Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU)

Laurence Ducharme-Crevier; Jamie Furlong-Dillard; Philipp Jung; Fabrizio Chiusolo; Matthew P Malone; Shashikanth Ambati; Simon J Parsons; Conrad Krawiec; Awni Al-Subu; Lee A Polikoff; Natalie Napolitano; Keiko M Tarquinio; Asha Shenoi; Andrea Talukdar; Palen P Mallory; John S Giuliano Jr; Ryan K Breuer; Krista Kierys; Serena P Kelly; Makoto Motomura; Ron C Sanders Jr; Ashley Freeman; Yuki Nagai; Lily B Glater-Welt; Joseph Wilson; Mervin Loi; Michelle Adu-Darko; Justine Shults; Vinay Nadkarni; Guillaume Emeriaud; Akira Nishisaki; National Emergency Airway Registry for Children (NEAR4KIDS), Pediatric Acute Lung Injury, Sepsis Investigators (PALISI) Network

doi:10.1007/s44253-024-00035-4

Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU)

Intensive Care Med Paediatr Neonatal. 2024;2(1):7. doi: 10.1007/s44253-024-00035-4. Epub 2024 Feb 23.

Authors

Laurence Ducharme-Crevier¹, Jamie Furlong-Dillard², Philipp Jung³, Fabrizio Chiusolo⁴, Matthew P Malone⁵, Shashikanth Ambati⁶, Simon J Parsons⁷, Conrad Krawiec⁸, Awni Al-Subu⁹, Lee A Polikoff¹⁰, Natalie Napolitano¹¹, Keiko M Tarquinio¹², Asha Shenoi¹³, Andrea Talukdar¹⁴, Palen P Mallory¹⁵, John S Giuliano Jr¹⁶, Ryan K Breuer¹⁷, Krista Kierys¹⁸, Serena P Kelly¹⁹, Makoto Motomura²⁰, Ron C Sanders Jr²¹, Ashley Freeman²², Yuki Nagai²³, Lily B Glater-Welt²⁴, Joseph Wilson²⁵, Mervin Loi²⁶, Michelle Adu-Darko²⁷, Justine Shults²⁸, Vinay Nadkarni²⁹, Guillaume Emeriaud¹, Akira Nishisaki²⁹; National Emergency Airway Registry for Children (NEAR4KIDS), Pediatric Acute Lung Injury, Sepsis Investigators (PALISI) Network

Affiliations

¹ Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada.
² Department of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, KY USA.
³ Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany.
⁴ Department of Anesthesia and Critical Care, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
⁵ Division of Critical Care Medicine, Department of Pediatrics, The University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR USA.
⁶ Division of Pediatric Critical Care, Department of Pediatrics, Albany Medical Center, Albany, NY USA.
⁷ Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB Canada.
⁸ Pediatric Critical Care, Department of Pediatrics, College of Medicine, Penn State Health Children's Hospital, Hershey, PA USA.
⁹ Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI USA.
¹⁰ Division of Pediatric Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA.
¹¹ Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA USA.
¹² College of Health Professions, the Medical University of South Carolina, Charleston, SC USA.
¹³ Division of Pediatric Critical Care, Department of Pediatrics, University of Kentucky School of Medicine, Lexington, KY USA.
¹⁴ Pediatric Critical Care, Medical Center/Children's Hospital and Medical Center of Omaha, University of Nebraska, Omaha, NE USA.
¹⁵ Division of Pediatric Critical Care Medicine, Duke University, Durham, NC USA.
¹⁶ Department of Pediatrics (Critical Care Medicine), Yale University School of Medicine, New Haven, CT USA.
¹⁷ Division of Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital, Buffalo, NY USA.
¹⁸ Pediatric Intensive Care Unit, Penn State Health, Philadelphia, PA USA.
¹⁹ Division of Pediatric Critical Care, OHSU Doernbecher Children's Hospital, Portland, OR USA.
²⁰ Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Obu, Aichi Japan.
²¹ Section of Critical Care, Department of Pediatrics, UAMS/Arkansas Children's Hospital, Little Rock, AR USA.
²² Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Georgia at the Medical College of Georgia, Augusta, GA USA.
²³ Division of Pediatric Critical Care Medicine, Kobe Children's Hospital, Kobe, Hyogo Japan.
²⁴ Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York/Northwell, Queens, NY USA.
²⁵ Pediatric Critical Care Medicine, University of Louisville, Louisville, KY USA.
²⁶ Department of Pediatric Subspecialties, Children's Intensive Care Unit KK Women's and Children's Hospital, Singapore, Singapore.
²⁷ Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia Hospital, Charlottesville, VA USA.
²⁸ Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.
²⁹ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA USA.

Abstract

Background: Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted.

Methods: We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO₂ > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI.

Results: A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759).

Conclusion: In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.

Keywords: Adverse events; Endotracheal intubation; Nasal intubation; Pediatric intensive care.

Grants and funding

UL1 TR001863/TR/NCATS NIH HHS/United States