RISK FACTORS FOR FAILED TRACHEAL INTUBATION IN PEDIATRIC

AND NEONATAL CRITICAL CARE SPECIALTY TRANSPORT

Kristen A. Smith, MD, M. David Gothard, MS, Hamilton P. Schwartz, MD, John S. Giuliano, Jr., MD,
Michael Forbes, MD, Michael T. Bigham, MD

Abstract ing odds of at least one intubation failure included, neonatal

patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of
Objective. Nearly 200,000 pediatric and neonatal transports an uncuffed tracheal tube (OR 6.85), and the pres-ence of a
occur in the United States each year with some patients requiring comorbid conditions (OR 2.64). Conclusions. There were higher
tracheal intubation. First-pass intubation rates in both pediatric rates of tracheal intubation failure in transported neonates when
and adult transport literature are variable as are the factors that compared to pediatric patients. This risk may be related to the
influence intubation success. This study sought to determine risk lack of benzodiazepine and neuromuscular blocking agents used
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factors for failed tracheal intubation in neonatal and pediatric to facilitate intubation. The presence of a comorbid condition is
transport. Methods. A retrospec-tive chart review was performed associated with a higher risk of tracheal intubation failure. Key
over a 2.5-year period. Data were collected from a hospital-based words: tracheal intubation; neonate; pediatric; specialty transport
neonatal/pediatric crit-ical care transport team that transports
2,500 patients annu-ally, serving 12,000 square miles. Patients
were eligible if they were transported and tracheally intubated by PREHOSPITAL EMERGENCY CARE 2015;19:17–22
the critical care transport team. Patients were categorized into two
groups for data analysis: (1) no failed intubation attempts and (2)
at least one failed intubation attempt. Data were tabulated us-ing
BACKGROUND
Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Re-sults. Approximately 200,000 newborns, infants, and chil-dren in
A total of 167 patients were eligible for enrollment and were the United States are transported to a higher level of care
1
cohorted by age (48% pediatric versus 52% neonatal). Neonates each year. Airway management is an es-sential component
were more likely to require multiple attempts at in-tubation when of resuscitation efforts and nearly half of pediatric or
For personal use only.

compared to the pediatric population (69.6% versus 30.4%, p = neonatal critical care transports re-quire some form of
0.001). Use of benzodiazepines and neu-romuscular blockade was 2–7
associated with increased success-ful first attempt intubation rates respiratory intervention prior to or during the transport.
(p = 0.001 and 0.008, re-spectively). Use of opiate premedication Tracheal intubation can be fraught with complica-tions
was not associated with first-attempt intubation success. The even in the most controlled environment, such as the
8,9
presence of comor-bid condition(s) was associated with at least operating room. In the fields of prehospi-tal and
one failed intu-bation attempt (p = 0.006). Factors identified with interfacility transport medicine, the setting is often less
increas- controlled and multiple variables may de-crease the
opportunities to perform a successful tra-cheal
4,10
intubation. Lack of pediatric intubation exper-tise,
limited resources, and a less-than-ideal intubation
6,7
environment further reduce the success rate.
Clinical outcome data within emergency medical
Received June 7, 2013 from the Johns Hopkins Children’s Center,
Department of Anesthesia and Critical Care, Baltimore, Maryland (KAS),
services (EMS) literature have demonstrated that pre-
BIOSTATS, Inc., East Canton, Ohio (MDG), Cincinnati Chil-dren’s hospital tracheal intubation by paramedic teams offers little
11
Hospital Medical Center, Department of Pediatrics, Division of benefit compared to bag-valve mask ventilation.
Emergency Medicine, Cincinnati, Ohio (HPS), Yale University, Yale Children, however, are known to have increased oxy-gen
Children’s Hospital, Department of Pediatrics, Division of Crit-ical Care consumption, decreased oxygen reserve, and in-creased
Medicine, New Haven, Connecticut (JSG), and Akron Chil-dren’s
gastric distention with bag-valve mask ven-tilation
Hospital, Department of Pediatrics, Division of Critical Care Medicine, 7,12
Akron, Ohio (MF, MTB). Revision received April 9, 2014; accepted for regardless of nasogastric tube placement. Desaturation
publication September 9, 2014. and bradycardia during bag-valve mask ventilation in an
The authors report no conflicts of interest. The authors alone are re- already unstable patient can result in significant morbidity
11,12
sponsible for the content and writing of the paper. and mortality. In pediatric and neonatal critical care
Author contributions: KS, MG, MB were involved in study design, data transport, it is often neces-sary to ensure a more stable
collection, data analysis, data review, and manuscript prepara-tion; HS, airway to optimize oxy-genation and ventilation during
JG, and MF were involved in study design, data review, and manuscript transport.
preparation. Studies have cited first-pass success rates for pediatric
Address correspondence to Michael T. Bigham, MD, FAAP, Medical tracheal intubation ranging from 33 to 95% for transport
Director, Transport Services, Akron Children’s Hospital, One Perkins and emergency department personnel (paramedics,
Square, Akron, OH 44308-1066, USA. E-mail: [email protected]
trainees, and attending
doi: 10.3109/10903127.2014.964888

