Research ArticleSpecial Article

Kittredge Lecture: Airway Safety in Neonatal and Pediatrics

Teresa A Volsko
Respiratory Care June 2022, 67 (6) 756-768; DOI: https://doi.org/10.4187/respcare.10017

Abstract

During invasive ventilatory support, infants and children are inherently at risk for developing injury or complications related to the insertion and maintenance of an endotracheal tube (ETT). It is essential for respiratory therapists to understand the factors that contribute to the propensity for harm while preparing for, inserting, securing, and maintaining the position of an ETT throughout the duration of use. Implementing care bundles based on the available literature is useful in reducing iatrogenic complications as well as the risk for morbidity and mortality of pediatric patients requiring an ETT to facilitate respiratory support.

Introduction

Safe and effective management of the airway is essential to the care of critically ill infants and children. To provide lower-airway protection and invasive ventilatory support, it is essential to place and maintain the endotracheal tube (ETT) in the mid-tracheal position.1 Despite technological advances in devices that facilitate the intubation procedure and differentiate tracheal from esophageal placement of an ETT, significant morbidity and mortality are associated with performing intubation emergently,2,3 repeated intubation attempts4,5 and malpositioned ETTs.6-8 In a prospective investigation of intubation-associated adverse events in a 100-bed, level 4 neonatal ICU, Hatch et al2 reported higher rates of adverse events when intubations were performed emergently (67%) compared to urgently or performed within 4 h of eminent need (35%) and electively (39%). Similarly, Carroll and colleagues3 reported emergent intubations in children performed outside of the operating room were more likely to be associated with a complication (odds ratio [OR] 3.0 [95% CI 1.1–4.1]) and occur during off-hours when the availability of more experienced proceduralists and staff was not available (OR 2.0 [95% CI 1.4–6.1]). In a prospective observational study that included 3,382 intubations from 19 different pediatric ICUs, a higher proportion of adverse events occurred when multiple attempts were required to successfully intubate the trachea.4 Desaturation, defined as the lowest SpO2 < 80% during an intubation procedure in children with an SpO2 > 80% prior to the procedure following pre-oxygenation, occurred in 16% of those with a first-time intubation success and more frequently when 2 (36%) or 3 or more (56%) intubation attempts were required to secure the airway; P < .001.4 Similarly, the occurrence of severe desaturation, defined as the lowest SpO2 < 70% during an intubation procedure in pediatric subjects with an SpO2 > 70% prior to the procedure after pre-oxygenation, also increased with intubation attempts.4 Twelve percent of all children in the cohort experienced severe desaturation when intubation was successful on the first attempt compared to 30% in those who required 2 intubation attempts and 44% in children who had 3 or more attempts to successfully place the ETT; P < .001.4 Nishisaki et al5 evaluated outcomes associated with 197 initial intubation procedures in a tertiary-care pediatric ICU and reported that although unwanted tracheal intubation–associated events occurred frequently (n = 38 [19.3%]; P < .001) these events were most commonly associated with more than 2 intubation attempts (n = 30 [15.3%]); P = .001. Repeated intubations, especially those performed emergently, increase the risk of laryngeal or tracheal injury and scarring.6

Malpositioned ETTs carry the risk for morbidity and mortality in critically ill neonates, infants, and children. ETTs that are too shallowly placed have the propensity to contribute to tracheal damage from an inflated cuff positioned between the vocal cords6 as well as harm associated with unplanned extubation (UE).7 Malpositioned ETTs contributing to UEs often result in an emergent re-intubation, which can be life threatening if the airway cannot be secured promptly.7 This is because the trachea of a neonate, infant, and small child is poorly supported by surrounding structures and prone to dynamic collapse during forced inspiration or expiration.7 ETTs that are positioned too deeply can irritate the carina8 or impair ventilation by excessively ventilating one lung and inadequately ventilating the contralateral lung when endobronchial intubation occurs.9

To improve patient safety and reduce the incidence of tracheal intubation–associated adverse events, clinicians must be aware of the anatomic and physiologic conditions that predispose infants and children to airway safety events, factors that can contribute to harm, and methods to mitigate adverse events during the dimensions of airway management. These dimensions include preparing for the procedure, performing endotracheal intubation, verifying proper position, as well as securing and maintaining proper position throughout the duration of need.

Anatomic and Physiologic Features of the Pediatric Airway

There are several anatomical features of the pedia-tric upper airway that make endotracheal intubation more difficult.

