Natalie Napolitano

Factors Associated with Adverse Events during Tracheal Intubation in the NICU

Background: The incidence of adverse tracheal intubation-associated events (TIAEs) and associated patient, practice, and intubator characteristics in the neonatal intensive care unit (NICU) setting are unknown. Objectives: To determine the incidence of adverse TIAEs and to identify factors associated with TIAEs in the NICU. Methods: Single-site prospective observational cohort study of infants who were intubated in a level 4 referral NICU between September 1, 2011 and November 30, 2013. A standardized pediatric airway registry was implemented to document patient, practice, and intubator characteristics and outcomes of intubation encounters. The primary outcome was adverse TIAEs. Results: Adverse TIAEs occurred in 153 of 701 (22%) tracheal intubation encounters. Factors that were independently associated with lower incidence of TIAEs in logistic regression included attending physician (vs. resident; odds ratio (OR) 0.4, 95% CI: 0.16, 0.98) and use of paralytic medication (OR 0.45, 95% CI: 0.25, 0.81). Severe oxygen desaturations (≥20% decrease in oxygen saturation) occurred in 51.1% of encounters and were more common in tracheal intubations performed by residents (62.8%), compared to fellows (43.2%) or attendings (47.5%; p = 0.008). Conclusions: Adverse TIAEs and severe oxygen desaturation events are common in the NICU setting. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.

Development of a Quality Improvement Bundle to Reduce Tracheal Intubation–Associated Events in Pediatric ICUs

Advanced airway management in the pediatric intensive care unit (PICU) is hazardous, with associated adverse outcomes. This report describes a methodology to develop a bundle to improve quality and safety of tracheal intubations. A prospective observational cohort study was performed with expert consensus opinion of 1715 children undergoing tracheal intubation at 15 PICUs. Baseline process and outcomes data in tracheal intubation were collected using the National Emergency Airway Registry for Children reporting system. Univariate analysis was performed to identify risk factors associated with adverse tracheal intubation–associated events. A multidisciplinary quality improvement committee was formed. Workflow analysis of tracheal intubation and pilot testing were performed to develop the Airway Bundle Checklist with 4 parts: (1) risk factor assessment, (2) plan generation, (3) preprocedure time-out to ensure that providers, equipment, and plans are prepared, (4) postprocedure huddle to identify improvement opportunities. The Airway Bundle Checklist developed may lead to improvement in airway management.

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. Setting: PICUs participating in NEAR4KIDS. Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. Measurements and Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58–229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1–7 yr and 18% for 8–17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4–21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24–2.60; p = 0.002), after adjusted for patient confounders. Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

The Development of Tracheal Intubation Proficiency Outside the Operating Suite During Pediatric Critical Care Medicine Fellowship Training: A Retrospective Cohort Study Using Cumulative Sum Analysis

Objective: Tracheal intubation is a core technical skill for pediatric critical care medicine fellows. Limited data exist to describe current pediatric critical care medicine fellow tracheal intubation skill acquisition through the training. We hypothesized that both overall and first-attempt tracheal intubation success rates by pediatric critical care medicine fellows improve over the course of training. Design: Retrospective cohort study at a single large academic children’s hospital. Materials and Methods: The National Emergency Airway Registry for Children database and local QI database were merged for all tracheal intubations outside the Operating Suite by pediatric critical care medicine fellows from July 2011 to January 2015. Primary outcomes were tracheal intubation overall success (regardless of number of attempts) and first attempt success. Patient-level covariates were adjusted in multivariate analysis. Learning curves for each fellow were constructed by cumulative sum analysis. Results: A total of 730 tracheal intubation courses performed by 33 fellows were included in the analysis. The unadjusted overall and first attempt success rates were 87% and 80% during the first 3 months of fellowship, respectively, and 95% and 73%, respectively, during the past 3 months of fellowship. Overall success, but not first attempt success, improved during fellowship training (odds ratio for each 3 months, 1.08; 95% CI, 1.01–1.17; p = 0.037) after adjusting for patient-level covariates. Large variance in fellow’s tracheal intubation proficiency outside the operating suite was demonstrated with a median number of tracheal intubation equal to 26 (range, 19–54) to achieve a 90% overall success rate. All fellows who completed 3 years of training during the study period achieved an acceptable 90% overall tracheal intubation success rate. Conclusions: Tracheal intubation overall success improved significantly during the course of fellowship; however, the tracheal intubation first attempt success rates did not. Large variance existed in individual tracheal intubation performance over time. Further investigations on a larger scale across different training programs are necessary to clarify intensity and duration of the training to achieve tracheal intubation procedural competency.

