Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department

BackgroundChallenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting.ObjectiveWe sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations.Design and methodsWe performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors.ResultsDuring the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy.ConclusionIncreasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.

Melon with a Twist: A Case of Nicotine Overdose After Ingestion and Aspiration of Vape Liquid

ABSTRACT We present the case of an active duty 21-year-old male with severe hypoxic respiratory failure after accidentally ingesting, and subsequently aspirating, vaping liquid while intoxicated. Because of the increasing prevalence of vaping devices, this case highlights a unique risk of vape liquids with concentrated nicotine levels and appetizing labels and aromas. Vaping-associated pulmonary injury has been previously described in multiple publications, but unlike those patients with pathology after inhaling vaping products, our patient ingested and subsequently aspirated the highly nicotinic substance. Most vape liquid products have enough nicotine to result in significant toxicity, which most concerningly can lead to nicotine-induced respiratory failure. This patient’s hypoxia appeared to be multifactorial as a result of both nicotine toxicity and aspiration, but ultimately treatment of both focused on supportive measures.In addition to understanding nicotine toxicity, this patient’s hypoxia secondary to agitation and aspiration requiring emergent airway management illustrates the importance of understanding the technique of Delayed Sequence Intubation and its proper application in the critical airway algorithm. By treating preoxygenation as a procedure, the patient received adequate oxygenation resulting in successful intubation without harmful desaturation during the procedure.Given the prevalence of tobacco use in the military as well as the increasing popularity of vaping devices, future military providers have a responsibility to their patients to be prepared for similar case presentations. Fortunately, this case demonstrates that when managed properly, otherwise healthy patients without comorbidities often recover without significant long-term sequelae.

Airway Foreign Bodies

The presentation of an airway foreign body can range from benign to truly life-threatening. Respiratory tract obstruction from an airway or esophageal foreign body is relatively rare but remains a leading cause of morbidity and mortality among children. This chapter discusses the evaluation and management for inhaled and aspirated foreign bodies in the upper aerodigestive and lower respiratory tracts. Using anatomical areas as a systematic approach, common presentations, physical findings, and diagnostic workup including imaging options are reviewed. Treatment modalities including emergent airway management and foreign body removal are discussed, with a focus on procedures that can be performed in an emergency department setting and indications for operative management.

Emergent Airway Management in Pediatrics

Airway management is the cornerstone to resuscitation efforts for the majority of critically ill pediatric patients. The etiology of arrest in children is more commonly from a respiratory than a cardiac process, and early and effective airway management can be life-saving. However, only a small proportion of pediatric patients ultimately require advanced airway management. In addition to its rarity, anatomic and physiologic differences in children can further complicate performance of this critical procedure. Familiarity these difference and knowledge of strategies to optimize procedural success are essential for every emergency practitioner. This chapter reviews important clinical pearls and pitfalls in the emergent management of the pediatric airway.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room

Background Little is known about reintubations that are performed outside of the operating room (outside-OR). Reintubation in general does not occur without risk and is associated with prolonged mechanical ventilation, higher incidence of nosocomial pneumonia, increased morbidity, mortality, and care of cost. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside-OR, including ICU and non-ICU settings. Methods A retrospectives cohort study design was used to review all emergent airway management outside-OR. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were demographics, location of intubation, indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital stay, 30-day in-hospital mortality, and overall in-hospital mortality. Results A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. Of the 336 performed intubations, 61 (18.1%) were reintubations. There was no statistical difference in admission demographics and comorbidities among reintubated and non-reintubated patients. Reintubations occurred after up to 30-days after extubation, including within 24-hours (8.2%, n=5), 24-72 hours (27.9%, n=17), 3-7 days, (23%, n=14), and 7-30 days after extubation (32.8%, n=20). Most of the reintubated patients were reintubated just once (56.9%; n=29), but some were reintubated two times (29.4%; n=15) or three times or more (13.7%; n=7). Reintubated patients had significant longer total ICU-stay (24±3 days vs. 12±1 day, p <0.001), hospital stay (37±3 vs.18±1, p<0.001), and total intubation days (8±1 vs. 7±0.6, p<0.02) than non-reintubated patients. The 30-day in-hospital mortality in reintubated patients was 13.7% (n=7) compared to non-reintubated patients 35.9% (n=80; p=0.002). Conclusion The reintubation rate was high, reaching 18%, in intubations performed outside-OR and is associated with a significant increase in hospital and ICU-stay. Almost half of the reintubation occurred in a non-ICU setting and more than 72-hours after extubation. The higher mortality rate among non-reintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation. Further research is needed to identify the causes for increased reintubation outside-OR and the difference in mortality between the two groups.