Anatomic Features of the Upper Airway

The head of infants and preschool-age children is larger relative to body size, the neck shorter, and the occiput more prominent.10 These features cause the neck to be flexed when lying supine.10 Their tongue is als`o larger, mandible shorter, and hypopharynx shorter in height and narrower in width.11 The larynx in this subpopulation of pediatric patients also lies more anterior and superior in the neck.11 Additionally, the epiglottis is more U shaped, more compliant or floppy, and less directly aligned with the trachea.11 These features inherently predispose infants and preschool-age children to airway obstruction and make it difficult to achieve a neutral position of the neck to open the airway.10,11 Laryngoscopy is also relatively more difficult because these features provide obstacles to aligning the oral, laryngeal, and tracheal axes.10,11 Often a folded towel or shoulder roll is used to achieve and maintain the neck in a neutral position and aid in aligning the 3 aforementioned axes during laryngoscopy to improve visualizing the vocal cords.

Anatomic Features of the Lower Airway

The pediatric airway is funnel or conical shaped and narrowest in the subglottic region of the airway.12 Compared to an adult, intubating the trachea of a neonate, infant, or child may be more difficult because the trachea is much shorter, narrower, and more compliant.13 The length of the trachea ranges from 4–6 cm in infants to 5–10 cm in older children13; Figure 1 The relatively short length of the trachea in infants and children makes it difficult to initially insert and/or maintain the ETT in the mid-tracheal position. Once the ETT is placed and secured in the proper position, malposition can occur with changes in head position. Kim et al14 reported ETT migration occurs with head flexion and extension in addition to when the head is rotated to the left or right. Caudal migration was noted with neck flexion as well as when the head was rotated to the left or right. ETT migrated 1.0 ± 0.5 cm with neck flexion, 0.6 ± 0.4 cm with head rotation to the left, and 1.1 ± 0.6 cm when the head was rotated to the right of a neutral position (P < .001). Statistically significant cephalad movement (1.8 ± 0.8 cm, P < .001) was also noted with neck extension. Head rotation to the side that the ETT was affixed resulted in significant displacement in more children (46%) than when the head was rotated to the opposite side (23%).14

Fig. 1.
Fig. 1.

An illustration of tracheal length, depicted by the arrow. A correctly positioned endotracheal tube lies below the thoracic inlet, depicted by the yellow hashed line at the level of the superior boarders of the mid clavicular heads and above the carina.

Physiologic Characteristics

Respiratory and cardiovascular physiology in neonates and infants can contribute to the propensity for adverse events during tracheal intubation, especially when there is an emergent need for invasive ventilatory support. Neonates, infants, and toddlers have immature respiratory control, inefficient use of the muscles of respiration, different airway and lung mechanics, and higher basal metabolic oxygen requirement.15 Preterm infants are particularly vulnerable. Unlike term infants and young children, neonates cannot respond as efficiently to hypercapnia by increasing their tidal volume and breathing frequency. Additionally, the presence of hypoxia depres-ses their hypercapnic ventilatory response.15 Intercostal muscles are poorly developed in this population and are less effective as accessory muscles of respiration. The shape of the thorax also differs. The ribs are horizontally aligned with the vertebral column, which reduces their ability to increase the cross-sectional area of the thorax during inspiration.16 Therefore, during inspiration the diaphragm bears the brunt of the work or load associated with breathing. Additionally, the diaphragm has less type 1 muscle fibers, which predispose neonates, infants, and small children to fatigue.16 The combination of these factors not only contributes to an earlier presentation of respiratory failure among neonates, infants, and very young children but compromises hemodynamic stability during intubation.16

The total lung and functional residual capacity (FRC) are much lower in neonates, infants, and toddlers. Since, in this subpopulation, the lungs are less compliant and the thorax is more compliant, closing volume is higher than the FRC, which increases the propensity for air trapping due to early closure of the terminal airways.17 Compared to adults and older children, infants and young children have a higher metabolic oxygen demand. The metabolic oxygen demand is 9.0 mL O2/kg/min in newborns and 10.9 mL O2/kg/min per active mass unit in a 1 y old child, which may cause a rapid desaturation during stressful procedures, such as endotracheal intubation.18 These physiologic characteristics impact the neonate, infant, and young child’s clinical status in health and contribute to hemodynamic instability when procedures such as endotracheal intubation are perfor-med to secure an airway and provide ventilatory support. Table 1 provides a summary of the anatomic and physiologic characteristics that predispose neonates, infants, and preschool-age children to adverse events during endotracheal intubation.

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Table 1.