Increased Occurrence of Tracheal Intubation-Associated Events During Nights and Weekends in the PICU.

Objectives:Adverse tracheal intubation–associated events are common in PICUs. Prior studies suggest provider and practice factors are important contributors to tracheal intubation–associated events. Little is known about how the incidence of tracheal intubation–associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. We hypothesize that tracheal intubations occurring during nights and weekends are associated with a higher frequency of tracheal intubation–associated events. Design:Retrospective observational cohort study. Setting:Twenty international PICUs. Subjects:Critically ill children requiring tracheal intubation. Interventions:None. Measurements and Main Results:We analyzed 5,096 tracheal intubation courses from July 2010 to March 2014 from the prospective multicenter National Emergency Airway Registry for Children. Frequency of a priori–defined tracheal intubation–associated events was the primary outcome. Occurrence of any tracheal intubation–associated events and severe tracheal intubation–associated events were more common during nights (19:00 to 06:59) and weekends compared with weekdays (19% vs 16%, p = 0.01; 7% vs 6%, p = 0.05, respectively). This difference was significant in emergent intubations after adjusting for site-level clustering and patient factors: for any tracheal intubation–associated events: adjusted odds ratio, 1.20; 95% CI, 1.02–1.41; p = 0.03; but not significant in nonemergent intubations: adjusted odds ratio, 0.94; 95% CI, 0.63–1.40; p = 0.75. For emergent intubations, PICUs with home-call attending coverage had a significantly higher frequency of tracheal intubation–associated events during nights and weekends (adjusted odds ratio, 1.29; 95% CI, 1.01–1.66; p = 0.04), and this difference was attenuated in PICUs with in-hospital attending coverage (adjusted odds ratio, 1.12; 95% CI, 0.91–1.39; p = 0.28). Conclusions:Higher occurrence of tracheal intubation–associated events was observed during nights and weekends. This difference was primarily attributed to emergent intubations. In- hospital attending physician coverage attenuated this discrepancy between weekdays versus nights and weekends but was not fully protective for tracheal intubation–associated events.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

Objectives: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. Design: A retrospective observational study using a multicenter emergency airway quality improvement registry. Setting: Thirty-five PICUs within general and children’s hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). Patients: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. Measurements and Main Results: Propensity score–matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62–0.75; p < 0.001). In propensity score–matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90–0.95; p < 0.001). Conclusions: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

1156: IMPROVING PATIENT VENTILATOR SYNCHRONY WITH MEASURING INTRINSIC PEEP TO SET VENTILATOR PEEP IN SBPD

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Infants with severe bronchopulmonary dysplasia (sBPD) and airway obstruction are at risk for dynamic hyperinflation and the development of intrinsic positive endexpiratory pressure (PEEPi). This complicates provision of respiratory support. Detection of PEEPi traditionally require paralysis to remove spontaneous effort. Matching set positive end-expiratory pressure (PEEP) to PEEPi has been shown in adults to improve patient-ventilator synchrony. This has not been described in BPD infants. Methods: We performed an interventional prospective pilot feasibility study to assess PEEPi in 12 infants ventilated for sBPD. Measurement of PEEPi was made by using concurrent esophageal pressure (Pes) monitoring and airway flow-time curves during spontaneous breathing. PEEPi on patient triggered pressure supported breaths was measured by subtracting the Pes reading at the start of the inspiratory effort from the Pes reading at the point of actual start of ventilator inspiratory flow. Ventilator PEEP was then systematically adjusted. Best PEEP setting was determined as the lowest PEEPi reading with minimal wasted efforts (WE). WE were counted as episodes of infant inspiration that failed to trigger a ventilator breath. Patient characteristics of synchrony (WE, FiO2, SpO2) were measured pre and post increase of PEEP. Results: Assessment of PEEPi was possible in all infants (birth GA 24.9 ± 1.4 wks studied at 48.8 ± 8.0 wks PMA). Beginning set PEEP was 16.4 ± 2.2 cmH2O (14–20 cmH2O). Eight required an increase, 1 a reduction, and 3 no change in the set level of PEEP based on the measured PEEPi. Those who had an increase in set PEEP, the average increase was 4.6 cmH2O (1-9cmH2O). Those with WE on initial PEEP, the average reduction was 18.9% at the chosen PEEP. In the 24 hours pre and post procedure, 6 of the 8 subjects who had PEEP increased had a reduction in FiO2 of 8.4 ± 5.8. No adverse events occurred. Conclusions: PEEPi exists in infants with sBPD and increasing the set PEEP improves synchrony. The use of concurrent esophageal manometry and flow-time tracings can detect PEEPi in these infants without the need for pharmacological paralysis.

Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-method Analysis*

Objectives: To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders. Design: Mixed methods. Setting: Thirteen PICUs of the National Emergency Airway Registry for Children network. Intervention: Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks. Measurements and Main Results: Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182–781). Five sites were early (median, 153 d; interquartile range, 146–267) and eight sites were late adopters (median, 783 d; interquartile range, 773–845). Focus groups identified common “promoter” themes—interdisciplinary approach, influential champions, and quality improvement bundle customization—and “barrier” themes—time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention. Conclusions: Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

43: DESATURATION DURING TRACHEAL INTUBATIONS IN PICUS IS PERVASIVE AND ASSOCIATED WITH ADVERSE OUTCOMES

Learning Objectives: The occurrence of desaturation during tracheal Intubations (TI) and the relation to indication and adverse TI associated events (TIAEs) across diverse Pediatric ICUs (PICUs) is unknown. Methods: Data from a multicenter TI database (NEAR4KIDS) across 31 PICUs from 1/2012-12/2014. All primary TIs with SpO2>90% after pre-oxygenation were included. TI indications were classified as: Respiratory (R), Hemodynamic (H), Respiratory+Hemodynamic (RH), or other (O). We defined moderate desaturation as SpO2 <80% and profound desaturation as SpO2 <70% during TI. We evaluated the association between moderate/profound desaturation with occurrence of any adverse TIAEs or severe TIAEs as well as number of attempts on the occurrence of moderate/ profound desaturation. Analysis was by χ2 and multivariate logistic regression. Results: Of 5,754 TIs, moderate desaturation was associated with TI indications: R 22% (755/3357), H 12% (44/359), RH 28% (94/341), O 11% (185/1697), p<0.001. The association of profound desaturation with TI indication were R 16%, H 8%, RH 20%, O 7%, p<0.001. TIs with moderate desaturation (SpO2< 80%), compared to those without, were associated with TIAEs (32% vs. 13%, p<0.001) and severe TIAEs (11% vs. 5%, p<0.001). Profound desaturation (SpO2<70%) was associated with TIAEs (36% vs.13%, p<0.001) and severe TIAEs (12% vs.5%, p<0.001). All findings persisted after adjusting for TI indications (i.e. severe TIAEs OR: 1.9, 95%CI 1.5–2.4 for moderate desaturation, OR: 2.4, 95%CI 1.8–3.1, for profound desaturation). The number of attempts required for a given TI was associated with moderate and profound desaturation (p<0.001). After adjusting for indication, the associations with moderate desaturation were: 2 attempts OR 3.4 (95%CI 2.9–4.0) and 3+ attempts OR 6.7 (95%CI 5.6–8.0), compared with 1 attempt. For profound desaturation the associations were: 2 attempts OR 3.7, 95%CI 3.0–4.5, and 3+ attempts OR 6.9, 95%CI 5.6–8.5. Conclusions: Moderate (SpO2<80%) and profound (SpO2<70%) desaturations are associated with TIAEs. Number of TI attempts is also associated with desaturation during TI.

Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit

&NA; The effect of video laryngoscopy on adverse events during neonatal tracheal intubation is unknown. In this single site retrospective cohort study, video laryngoscopy was independently associated with decreased risk for adverse events during neonatal intubation.