The Dangers of Tracheal Intubation in the PICU*

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Tracheal intubation is a key element of anesthetic, emergency medicine, and intensive care medicine practice for both adults and children. While airway catastrophes are rare, minor and major complications are common but these have been relatively poorly studied until recently, and the true incidence of tracheal intubation associated events (TIAEs), as well as the consequences associated with these TIAEs, is not well understood. There is a paradox that some of the best trained personnel manage low-risk airways under ideal circumstances in the operating room, whereas some of the highest risk patients are often managed by the least experienced personnel, in less than ideal circumstances such as in a hospital ward and often at unsociable hours. It is therefore essential to have a good understanding of the epidemiology of TIAEs, in order to better inform the teaching and recurrent training of advanced airway management in order to improve our patients’ outcomes.
It is estimated that the incidence of a “Can’t Intubate and Can’t Oxygenate” situation in anesthesia is about one in 5,000 cases, with the need for an emergency surgical airway (cricothyrotomy or tracheostomy) in about one in 50,000 (1), whereas in the emergency department (ED), the incidence of cricothyrotomy is closer to 1% and prehospital unsuccessful airway management is much more common. The only nationwide epidemiologic study of complications of airway management was the Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society in the United Kingdom which established a denominator of 2.9 million general anesthetics in 12 months, and documented 133 major adverse airway events in anesthesia with another 36 from ICU and 15 from the ED over that time period (2). Alarmingly, there was a 38-fold higher incidence of death or brain damage due to adverse airway events in the ED compared with the operating room and a 58-fold increase in the ICU (3).
Compared with the experience in anesthesia, studies looking specifically at prehospital and ED airway management document an incidence of tracheal intubation success as low as 77% (and 74.3% in children under 10 yr old) up to 90% and an incidence of cricothyrotomy of 0.8–0.9% (4, 5). We can speculate about the reasons for this vast difference between outcomes in the ED and in the operating room. There is no doubt that emergency patients are at much higher risk of complications, are often physiologically unstable in addition to the presence of their critical illness or injury, and are being intubated in the more chaotic environment of an ED with associated time pressures and conflicting priorities. Anesthesiologists and anesthetists are the undoubted experts at managing “anatomically” difficult airways, but intensivists and emergency physicians are more often asked to deal with patients who are anatomically normally but “physiologically” very difficult, which requires a whole different set of skills in airway management.
The National Emergency Airway Registry (NEAR) was established to collect prospective observational data on all tracheal intubation episodes in participating centers and has been now collecting data for nearly 20 years, since 1997. Most important has been the use of strict and clear definitions which has allowed some much more accurate epidemiology, particularly about the less severe TIAEs which have usually gone unreported in other studies. NEAR reported the outcomes of nearly 9,000 ED intubations in 2011, where the first method of intubation was successful in 95% of attempts and ultimately intubation successful in 99%, with emergency surgical airways in 0.84% of cases (6). One or more TIAEs were documented in 9% of intubations, with an average of 12 per 100 encounters.

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