Anatomic and Physiologic Characteristics of Neonates, Infants, and Young or Preschool-Age Children That Increase the Risk for Adverse Events During Intubation

Interventions to Improve Safety During Endotracheal Intubation

Although adverse events can occur throughout the dimensions of airway management, the intubation procedure carries a high risk for adverse events or complications that vary in severity from minor to significant harm; Table 2. The use of technology and implementation of better practices such as videolaryngoscopy19,20 and apneic oxygenation,21 respectively, have a positive impact on minimizing complications and adverse events during intubation. However, their utility is limited if the equipment is incorrectly used or variations from the proper procedure are operationalized by the team preparing and stabilizing the child for the clinician performing the intubation procedure.22

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Table 2.

Minor or Nonsevere and Severe Adverse Effects Reported in the Literature That Occurred During Endotracheal Intubation3-5,23,28

There are 3 factors clinicians must consider to mitigate the propensity for harm while preparing for and inserting an ETT. These include the infant or child’s condition, assisting team preparation and competence, and the proceduralist’s psychomotor skills. Although these factors are addressed separately, it is difficult to distinguish which of those 3 factors has the greatest impact on reducing harm. Attention to implementing processes that incorporate steps to assess and optimize the infant or child’s clinical condition, team preparation and communication, and proceduralist competency can potentially have the greatest impact.

Assessing Hemodynamic Stability Prior to Intubation

It is essential to evaluate the infant or child’s hemodynamic status as the proceduralist is preparing to intubate the trachea. Taking time to assess and optimize hemodynamic stability is important to minimizing harm. Nishisaki et al23 reported a higher incidence of a severe adverse events such as severe hypotension requiring intervention (n = 62, 3.4%) and cardiac arrest without immediate return of spontaneous circulation (n = 24, 1.3%) during intubation when children had a history of a difficult airway or were hemodynamically unstable prior to the intubation attempt. Children with preexisting cardiac conditions were also more likely to have an airway feature, such as limited neck extension, upper-airway obstruction, or a short thyromental space, that made a successful intubation more difficult; (P < .001).24 In children requiring invasive ventilatory support, hemodynamic instability contributed to more frequent procedural-associated cardiac arrest in children with congenital cardiac defects compared to those who had a normal cardiac architecture (2.80% vs 1.28%, P < .001).24

Preparing for Intubation

Team dynamics and preparation prior to and during intubation also play an important role in reducing harm. In a small, prospective, single-institution study, Löllgenet al25 reported adverse events associated with clinical team preparation and collaboration when performing endotracheal intubation in the emergency department. Oxygen desaturations and hypotension occurred in one in every 4 children, newborn–6 y of age, secondary to equipment failure, inability to secure intravenous access, and erroneous or insufficient drug preparation. The authors suggested that the use of an intubation checklist including the preparation of equipment and recommendations for drug use would optimize team preparation, facilitate communication, and minimize the occurrence of adverse events of intubation in children.25 The value of checklists in improving team preparation is exemplified by Hatch et al,26 who sequentially implemented and tested 3 quality improvement interventions: checklist for intubation, premedication algorithm, and computerized provider order entry set for intuba-tion. This 3-step process provided a standardized clinical approach to the intubation procedure, a process for the clinical team to communicate and perform the intubation systematically. The process reduced variation in practice by ensuring medications and equipment were available and functional, the patient’s hemodynamic stability was optimized, and the team was prepared to assist the proce-duralist.26 The use of these interventions promoted communication, teamwork, preparation, and situational awareness that resulted in a 10% absolute and sustained reduction in intubation-associated adverse events in the neonatal ICU.26 The length of time from decision to intubate until the ETT was secured was 6 min longer than baseline (pre-intervention 27 min [interquartile range [IQR] 18–45]; post intervention 33 min [IQR 22–51]; P = .01).26 However, the authors reported no increase in the number of infants who had clinical decompensation while awaiting intubation (P > .99), medication errors (P = .6), or side effects from medications prescribed on the algorithm such as hypotension (P = .1) or chest wall rigidity (P = .7).26

Proceduralist Training and Competence

Respiratory therapists perform endotracheal intubation electively and emergently across various settings within community hospitals, academic medical centers, and during interfacility transport. Overall intubation success rates for respiratory therapists were reported as high as 76.1%, with first-time intubation success rates of 60.6%, which is similar to other medical providers.27 The education and hands-on training a proceduralist receives have a direct impact on the psychomotor skills the clinician acquires and play an important role in optimizing patient outcomes. Endotracheal intubation performed by less experienced proceduralists was associated with a reduced first-time intubation success rate,28 as well as an increased frequency of multiple intubation attempts,29,30 and endotracheal intubation–associated adverse events.5,23,31

