2 &lt; 80%). UE trends were assessed over time. A multivariable logistic regression model was developed to evaluate the association between UE and AAO, while controlling for patient, provider, and practice confounders. Results UE was reported as TI indication in 373 (1.6%) patients, with the proportion increasing over time: 0.1% in 2014 to 2.8% in 2020 (p &lt; 0.001). TIs after UE versus TIs without preceding UE were more common in infants (62 vs. 48%, p &lt; 0.001), males (63 vs. 56%, p = 0.003), and children with a history of difficult airway (17 vs. 13%, p = 0.03). After controlling for potential confounders, TI after UE was not significantly associated with AAO (adjusted odds ratio [aOR]: 1.26, 95% confidence interval [CI]: 0.99–1.62, p = 0.06). However, TI after UE was significantly associated with peri-intubation hypoxia (aOR: 1.35, 95% CI: 1.02–1.79, p = 0.03). Conclusions UE is increasing as an indication for TI, and is more common in infants and children with a history of difficult airway. As TI after UE was associated with increased peri-intubation hypoxia, future study should focus on identifying causality and mitigating peri-intubation risk.

Beyond laryngoscopy: Trends in advanced technique endotracheal intubation in pediatric intensive care units across the United States

Beyond laryngoscopy: Trends in advanced technique endotracheal intubation in pediatric intensive care units across the United States

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success

Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU).

Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.

First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry.

In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations. We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test. Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic). Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.

Clonal Hematopoiesis of Indeterminate Potential Is Associated with Current Smoking Status and History of Exacerbation in Patients with Chronic Obstructive Pulmonary Disease.

There is limited data regarding the clinical outcomes of clonal hematopoiesis of indeterminate potential (CHIP) in patients with chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the clinical significance of CHIP as a COPD biomarker. This retrospective study was conducted on patients with COPD who were enrolled prospectively in the Seoul National University Hospital Airway Registry from January 2013 to December 2019 and underwent pulmonary function and blood tests. We evaluated the CHIP score according to smoking status and severity of airflow obstruction. We analyzed next-generation sequencing data to detect CHIP in 125 patients with COPD. Current smokers had a higher prevalence of CHIP in combination of DNMT3A, TET2, and PPM1D (DTP), DNA methyltransferase 3 alpha (DNMT3A), and protein phosphatase, Mg2+/Mn2+ dependent 1D (PPM1D) genes than in never- or ex-smokers. CHIP of DTP and DNMT3A genes was significantly associated with current smokers (adjusted odds ratio [aOR], 2.80; 95% confidence interval [CI], 1.01 to 7.79) (aOR, 4.03; 95% CI, 1.09 to 14.0). Patients with moderate-to-severe airflow obstruction had a higher prevalence of CHIP in most of the explored genes than those with mild obstruction, although the difference was not statistically significant. CHIP in ASXL transcriptional regulator 1 (ASXL1) genes was significantly associated with history of mild, severe, and total acute exacerbation. Given that CHIP in specific genes was significantly associated with current smoking status and acute exacerbation, CHIP can be considered as a candidate biomarker for COPD patients.

Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service.

To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service. We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians. Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively. On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.

Current Status of Difficult Airway Information Dissemination at a Tertiary Pediatric Hospital.

Difficult airway is one of the most common potential risk factors for increased fatality in craniofacial/plastic surgery patients. To date, there is no well-established and all-around difficult airway notification system in China, which has recently been recommended by existing guidelines to improve the care of patients with known difficult airways. This study aimed to investigate the current status of critical information communication concerning difficult airway management in our institute. Vital information required to establish a difficult airway registry and notification system was collected through a literature review and expert suggestions. After approval by the Research Ethics Board, 3 online questionnaires were developed and sent to surgeons, anesthesiologists, and proxies of the patients. Knowledge of difficult airways, the willingness to be involved in the difficult airway notification system, and the way to disseminate the information were investigated in the 3 groups. The specific information that was disseminated, required, and available was investigated in the anesthesiologist group. Compared with the surgeons and anesthesiologists, significantly fewer patients knew the definition of a difficult airway and thought it was a potential risk factor. There were no significant differences in the willingness to be informed of the difficulty encountered during airway management. Significant differences were detected in the willingness and way to disseminate the airway information when the participants communicated with different groups. Significantly more patients would disseminate the information to the surgeon and significantly more surgeons would disseminate the information to the patient and the other surgeon. Significantly more anesthesiologists would disseminate the information to the patient and the other anesthesiologists. A significant difference was observed between what was expected and what was available for the anesthesiologist to retrieve the airway information of a patient with known airway difficulty. Significantly more anesthesiologists would notify only the patient of the diagnosis of a difficult airway both oral and written, whereas significantly more anesthesiologists would notify the other anesthesiologist of the specific difficulties in oral only. Most participants agreed to be involved in the difficult airway notification system despite the significantly lower percentage in the patient group (89%). Difficult airway information dissemination is, at the time of this writing, ineffective, which leads to a large gap between the expectation and practice of the anesthesiologist when caring for a patient with a difficult airway. Thus, a difficult airway registry and notification system should be developed, that has a solid foundation in all the participants.

Predictors of first-pass success intubations in the emergency departments in Germany: analysis of the German Airway Registry between 2015 and 2022.

Predictors of first-pass success intubations in the emergency departments in Germany: analysis of the German Airway Registry between 2015 and 2022.

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study.

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]). Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS). Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020. A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry. None. We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822). Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

Comparison of Intubating Conditions with Succinylcholine Versus Rocuronium in the Prehospital Setting

Objective Rapid sequence intubation (RSI) is frequently performed by emergency medical services (EMS). We investigated the relationship between succinylcholine and rocuronium use and time until first laryngoscopy attempt, first-pass success, and Cormack-Lehane (CL) grades. Methods We included adult patients for whom prehospital RSI was attempted from July 2015 through June 2022 in a retrospective, observational study with pre-post analysis. Timing was verified using recorded defibrillator audio in addition to review of continuous ECG, pulse oximetry, and end-tidal carbon dioxide waveforms. Our primary exposure was neuromuscular blocking agent (NMBA) used, either rocuronium or succinylcholine. Our prespecified primary outcome was the first attempt Cormack-Lehane view. Key secondary outcomes were first laryngoscopy attempt success rate, timing from NMBA administration to first attempt, number of attempts, and hypoxemic events. Results Of 5,179 patients in the EMS airway registry, 1,475 adults received an NMBA while not in cardiac arrest. Cormack-Lehane grades for succinylcholine and rocuronium were similar: grade I (64%, 59% [95% CI 0.64–1.09]), grade II (16%, 21%), grade III (18%, 16%), grade IV (3%, 3%). The median interval from NMBA administration to start of the first attempt was 57 s for succinylcholine and 83 s for rocuronium (mean difference 28 [95% CI 20–36] seconds). First attempt success was 84% for succinylcholine and 83% for rocuronium. Hypoxemic events were present in 25% of succinylcholine cases and 23% of rocuronium cases. Conclusions Prehospital use of either rocuronium or succinylcholine is associated with similar Cormack-Lehane grades, first-pass success rates, and rates of peri-intubation hypoxemia.

Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019).

To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019. Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia. Critically ill children requiring TI in a PICU or pediatric cardiac ICU. None. Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021). TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

396 Brazilian Airway Registry COoperation: Comparison Between Intubations Performed With or Without Videolaryngoscope

396 Brazilian Airway Registry COoperation: Comparison Between Intubations Performed With or Without Videolaryngoscope