17
 18 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1

5,6,13,14 sion 3.5.1 (www.cdc.gov). The database included de-tailed

physicians). The reasons for the variable intu-bation
success rates among these studies have not been adequately trip information, such as mode and length of transport,
explored. In this study, we sought to identify risk factors indication for intubation, medications, self-reported
for failed tracheal intubation in neonatal and pediatric complications of intubation, and patient co-morbidities.
transport patients. The person performing the intubation and his/her
experience level was extracted from depart-mental
employment records.
METHODS Patients were cohorted a priori into two groups for
This single institution retrospective study was re-viewed comparison and analysis: 1) patients with no failed
and approved by the Akron Children’s Hos-pital intubation attempts and 2) patients with at least one failed
institutional review board. The transport team is a intubation attempt. An intubation attempt was defined by
combined neonatal/pediatric transport team with a mix of an attempt at laryngoscopy, regardless of an attempt to pass
dedicated and unit-based critical care trans-port services. a tracheal tube. A failed intubation attempt was defined as
Online medical control is provided by pediatric emergency either laryngoscopy with no attempt at tracheal tube
or critical care physicians as well as neonatologists. The placement or laryngoscopy with esophageal placement of a
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composition of the team in-cludes a pediatric or neonatal tracheal tube. There was no real-time record of desaturation
transport nurse, a trans-port paramedic, and a transport during each intubation attempt, though intubation practice
respiratory thera-pist. The critical care team transports includes preoxygenation and abandonment of intuba-tion
approximately 2,500 patients annually. The local critical attempt with desaturation below 90%. Successful
care transport paradigm includes the use of local EMS for placement was confirmed with end-tidal colorimetric
the regional transfer of non-critically ill patients to our capnometry, symmetric breath sounds by auscultation, and
tertiary re-gional children’s hospital and reserves the use of chest radiography, when available. Data collected were
the critical care transport team for patients with active or analyzed using appropriate statistical tests, including two-
high risk for development of critical care issues includ-ing sample t-test, nonparametric analog (Kruskal-Wallis) test
cardiac, respiratory, or neurologic failure. The pa-tients are for non-normally distributed data, and Pearson chi-square
transported via one of four ground units or one dedicated test via SPSSv17.0 (SPSS, Chicago). Odds ratios with 95%
helicopter servicing 12,000 square miles in confidence intervals were also computed for factors
For personal use only.