Unfortunately, a universally accepted training and competency assessment for performing endotracheal intubation does not exist. In a survey of intubation training methods, skill maintenance, and recertification requirements, Miller reported simulation training (86%), supervised intubations (84%), and classroom training (65%) were the most common methods respiratory therapists used to learn and acquire intubation procedural skills.32 The number of supervised intubations required to credential a respiratory therapist varied. Sixty-two percent of survey respondents reported requiring between 1–5 (95% CI 0.45–0.76); 29 required between 6–10 (95% CI 0.17–0.46), and 9% required > 10 (95% CI 0.02– 0.24) supervised attempts.32 In over three quarters (78%) of centers where respiratory therapists performed endotracheal intubation, skill recertification was automatic if the proceduralist performed the pre-established minimum number of intubations annually.32

The literature supports the use of deliberate practice or opportunities to perform endotracheal intubation in controlled and emergent simulated settings, coupled with performance feedback improves a proceduralist’s ability to achieve and maintain competence. In a prospective randomized controlled study, physicians and paramedics who received supervised simulated practice with feedback at scheduled intervals achieved and maintained higher intubation competency scores over time (P < .001) compared to the control or those who received only didactic training and competency assessment without feedback or those who only received didactic training but were provided feedback only after each competency assessment.33 Bishop et al34 assessed retention of intubation skills 12 months after respiratory therapists received initial training. Intubation procedural competency was evaluated by an anesthesiologist in the operating room. Respiratory therapists who performed all the steps identified in the intubation procedure correctly were associated with a higher first-time intubation success rate compared to those who incorrectly performed one or more procedural steps (P < .01). The authors cited the most commonly occurring procedural errors as levering the blade on the upper teeth (13.2%) and tube not inserted from the right side of the mouth (26.9%).34 Eighty percent of intubations (8 of 10) were unsuccessful when the respiratory therapist levered the laryngoscope blade.34 The authors reported 50% of intubations (6 of 12) were unsuccessful when the tube was not inserted from the right side of the face.34 Respiratory therapists who scored higher on the written examination assessing procedural knowledge required fewer intubations to demonstrate competency and achieve recertification (r = −0.8, P < .05).34 The number of emergent intubations the respiratory therapists performed during the 1-y period after initial training had little impact on retention of skills and ability to correctly perform the procedure during competency assessment. The authors reported a poor correlation (r = −0.25, P > .99) between the number of emergent intubations the therapists performed during the 1-y period from training to reassessment and skill retention and the number of intubations needed to be recertified.34

Practices to Safely Predict and Verify ETT Intratracheal Position

Once intratracheal placement of an ETT is conform-ed, achieving and maintaining proper position with the trachea is essential to reducing the propensity for tracheal intubation–associated adverse events. Guidelines or methods exist to predict acceptable depth of ETT placement to minimize the risk of placing an ETT to shallowly or deeply. Confirmation of ETT position is an essential component of care immediately following placement as well as throughout the duration of need.

Predicting ETT Insertion Depth

Guidelines used to predict acceptable ETT placement are easily memorable, simple calculations based on anthropometric measures, such as weight, height, age or other measures, such as ETT internal diameter (ID); Table 3. However, prior to adopting a particular method, it is important to consider the accuracy with which those guidelines predict proper intratracheal placement, especially since malposition can cause harm, increase ICU and hospital lengths of stay, as well as the cost of care.35 The literature reports that ETTs are generally placed too deeply when pediatric advanced life support (PALS) guidelines are used to predict tracheal insertion depth during interfacility transport36 as well as in the operating room,37 ICU, and emergency department.38 In a retrospective, single-institution study, the first chest radiograph obtained after intubation in the operating room, emergency department, pediatric ICU, or during interfacility transport identified improperly placed ETTs (malposition) in 69% or 330 of the 477 subjects when PALS39 or Neonatal Resuscitation Program (NRP)40 guidelines (Table 3) were used to predict ETT insertion depth.41 A majority (88%, n = 291) of malpositioned ETTs resulted in an endobronchial intubation or in an ETT that was < 1 cm from the carina.41

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Table 3.

