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J Pediatr Intensive Care
DOI: 10.1055/s-0042-1760413
Original Article

Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children

C. Hunter Daigle 
1   Division of Critical Care Medicine, Department of Pediatrics, University of Texas at Austin, Dell Children's Medical Center, Austin, Texas, United States
,
Elizabeth K. Laverriere
2   Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Benjamin B. Bruins
2   Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Justin L. Lockman
2   Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
John E. Fiadjoe
3   Department of Anesthesiology, Critical Care, and Pain Medicine. Boston Children's Hospital. Boston, Massachusetts, United States
,
Nancy McGowan
4   Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Natalie Napolitano
4   Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Justine Shults
5   Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
,
Vinay M. Nadkarni
6   Center for Simulation, Advanced Education and Innovation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Akira Nishisaki
6   Center for Simulation, Advanced Education and Innovation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
for the National Emergency Airway Registry for Children: NEAR4KIDS Investigators Pediatric Acute Lung Injury Sepsis Investigators (PALISI) › Author Affiliations Funding Drs. Nadkarni and Nishisaki were supported by the Agency for Healthcare Research and Quality (AHRQ R03HS021583, R18 HS022464, R18HS024511). Dr. Nadkarni is supported by the Endowed Chair in Critical Care Medicine at Children's Hospital of Philadelphia. Napolitano was supported by AHRQ R18HS022464, R18HS024511 and has research or consulting relationships with Drager, Philips/Respironics, Actuated Medical, Smiths Medical, and VERO-Biotech.
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Abstract

Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p< 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.

Keywords

mask ventilation - hypoxemia - intensive care unit - pediatric critical care - tracheal intubation - adverse events

Corresponding author completed the work at the Children's Hospital of Philadelphia.




