Download PDF
J Pediatr Intensive Care 2023; 12(03): 180-187
DOI: 10.1055/s-0041-1731024
Original Article

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

Chetna K. Pande 
1   Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, United States
,
Kelsey Stayer
2   Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Thomas Rappold
2   Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
3   Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Madeleine Alvin 
3   Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
,
Keri Koszela 
4   Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
,
Sapna R. Kudchadkar 
3   Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
5   Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
› Author Affiliations Funding This publication was funded by the Johns Hopkins Institute for Clinical and Translational Research, which is funded in part by grant number (UL1 TR003098) from the National Center for Advancing Translational Sciences a component of the National Institutes of Health, and NIH Roadmap for Medical Research.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

Keywords

critical illness - quality improvement - intubation - laryngoscopy - intensive care units - pediatric - critical care

Note

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, NCATS, or NIH.


Authors' Contributions

Each author contributed to the study concept, design, data collection, writing, and data analysis. S.K. was directly involved in study design, as well as institutional liaisons and consultation, and final review of manuscript prior to submission.


Supplementary Material



Publication History

Received: 28 January 2021

Accepted: 15 April 2021

Article published online:
03 July 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Cook CD, Sutherland JM, Segal S. et al. Studies of respiratory physiology in the newborn infant. III. Measurements of mechanics of respiration. J Clin Invest 1957; 36 (03) 440-448
    CrossrefPubMedGoogle Scholar
  • 2 Saikia D, Mahanta B. Cardiovascular and respiratory physiology in children. Indian J Anaesth 2019; 63 (09) 690-697
    CrossrefPubMedGoogle Scholar
  • 3 Lee JH, Turner DA, Kamat P. et al; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), National Emergency Airway Registry for Children (NEAR4KIDS). The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study. BMC Pediatr 2016; 16: 58
    CrossrefPubMedGoogle Scholar
  • 4 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
  • 5 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
  • 6 Lin J, Zhang Y, Xiong L, Liu S, Gong C, Dai J. High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis. Arch Dis Child 2019; 104 (06) 564-576
    CrossrefPubMedGoogle Scholar
  • 7 Ramnarayan P, Lister P, Dominguez T. et al; United Kingdom Paediatric Intensive Care Society Study Group (PICS-SG). FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Crit Care 2018; 22 (01) 144
    CrossrefPubMedGoogle Scholar
  • 8 Milési C, Essouri S, Pouyau R. et al; Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP). High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study). Intensive Care Med 2017; 43 (02) 209-216
    CrossrefPubMedGoogle Scholar
  • 9 Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013; 20 (01) 71-78
    CrossrefPubMedGoogle Scholar
  • 10 Löllgen RMC, Pontin J, Gow M, McCaskill ME. Adverse events and risk factors during emergency intubation in a tertiary paediatric emergency department. Eur J Emerg Med 2018; 25 (03) 209-215
    CrossrefPubMedGoogle Scholar
  • 11 Cabrini L, Landoni G, Baiardo Redaelli M. et al. Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials. Crit Care 2018; 22 (01) 6
    CrossrefPubMedGoogle Scholar
  • 12 Nett S, Emeriaud G, Jarvis JD, Montgomery V, Nadkarni VM, Nishisaki A. NEAR4KIDS Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for childrena . Pediatr Crit Care Med 2014; 15 (04) 306-313
    CrossrefPubMedGoogle Scholar
  • 13 Hatch LD, Grubb PH, Lea AS. et al. Interventions to improve patient safety during intubation in the neonatal intensive care unit. Pediatrics 2016; 138 (04) e20160069
    CrossrefPubMedGoogle Scholar
  • 14 Sawyer T, Foglia EE, Ades A. et al; National Emergency Airway Registry for Neonates (NEAR4NEOS) investigators. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104 (05) F461-F466
    CrossrefPubMedGoogle Scholar
  • 15 Shiima Y, Hsieh TC, Long A, Donoghue A. Videographic assessment of pediatric tracheal intubation technique during emergency airway management. Pediatr Crit Care Med 2018; 19 (03) e136-e144
    CrossrefPubMedGoogle Scholar
  • 16 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
  • 17 Engorn BM, Newth CJL, Klein MJ, Bragg EA, Margolis RD, Ross PA. Declining procedures by pediatric critical care medicine fellowship trainees. Front Pediatr 2018; 6: 365
    CrossrefPubMedGoogle Scholar
  • 18 Branca A, Tellez D, Berkenbosch J. et al; National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). The new trainee effect in tracheal intubation procedural safety across picus in north america: a report from national emergency airway registry for children. Pediatr Crit Care Med 2020; 21 (12) 1042-1050
    CrossrefPubMedGoogle Scholar
  • 19 Gabrani A, Kojima T, Sanders Jr RC. et al; National Emergency Airway Registry for Children (NEAR4KIDS) Collaborators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Downward trend in pediatric resident laryngoscopy participation in PICUs. Pediatr Crit Care Med 2018; 19 (05) e242-e250
    CrossrefPubMedGoogle Scholar
  • 20 Nishisaki A, Ferry S, Colborn S. et al; National Emergency Airway Registry (NEAR), National Emergency Airway Registry for kids (NEAR4KIDS) Investigators. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med 2012; 13 (01) e5-e10
    CrossrefPubMedGoogle Scholar
  • 21 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
  • 22 Wraight TI, Ganu SS. High-flow nasal cannula use in a paediatric intensive care unit over 3 years. Crit Care Resusc 2015; 17 (03) 197-201
    PubMedGoogle Scholar
  • 23 Brodsky L. Chapter 35: Structure and development of the upper respiratory system in infants and children. In: Fuhrman BP, Jerry J. eds. Pediatric Critical Care. 4th edition.. Missouri, US: Mosby; 2011: 485-489 ISBN 9780323073073
    Google Scholar
  • 24 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
  • 25 Goto T, Gibo K, Hagiwara Y. et al. Factors associated with first-pass success in pediatric intubation in the emergency department. West J Emerg Med 2016; 17 (02) 129-134
    CrossrefPubMedGoogle Scholar
  • 26 Carroll CL, Spinella PC, Corsi JM, Stoltz P, Zucker AR. Emergent endotracheal intubations in children: be careful if it's late when you intubate. Pediatr Crit Care Med 2010; 11 (03) 343-348
    PubMedGoogle Scholar