Commonly Used Endotracheal Tube Depth Guidelines Based on Anthropometric Measures or Endotracheal Tube Size

Lau et al42 modified the age-based formula historically recommended by PALS for children > 1 y and found the modified formula ([age in y/2] +13) underestimated the depth of insertion in approximately one quarter of the children studied. Predictive formulas, based on the ETT ID (3* ETT ID mm), were limited to the use of ETTs with an ID > 3.0 mm and were associated with malposition rates of 15–25%.43 In a small cohort of children < 2 y old, Santos and colleagues44 evaluated the effectiveness of 3 different formulas for estimating ETT insertion depth in children. The formulas based on height measured in centimeter ([height/10] + 5) had the strongest correlation (r = 0.88, P < .05, concordance correlation coefficient = 0.88) with ideal depth as determined by chest radiograph compared to that which used the ID of the ETT (3* ETT ID mm) or a weight-based formula (weight in kg + 6). The correlation between ETT diameter–based calculation and depth on chest radiograph was r = 0.80, P < .05, and concordance correlation coefficient 0.78, whereas the correlation between the weight-based calculation and depth on chest radiograph was r = 0.75, P < .05, with a concordance correlation coefficient 0.43.48

Using a bootstrapping technique to create 10,000 independent samples from a random sampling of 477 children between 1–18 y of age, the use of a regression equation (0.8636 * [height in cm0.6223]) had a good, positive correlation with correct intratracheal ETT position on chest radiograph (r2 = 0.59).45 Clinical use of the regression equation in a very small cohort of children (n = 11) resulted in correctly positioned ETTs in all subjects where the study protocol was strictly adhered to (n = 7, 67%).45 The authors reported 4 occurrences where protocol violations occurred because the provider preferred determining depth of ETT by PALS age-based-guidelines, all of which resulted in the ETT malposition.40 When the regression equation was used to predict where each of the 4 malpositioned ETTs were to be repositioned, correct intratracheal positioning was confirmed in all.45

NRP guidelines adopted a method predicting intratracheal depth that was described in the late 1970s by Tochen.46 This simple weight-based rule adds 6 to weight in grams to determine the centimeter marking at which the ETT is inserted and secured in place, (eg, 6 + 1,000 = 7 cm).40 Peterson et al47 evaluated the accuracy with which NRP weight-based guidelines predicted correct ETT placement in preterm infants in neonatal ICU. After controlling for head position, the depth guideline overestimated insertion depth in low birthweight preterm infants or those weighing < 750 g. The tip of the ETT was significantly below the mid-tracheal position (mean 0.62 cm [95% CI 0.30–0.93], P = .002) in this cohort.47 Similarly, Chung et al48 reported that the use of the NRP depth guidelines resulted in ETTs placed too deeply in 30 or 21.6% of the 139 neonates studied. Most of those whose ETTs were malpositioned weighed < 1,500 g (n = 75, 54%).48 Complications such as uneven lung inflation (n = 14, 10%) and pneumothorax (n = 20, 14%) were reported in those whose ETT was placed too deeply. Although shallow placement occurred more frequently (n = 90, 64.7%), there was a low rate of UE (n = 3, 2%).48

Bartle and colleagues49 evaluated the predictive value of a modification of the depth guidelines endorsed by NRP in a cohort of 131 preterm infants weighing > 1 kg. The use of the modified formulas 5.0 cm + 1 cm/kg for preterm infants weighing < 500 g and 5.5 cm +1 cm/kg for preterm infants weighing 500–999 g accurately predicted ETT tip position in 47% of those studied. A sensitivity of 46.6%, specificity of 53.6%, and positive predictive value of 68.8% were reported. Post hoc analysis revealed these formula modifications provided a closer approximation of actual ETT depth (47%) compared to NRP guidelines (23%).49

Guidelines to predict correct insertion depth may be very helpful in minimizing harm associated with ETTs that are placed too deeply or shallowly by the proceduralist. Recent data, from internally validated insert depth guidelines,45,49 are promising. However, prospective evaluation with a larger, more diverse population is needed to externally validate their clinical utility.

