Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU

Objective: To describe the current practice of pediatric airway management at referring hospitals and the associated adverse events compared to a receiving tertiary pediatric ICU.

Method: Retrospective chart and transport record review of all emergency critical care transports to our Pediatric ICU over 3 years. Data regarding tracheal intubation procedure, pre-defined adverse Tracheal Intubation Associated Events (TIAEs), and airway events before, during, and after the inter-hospital transport were collected using a standard National Emergency Airway Registry for children (NEAR4KIDS) definition. Tracheal intubation outcomes were compared to in-hospital P ICU intubations.

Results: 253/1489 (17%) of critical care transports had airway management, all by tracheal intubation. The most common condition was seizure (34%), followed by pulmonary/lower airway disease (16%). 49 (19%) had TIAEs; the most common event was mainstem bronchial intubation (13%). Incidence of TIAEs was similar to PICU (p=0.69). Thirteen had an inappropriate tracheal tube position upon PICU arrival, but none experienced accidental extubation during transport. An uncuffed tracheal tube was used in 108/172 (63%) of patients<8 years, significantly higher than PICU (20%, p<0.0001). 124 (49%) were extubated within 24 h, 153 (60%) within 48 h. Two patients had the tracheal tube changed to cuffed from uncuffed due to air leak.

Conclusion: Provider reported adverse TIAEs are common during airway management in children requiring critical care transport, but not higher compared to PICU intubations. Most inter-hospital transport patients are intubated with an uncuffed tracheal tube. Subsequent tracheal tube change from uncuffed to cuffed tube is rarely required.