Prospective study of airway management of children requiring endotracheal intubation before admission to a pediatric intensive care unit

Objective: To prospectively identify complications related to airway manage ment in children before pediatric intensive care unit (ICU) admission. Design: A descriptive, prospective study covering an 18-month period. A sur vey was completed at the time of admission to obtain demographic data, reas on for endotracheal (ET) intubation, medications administered, location of and personnel responsible for ET intubation, and major/minor variances asso ciated with airway management Major variances were defined as technical pro blems resulting in a significant risk far airway trauma and increased morbi dity. Minor variances were problems that should be avoided, but which do no t significantly increase the immediate risk to the patient. Additional info rmation obtained included whether a chest radiograph (CXR) was obtained and if postextubation problems occurred, such as strider requiring treatment o r reintubation. Setting: Community hospitals, emergency rooms, children's hospital emergenc y rooms Patients: All children less than or equal to 18 yrs of age receiving ET int ubation before admission to the pediatric ICU, except those in cardiovascul ar arrest. Measurements and Main Results: Data were collected on 250 consecutive patie nts. Major or minor variances were noted in 135 (54%) patients and in 66% o f patients less than or equal to 1 yr of age (p = .02865; odds ratio, 2.0). Twenty-six percent of patients less than or equal to 1 yr of age received an anticholinergic agent before ET intubation compared with 40% of older pa tients (p = .04343; odds ratio, 0.504). Eleven patients received a neuromus cular blocking agent (NMBA) without a sedative/analgesic agent. Major varia nces occurred in 54% of patients who did not receive a NMBA and in 27% of p atients who received a NMBA (p = .00002; adds ratio, 0.307). Forty-one pati ents (16%) were intubated with an inappropriately sized ET tube. Postintuba tion CXRs were obtained in 65% of patients managed outside of a children's hospital and in 93% of patients in a children's hospital emergency room (p < .00001; odds ratio, 7.199). Variances detectable by CXR went unrecognized in 40% of patients, despite obtaining a CXR. Conclusions: Emergency airway management in children can he fraught with pr oblems. Most variances could be avoided by improved education regarding app ropriate ET tube size, appropriate medication use, and improved training fo r evaluation of ET tube placement.