Confirming Intratracheal Position

Verifying the intratracheal position of an ETT is important during elective or emergent intubation and is essential to ongoing clinical care for infants and children receiving invasive mechanical ventilatory support. The initial assessment of intratracheal placement consists of physical examination, including auscultation of the chest and epigastrium, and can also be facilitated by capnography, chest radiography, and/or the use of light/sound–transmitting devices.50 Chest radiography provides additional value by confirming the intratracheal position of the ETT tip and detecting post-procedural complications.51 However, it is important to recognize this method only provides a single snapshot of the ETT position and cannot detect changes in ETT position that can occur during bedside care in the ICU. Changes in head position during routine care or bedside procedures can cause the ETT to migrate cauda with neck flexion and cephalad with neck extension that can cause the ETT to be positioned too shallowly or deeply.52 Cuffed ETTs that migrate and are positioned too shallowly during routine care or bedside procedures can contribute to UE or vocal cord irritation/damage when an inflated cuff is improperly positioned between the vocal cords.53 Carinal irritation and reactive bronchospasm can occur when ETTs migrate too deeply, and impaired gas exchange due to underexpansion of the nonventilated lung and overdistention and trau-ma to the contralateral lung occur with an inadvertent endobronchial intubation.53 Additionally, diagnostic radiographs expose infants and children to radiation and are associated with higher long-term malignancy risk in infants and children because they have greater tissue radiosensitivity.54 Infants and young children are at greater risk for long-term consequences because there is also an inverse exponential relationship between the risk of radiation exposure and age at exposure.54 There is a dearth of information reporting the frequency with which chest radiography should be used to assess ETT position during ongoing care. When used, respiratory therapists play an important role in ensuring the accuracy with which the radiographic image is used to determine ETT position by ensuring the head is midline and in a neutral position. Therefore, chest radiography obtained for any purpose, such as confirming the position of lines, drains and indwelling catheters, or for evaluating the presence of or changes in lung pathology, can be used to also evaluate ETT tube position. When an ongoing assessment or real-time monitoring of ETT position is needed, chest radiography alone appears to be an impractical tool. This tool can, however, be used in conjunction with frequent assessment of tube position at the gums to determine whether tube migration has occurred and repositioning is warranted. It can also be used in conjunction with other assessment tools such as ultrasound to assess and monitor tube position at the point of care.

Point-of-care ultrasonography has been shown to be effective for verifying ETT position in adults and is of growing interest in pediatrics. In a small prospective observational study of children newly born–18 y of age who required endotracheal intubation and ventilatory support during an elective cardiac catheterization, Atim and colleagues55 inflated the ETT cuff with sterile saline and used point-of-care ultrasound to detect and position the ETT cuff at the suprasternal notch. The accuracy with which point-of-care ultrasound determined the correct intratracheal position, defined as the tip of the ETT at/below clavicle and ≥ 1 cm above carina confirmed by chest radiography, was reported at 95% CI 86–98. No adverse effects were reported during manipulation of the cuff prior to, during, or after the procedure.55 In a review of the literature, Sheth et al56 reported point-of-care ultrasound obtained a view of the ETT tip in > 80% of neonates and infants across 9 prospective observational studies. Correlation of the position of the ETT tip with chest radiography varied from 73–100% of cases and was attributed to differences in procedural technique and training.56 The use of ultrasound as a monitoring tool requires cuff maintenance in terms of inflating the cuff with saline before use and extracting the saline and inflating the cuff with air after ultrasound assessment of ETT position. Training and expertise in performing the procedure and interpreting results impact the accuracy with which ETT position is determined.55,56 The rigor with which training and competency assessment is performed is key to improving the safety and accuracy of this diagnostic tool.

Care Bundle Use to Maintain an ETT Safely and Effectively for the Duration of Use

Maintaining proper position within the trachea is multidimensional and includes securing the ETT, cuff care, and suctioning practices. These dimensions of care are important for preventing injury due to malposition, unplanned device removal, tracheal wall damage, and injury to the skin and surrounding tissues. Care bundles play an important role in reducing harm by standardizing care and providing visual and procedural aids to support clinicians in their use. Collectively, practices implemented within care bundles have the potential to reduce errors and make outcomes more predictable.

Reducing Injury Due to Malposition and Unplanned Extubation

UE or the unintended displacement or removal of an ETT compromises the quality of care provided in an ICU by contributing to significant adverse events that increase lengths of stay and the cost of hospitalized care.57 Many factors contribute to UE. In a comprehensive review of UEs in the neonatal ICU, Silva and colleagues58 reported restlessness/agitation (n = 13, 89%), poorly secured ETT (n = 8.5, 31%), ETT manipulation (n = 17, 30%), and procedures performed at the bedside (n = 27.5, 51%) increased risk for UE. Veldman et al59 reported UEs occurred most frequently with neonates when the ETT was difficult to secure (n = 4, 33%), there was handling or repositioning by nursing staff during care (n = 2, 17%), or when spontaneously active (n = 3, 25%). In a prospective multi-center trial of children requiring invasive ventilatory support in the pediatric ICU, Fitzgerald and colleagues60 reported the rate of UE (number of UEs per 100 ventilated d) occurred more frequently in younger children (0.83 for children < 6 y old vs 0.45 for children ≥ 6 y; P = .001) when inadequate sedation was provided (OR 9.1 [95% CI 4.5–18.5]), the integrity of the ETT was compromised or loosened (OR 10.4 [95% CI 5.0–22.2]), or an elective extubation was planned to occur within 12 h of the decision to extubate (OR 2.3 [95% CI 1.3–4.1]).

