Elsevier

Resuscitation

Volume 83, Issue 11, November 2012, Pages 1363-1368
Resuscitation

Clinical Paper
The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: A 13-emergency-department registry study

https://doi.org/10.1016/j.resuscitation.2012.03.010Get rights and content

Abstract

Background

We investigated which factors are associated with successful paediatric endotracheal intubation (ETI) on the first attempt in emergency department (EDs) from multicentre emergency airway registry data.

Methods

We created a multicentre registry of intubations at 13 EDs and performed surveillance over 5 years. Each intubator filled out a data form after an intubation. We defined “paediatric patients” as patients younger than 10 years of age. We assessed the specialty and level of training of intubator, the method, the equipment, and the associated adverse events. We analysed the intubation success rates on the first attempt (first-pass success, FPS) based on these variables.

Results

A total of 430 ETIs were performed on 281 children seen in the ED. The overall FPS rate was 67.6%, but emergency medicine (EM) physicians showed a significantly greater success rate of 74.4%. In the logistic regression analysis, the intubator's specialty was the only independent predictive factor for paediatric FPS. In the subgroup analysis, the EM physicians used the rapid sequence intubation/intubation (RSI) method and Macintosh laryngoscope more frequently than physicians of other specialties. ETI-related adverse events occurred in 21 (7.2%) out of the 281 cases. The most common adverse event in the FPS group was mainstem bronchus intubation, and vomiting was the most common event in the non-FPS group. The incidence of adverse events was lower in the FPS group than in the non-FPS group, but this difference was not statistically significant.

Conclusions

The intubator's specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well structured airway skill training program, and more actively using the RSI method are important and this could explain this differences.

Section snippets

Study design

This study was a prospective observational study using data from a multicentre airway registry. The registry was formed from a network of 13 academic EDs. The data used for this study were collected from April 2006 to December 2010. All of the EDs employ full-time emergency medicine (EM) physicians and run 4-year EM residency training programs. In every ED, ETIs are performed both by EM physicians (residents and specialists) and physicians from other specialties (residents only) who are

Patient demographic data, indications for ETI and number of ETI attempts until success

A total of 10,942 ED patients were admitted during the study, and 281 (2.6%) of these patients were paediatric patients. Of the paediatric subjects, 170 were males, and 111 were females (Table 1). The median age of the 281 children studied was 23.8 months (IQR: 4.8–75.6 months): 50.2% were younger than 2 years and showed the largest anatomical–physiological differences from the adults; 13.5% were 8 years or older and were the most anatomically–physiologically similar to the adults; and 36.3%

Discussion

To date, most studies of paediatric airway management have been conducted with infants in the operating room or intensive care unit (ICU), and research on ETIs in paediatric ED patients has been scarce.7, 8, 9, 10, 11 Research is probably scarce because the rate of attempting intubation in paediatric ED patients is relatively low compared to that for the operating room or ICU.12 In this study, a total of 10,978 patients were enrolled in the registry, but only 281 (2.56%) of them were paediatric

Conclusions

The intubator's specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well-structured airway skill training program and more actively using the RSI method are important and this could explain this differences.

Competing interest

None.

Acknowledgments

We thank the effort and work of the Korean Emergency Airway Management Registry Investigators responsible for the input of the data: Young Min Kim, Young Soon Cho, Han Jin Cho, Young Min Oh, Hyunggoo Kang, Goo Hyun Kang, Hyung Min Lee, Jun Seok Park, and Soo Jin Kim. We also thank deeply the specialists of the emergency medicine of each hospital who made efforts to the registry input while treating emergency patients diligently.

References (20)

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    These results are similar to prior literature showing increased difficulty with EMS intubation of younger patients.26,27,29,33 Our findings are also consistent with hospital-based findings indicating that emergency department intubation of children is more challenging than in adults.34 We found greater disparity in ETI FPS rates between adults and pediatrics than two studies of a national EMS cohort which found similar overall ETI rates between adults and pediatrics.

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2012.03.010.

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