Publication History

Received: 03 August 2022

Accepted: 08 December 2022

Article published online:
13 January 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Daigle CH, Fiadjoe JE, Laverriere EK. et al; National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Difficult bag-mask ventilation in critically ill children is independently associated with adverse events. Crit Care Med 2020; 48 (09) e744-e752
    CrossrefPubMedGoogle Scholar
  • 2 Valois-Gómez T, Oofuvong M, Auer G, Coffin D, Loetwiriyakul W, Correa JA. Incidence of difficult bag-mask ventilation in children: a prospective observational study. Paediatr Anaesth 2013; 23 (10) 920-926
    CrossrefPubMedGoogle Scholar
  • 3 Nafiu OO, Reynolds PI, Bamgbade OA, Tremper KK, Welch K, Kasa-Vubu JZ. Childhood body mass index and perioperative complications. Paediatr Anaesth 2007; 17 (05) 426-430
    CrossrefPubMedGoogle Scholar
  • 4 Tait AR, Voepel-Lewis T, Burke C, Kostrzewa A, Lewis I. Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology 2008; 108 (03) 375-380
    CrossrefPubMedGoogle Scholar
  • 5 Langeron O, Masso E, Huraux C. et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92 (05) 1229-1236
    CrossrefPubMedGoogle Scholar
  • 6 Brambrink AM, Braun U. Airway management in infants and children. Baillieres Best Pract Res Clin Anaesthesiol 2005; 19 (04) 675-697
    CrossrefPubMedGoogle Scholar
  • 7 Pediatric Advanced Life Support Provider Manual. American Heart Association; TX; 2016: 61-67
    Google Scholar
  • 8 Frerk C, Mitchell VS, McNarry AF. et al; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115 (06) 827-848
    CrossrefPubMedGoogle Scholar
  • 9 Apfelbaum JL, Hagberg CA, Caplan RA. et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118 (02) 251-270
    CrossrefPubMedGoogle Scholar
  • 10 Apfelbaum JL, Hagberg CA, Connis RT. et al. 2022 American Society of Anesthesiologists Practice Guidelines for management of the difficult airway. Anesthesiology 2022; 136 (01) 31-81
    CrossrefPubMedGoogle Scholar
  • 11 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
    Google Scholar
  • 12 Graciano AL, Tamburro R, Thompson AE, Fiadjoe J, Nadkarni VM, Nishisaki A. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med 2014; 40 (11) 1659-1669
    CrossrefPubMedGoogle Scholar
  • 13 Li S, Rehder KJ, Giuliano Jr JS. et al; National Emergency Airway Registry for Children (NEAR4KIDS) Investigators, Pediatric Acute Lung Injury and Sepsis Investigator PALISI Network Investigators. Development of a quality improvement bundle to reduce tracheal intubation-associated events in pediatric ICUs. Am J Med Qual 2016; 31 (01) 47-55
    CrossrefPubMedGoogle Scholar
  • 14 El-Orbany M, Connolly LA. Rapid sequence induction and intubation: current controversy. Anesth Analg 2010; 110 (05) 1318-1325
    CrossrefPubMedGoogle Scholar
  • 15 Mace SE. Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am 2008; 26 (04) 1043-1068 , x
    CrossrefPubMedGoogle Scholar
  • 16 Sagarin MJ, Chiang V, Sakles JC. et al; National Emergency Airway Registry (NEAR) investigators. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18 (06) 417-423
    CrossrefPubMedGoogle Scholar
  • 17 Li S, Hsieh TC, Rehder KJ. et al; for National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Frequency of desaturation and association with hemodynamic adverse events during tracheal intubations in PICUs. Pediatr Crit Care Med 2018; 19 (01) e41-e50
    CrossrefPubMedGoogle Scholar
  • 18 Mokhateb-Rafii T, Bakar A, Gangadharan S. et al; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Hemodynamic impact of oxygen desaturation during tracheal intubation among critically ill children with cyanotic and noncyanotic heart disease. Pediatr Crit Care Med 2019; 20 (01) 19-26
    CrossrefPubMedGoogle Scholar
  • 19 Nishisaki A, Turner DA, Brown III CA, Walls RM, Nadkarni VM. National Emergency Airway Registry for Children (NEAR4KIDS), Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med 2013; 41 (03) 874-885
    CrossrefPubMedGoogle Scholar
  • 20 Lee JH, Nuthall G, Ikeyama T. et al; National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Tracheal intubation practice and safety across international PICUs: a report from National Emergency Airway Registry for Children. Pediatr Crit Care Med 2019; 20 (01) 1-8
    CrossrefPubMedGoogle Scholar
  • 21 Komatsu R, Kasuya Y, Yogo H. et al. Learning curves for bag-and-mask ventilation and orotracheal intubation: an application of the cumulative sum method. Anesthesiology 2010; 112 (06) 1525-1531
    CrossrefPubMedGoogle Scholar
  • 22 Parker MM, Nuthall G, Brown III C. et al; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Relationship between adverse tracheal intubation associated events and PICU outcomes. Pediatr Crit Care Med 2017; 18 (04) 310-318
    CrossrefPubMedGoogle Scholar
  • 23 Niles D, Sutton RM, Donoghue A. et al. “Rolling Refreshers”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation 2009; 80 (08) 909-912
    CrossrefPubMedGoogle Scholar
  • 24 Niles DE, Nishisaki A, Sutton RM. et al. Improved retention of chest compression psychomotor skills with brief “Rolling Refresher” training. Simul Healthc 2017; 12 (04) 213-219
    CrossrefPubMedGoogle Scholar
  • 25 Sanders Jr RC, Giuliano Jr JS, Sullivan JE. et al; National Emergency Airway Registry for Children Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network. Level of trainee and tracheal intubation outcomes. Pediatrics 2013; 131 (03) e821-e828
    CrossrefPubMedGoogle Scholar
  • 26 Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth 1994; 41 (09) 771-774
    CrossrefPubMedGoogle Scholar
  • 27 Crulli B, Loron G, Nishisaki A, Harrington K, Essouri S, Emeriaud G. Safety of paediatric tracheal intubation after non-invasive ventilation failure. Pediatr Pulmonol 2016; 51 (02) 165-172
    Google Scholar
  • 28 Black AE, Flynn PER, Smith HL, Thomas ML, Wilkinson KA. Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth 2015; 25 (04) 346-362
    CrossrefPubMedGoogle Scholar
  • 29 Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006; 295 (03) 324-327
    CrossrefPubMedGoogle Scholar
  • 30 von Ungern-Sternberg BS, Erb TO, Reber A, Frei FJ. Opening the upper airway—airway maneuvers in pediatric anesthesia. Paediatr Anaesth 2005; 15 (03) 181-189
    CrossrefPubMedGoogle Scholar
  • 31 Van de Voorde P, Turner NM, Djakow J. et al. European Resuscitation Council Guidelines 2021: paediatric life support. Resuscitation 2021; 161: 327-387
    CrossrefPubMedGoogle Scholar
  • 32 Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H. et al; PeDI Collaborative. A retrospective analysis of neuromuscular blocking drug use and ventilation technique on complications in the pediatric difficult intubation registry using propensity score matching. Anesth Analg 2020; 131 (02) 469-479
    CrossrefPubMedGoogle Scholar
  • 33 Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66 (03) 163-167
    CrossrefPubMedGoogle Scholar
  • 34 Joffe AM, Ramaiah R, Donahue E. et al. Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial. BMC Anesthesiol 2015; 15 (01) 134
    CrossrefPubMedGoogle Scholar
  • 35 Tarquinio KM, Howell JD, Montgomery V. et al; National Emergency Airway Registry for Children, Pediatric Acute Lung Injury and Sepsis Investigators Network. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med 2015; 16 (03) 210-218
    CrossrefPubMedGoogle Scholar
  • 36 Fiadjoe J, Nishisaki A. Normal and difficult airways in children: “What's New”-Current evidence. Paediatr Anaesth 2020; 30 (03) 257-263
    CrossrefPubMedGoogle Scholar
  • 37 Sullivan EH, Gibson LE, Berra L, Chang MG, Bittner EA. In-hospital airway management of COVID-19 patients. Crit Care 2020; 24 (01) 292
    CrossrefPubMedGoogle Scholar
  • 38 Pinto M, Polikoff L, Napolitano N. et al. 310: COVID-19 impact on pediatric tracheal intubation in the pediatric ICU. Crit Care Med 2021; 49 (01) 142
    CrossrefPubMedGoogle Scholar