The implementation of quality initiatives such as airway management bundles is instrumental in reducing the rate of and complications associated with UE.58 The implementation of an airway care bundle, including adopting a standardized process for turning intubated infants; using 2 caregivers at the bedside to hold the ETT in place during care or procedures at the bedside; weekly assessment of ETT position with growth or weight gain; and collaborative nurse and respiratory therapist assessments, where ETT position was discussed and evaluated as a team, resulted in reduction of 1.1 UEs/100 intubated days (3.8/100 intubated days pre-intervention vs 2.7/100 intubated days post intervention; (P = .01).61 Attention to extubation readiness was associated with a statistically significant decrease in the number of intubated days between the pre- and post-improvement groups (P < .001).61 In a multi-center quality improvement initiative, Klugman et al62 reported a 24.1% aggregate reduction in UE (baseline rate 1.135 per 100 ventilator days vs post-improvement rate of 0.862 per 100 ventilator days) as well as an absolute reduction in cardiovascular collapse following UE (36.6%) in infants and children requiring invasive ventilatory support in neonatal, pediatric, and cardiovascular ICU across 43 children’s hospitals. Common key drivers for UE and airway bundle elements are summarized in Table 4.

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Table 4.

A Summary of the Key Drivers That Contribute to Unplanned Extubations and Airway Management Bundle Elements Common to Unplanned Extubation Quality Improvement Initiatives

Preventing Respiratory Device Securement–Related Hospital-Acquired Pressure Injury

Although securing methods and devices is helpful in maintaining the ETT in proper position, it is essential to implement measures to prevent injury to the skin with use. Hospital-acquired pressure injuries are a significant source of morbidity, pain, patient dissatisfaction, and can significantly increase the cost of care.63 The pediatric population has distinctive factors that alter the risk for injury to the skin from devices or materials used to secure an ETT in position. Their normal physiologic responses to illness increase the propensity for overhydration or underhydration of the skin to occur. Infants and young children have a higher proportion of water content and increased metabolic demand in response to infection and hyperthermia, which in turn increases the risk for dehydration.64 Dehydrated skin lacks the protective moisture that makes skin more resistant to trauma and is, therefore, more predisposed to injury. Infants and children are also more prone to rapidly develop fluid and electrolyte disturbances and develop localized edema in response to fluid resuscitation.64 These alterations increase the risk for areas of tissue destruction to develop when the soft tissue of the face is compressed between a bony prominence and an external surface for a prolonged period of time.65 Additionally, the skin of preterm infants is underdeveloped, which compromises the skin’s protective barrier function. The outermost layer of the epidermis or stratum corneum is much thinner and has fewer layers (2–3) in preterm infants compared to 10–20 layers in a full-term infant.66 The literature reports daily nursing care such as bathing, moisturizing, or removing adhesives can disrupt a neonate’s normal barrier function, increasing the risk for hospital-acquired injury to their skin.66

Skin care bundles, including standardized skin assessments, patient skin care, care indirectly related to skin (pain control, nutrition, hydration), the use of products to redistribute pressure, and family engagement, have effectively reduced the risk for and incident of skin breakdown; Table 5. In a quality improvement initiative, implementing cycles of small tests of change, Visscher et al67 implemented a comprehensive training program highlighting the causes of and interventions for pressure injury prevention, embedded a standardized tool for daily skin assessments, as well as implemented body and medical device repositioning guidelines in the pediatric and neonatal ICUs of a free-standing children’s hospital. Clinical staff were empowered as agents of change through a skin champion program, and skin care rounds were incorporated into unit workflows. A 50% reduction in the rate of pressure injury (14.3/1,000 patient days pre-intervention vs 3.7/1,000 patient days post-intervention; P < .05) in the pediatric ICU was realized.67 Although the interventions were not solely targeted on reducing respiratory device–related skin injury, prior to the initiation of the improvement work a high proportion of pressure injuries was related to invasive and noninvasive respiratory devices. Particular attention was paid to the type of securing devices used and how the adhesive portion of the securing device was removed to minimize injury (skin stripping, skin tears). No significant change in the mean rate of pressure injury (0.9/1,000 patient days) was realized in the neonatal ICU.67 Standardized skin assessments in conjunction with use of ETT-securing devices that allowed to position the ETT at the lip to be changed (OR 0.592 [95% CI 0.422–0.832], P = .003) and nutritional support and hydrations (OR 0.206 [95% CI 0.156–0.272], P < .001) significantly reduced pressure injury in children requiring mechanical ventilatory support.68

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Table 5.