northeastern/eastern/central Ohio. significantly associated with intubation failure. Factors that

were significantly (p < 0.05 via two-sided testing)
Intubation is primarily the responsibility of the respi- associated with at least one intubation failure were
ratory therapist, though all team members are trained and included in a multivariate logistic regression model. To
maintain intubation competencies. The transport team is minimize the effects of multicollinearity since several
accredited by the Commission on Accredita-tion of significant factors were correlated, a backward stepwise
Medical Transport Systems (CAMTS) and meets or elimination proce-dure was performed to exclude
exceeds intubation training competency using a insignificant predictor variables of failed intubation and
combination of live-patient intubations in the critical care therefore identify the strongest predictor variables when
settings, the transport settings, and the operat-ing rooms, taken in concert.
plus additional simulated intubation expe-rience. The local
pediatric transport team intubation protocols delineate the
standard use of a sedative and a neuromuscular blocking RESULTS
agent prior to intubation. The neonatal intubation protocols
do not standardize the use of a sedative and/or a The critical care transport team performed 4,546 trans-
neuromuscular block-ing agent, but rather defer that ports over this 2.5-year study period, with 904 requir-ing
decision to the medical control physician on a case-by-case invasive or noninvasive ventilatory support. Of these, 736
basis. were excluded because they were either in-tubated by the
Study patients included all neonatal and pediatric referring hospital, had a preexisting tra-cheostomy, or were
patients less than 18 years of age who were intubated by managed using noninvasive ven-tilation. Data from the
the Akron Children’s critical care transport team from remaining 168 eligible patients were analyzed. During
January 2007 through June 2009. Neonates were defined as analysis, one additional patient was excluded due to
patients less than 30 days of age transferred from local incomplete data in the medical record, yielding 167
newborn nurseries or delivery hospitals. Pe-diatric patients patients for final analysis.
were those greater than 30 days of age or patients less than Patient demographics are reported in Table 1 with 52%
30 days who had been discharged from the newborn neonates and 48% pediatric. Neonates were more likely to
nursery. Data were extracted by a single pediatric resident require multiple intubation attempts com-pared to the
in her second post-graduate year of training (KS). Data pediatric cohort (69.6 versus 43.2%, p = 0.001) (Table 2).
were then entered into a customized data collection tool The clinical indication for intubation was not associated
using Epi Info Ver- with intubation success or failure
 K. A. Smith et al. RISK FACTOR FOR FAILED INTUBATION 19

TABLE 1. Demographics
At least one failed intubation attempt No failed intubation attempts P-value Overall
Category/subcategory n = 56 n = 111 n = 167
Gender, n (%)
Male 35 (62.5) 66 (59.5) 101 (60.5)
Race, n (%)
White/Caucasian 43 (76.8) 87 (78.4) 130 (77.8)
Black/African American 10 (17.9) 12 (10.8) 22 (13.2)
Nonwhite/Other 2 (3.6) 11 (9.9) 13 (7.8)
Nonwhite/Hispanic 1 (1.8) 1 (0.9) 2 (1.2)
Neonatal population, n 39 48 87
Gestational age (weeks), mean (SD) 32.1 (4.75) 32.5 (6.23) 0.30 32.3 (5.59)
Weight (kg), mean (SD) 2.0 (0.96) 2.2 (0.99) 0.27 2.1 (0.97)
Pediatric population, n 17 63 80
Age (months), mean (SD) 27.1 (66.17) 17.8 (43.98) 0.47 19.8 (49.18)
Weight (kg), mean (SD) 12.1 (21.13) 8.8 (10.17) 0.36 9.5 (13.17)
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(Table 2). Tracheal tube size ≤2.5 mm and the use of this study included abdominal wall defects, asthma,
uncuffed tracheal tubes were associated with multiple cerebral palsy, congenital heart disease, epilepsy,
failed attempts at intubation (p = 0.033 and <0.001, re- developmental delay, genetic syndromes, history of
spectively) (Table 2). prematurity, laryngomalacia, and/or tracheomalacia. The
Furthermore, the use of benzodiazepines and neu- use of benzodiazepine premedication (OR 0.34, 95%
romuscular blockade was associated with first-pass confidence interval 0.17–0.66) or neuromuscular blockade
intubation success (p = 0.001 and 0.008, respectively), (OR 0.31, 95% confidence interval 0.15–0.61) were
whereas the use of opiate premedication was not (Table 3). protective against at least one failed intubation attempt. Of
The presence of a preexisting comorbid condition was the six significant univariate factors, three were significant
associated with intubation attempt failure (p = 0.006) in predicting intubation failure in the final, reduced logistic
(Table 3). The referring hospital’s failed intubation regression model: neonatal patient, uncuffed tube, and
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attempt(s) prior to transport team arrival did not correlate failure to use neuromuscu-lar blocking (NMB)
with failure of intubation by the transport team (Table 3). premedication. Each of the three remaining factors was
significant (p < 0.05) in the final, reduced logistic
After univariate analysis, we identified several factors regression model, indicating their significant additive
that increased the odds of at least one failed intubation influence on the accuracy of the final predictive model.
attempt. These included neonatal patients (OR 3.01, 95%
confidence interval 1.52–5.96), tracheal tube size less than
or equal to 2.5 mm (OR 3.78, 95% confidence interval
1.52–9.40), use of an uncuffed tracheal tube (OR 6.85, DISCUSSION
3.06–15.35), and preexisting comorbid conditions (OR This study provided a detailed review of all pediatric and
2.64, 95% confidence in-terval 1.30–5.38). Comorbid neonatal critical care transport team intubations occurring
conditions identified in over 2.5 years. We identified multiple risk