A Summary of the Key Drivers That Contribute to Respiratory Device–Related Hospital-Acquired Pressure Injuries and Bundle Elements Common to Reducing Harm Through Quality Improvement Initiatives

Safe Removal of Airway Secretions

Maintaining airway patency is essential to the care of intubated pediatric patients across all age ranges. Adopting safe suctioning practices can reduce the potential for tracheal injury, hypoxemia, alterations in lung volume, as well as deleterious effects in hemodynamic status and intracranial pressure.69 Lack of standardized suctioning practices contributes to complications and patient harm. In a prospective observational study of children requiring invasive mechanical ventilatory support in a pediatric ICU, Schultz et al70 reported suctioning-associated adverse events occurred in 22% (211/955) of suctioning episodes. Desaturation was the most commonly observed adverse event, occurring in 19% of all suctioning events (180/955), 69% of which required intervention to stabilize the child’s oxygenation status.70 The authors reported the risk of desaturation decreased as the ID of the ETT increased (OR 0.59 [95% CI 0.37–0.95], P = .03) and increased with the normal saline instillation during suctioning (adjusted OR 3.23 [95% CI 1.99–5.40], P < .001).70

Clinical practice guidelines address interventions to safely remove secretions from the airway and maintain patency of an ETT. The most recent American Association for Respiratory Care artificial airway clinical practice guideline includes recommendations for the suctioning frequency, dimensions of suction catheters, vacuum pressure, and suction catheter insertion depth in neonatal and pediatric populations.71 Although the evidence was limited in neonatal and pediatric populations, the authors recommended as-needed suctioning was as effective as routine suctioning for secretion removal without increasing morbidity or mortality.71 A dearth of evidence is available to establish new standards for the suction catheter size or vacuum pressure required for secretion removal.71 Recommendations from previously published clinical practice guidelines72 supported the selection and use of suction catheters that occupied < 50% of the ETT lumen during suctioning of pediatric patients and < 70% in neonates. Ideally, vacuum pressure should be set at a pressure sufficient to remove secretions but not so high that it can cause mucosal damage or lung volume loss. Current guidelines only address suction pressure ranges for neonates and recommend a vacuum pressure of −80 to −100 mm Hg be applied during the suctioning procedure.71 Advancing the suction catheter deeply or beyond the tip of the ETT may promote mucosal trauma, airway bleeding, and can also cause major alveolar collapse and hypoxemia.73 Additionally, no evidence exists to support more effective secretion removal when the suction catheter is advanced beyond the ETT tip.74 Therefore, shallow suctioning depths were adopted as measure to minimize the propensity for harm during the suctioning procedure for pediatric patients across a range of ages, from neonates to older children.75

Summary

Respiratory therapists play an integral role in safely achieving and maintaining a secure artificial airway. The interventions needed are multifocal and begin with rigorous training programs and competency assessments to ensure proceduralists achieve and maintain mastery of the skills needed to successfully intubate the trachea. Processes that promote communication, teamwork, and situational awareness as methods to assess team readiness and maximize hemodynamic stability prior to the procedure are also key to reducing endotracheal intubation–related adverse events. Although there is no best way to predict the correct ETT intratracheal insertion depth, height-based formulas show promise as better predictors of tracheal length and acceptable ETT placement. Once positioned, securing the ETT in place to minimize the propensity for malposition should not compromise the integrity of the skin. Safety bundles for maintaining skin integrity, safely removing secretions, and preventing respiratory device–related pressure injury and UEs are important to the ongoing care neonates, infants, and children receive during invasive mechanical ventl-iatory support. The vigilance with which a comprehensive approach to airway management is implemented has the potential to reduce the overall risk for and incidence of injury in mechanically ventilated pediatric patients.

Footnotes

  • Correspondence: Teresa A Volsko MBA MHHS RRT FAARC, Department of Quality and Data Integration, The Centers, 3500 Euclid Avenue, Cleveland, Ohio 44103. E-mail: teresa.volsko{at}thecentersohio.org

  • Ms Volsko discloses relationships with First Energy, Actuated Medical, and Neotech.

  • Ms Volsko presented a version of this paper as the Philip Kittredge Memorial Lecture at AARC Congress 2021 LIVE!, held virtually December 9, 2021.

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