TABLE 2. Intubation indications and tracheal tube characteristics

At least one failed intubation attempt No failed intubation attempts
a
Category/subcategory n = 56 n = 111 P-value

Patient population 0.001

Neonatal, n (%) 39 (69.6) 48 (43.2)
Pediatric, n (%) 17 (30.4) 63 (56.8)
Clinical indication for intubation, n (%) 0.095
Respiratory distress/work of breathing 49 (87.5) 95 (85.6)
Mental status 2 (3.6) 12 (10.8)
Other, not specified 3 (5.4) 1 (0.9)
Hypoxemic respiratory failure 2 (3.6) 1 (0.9)
Shock, cardiac 0 (0) 2 (1.8)
Tube size (mm, inner diameter), n (%) 0.033
≤2.5 14 (25) 9 (8.1)
≥2.5 42 (75) 102 (91.9)
Tube type, n (%) < 0.001
Cuffed 9 (16.1) 63 (56.8)
Uncuffed 47 (83.9) 48 (43.2)
a P-value from Pearson’s chi-square test.
 20 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1

TABLE 3. Preintubation characteristics

At least one failed intubation attempt No failed intubation attempts
a
Category/subcategory n = 56 n = 111 P-value

Benzo used for premedication, n (%) 0.001

Midazolam 18 (32.1) 65 (58.6)
None 38 (67.9) 46 (41.4)
NMB used for premedication, n (%) 0.008
Rocuronium 5 (8.9) 20 (18)
Succinylcholine 10 (17.9) 40 (36)
Vecuronium 1 (1.8) 3 (2.7)
None 40 (71.4) 48 (43.2)
Narcotic used for premedication, n (%) 0.384
Morphine 3 (5.4) 3 (2.7)
None 53 (94.6) 108 (97.3)
Comorbid condition, n (%) 0.006
Yes 42 (75) 59 (53.2)
No 14 (25) 52 (46.8)
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Previous attempts to intubate, n (%) 0.091

At least one previous attempt 8 (14.3) 14 (12.6)
No previous attempts 48 (85.7) 97 (87.4)
Number of intubation attempts prior to transport, median (range) 0.469
0 (0–7) 0 (0–7)

a P-value from Pearson’s chi-square test for categorical variables. P-value from two-sample Student’s t-test for numeric variables. Benzo, benzodiazepine; NMB, neuromuscular
blocking agent.

factors associated with increased risk of at least one failed minister premedication to the neonatal population. In the
intubation attempt. United States prior to 2000, sedation and anal-gesia were
Additional risk inherent to the transport setting is the rarely used during the process of intuba-tion. Only 3% of
emergency nature of transport intubations. Anes-thesia data neonatal intensive care units (NICUs) in 1994 reported
have long-established that 1 in 10 emer-gency intubations using neurosedatives routinely in the practice of
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(regardless of the personnel per-forming the intubation) 20

intubating. More recently, European NICUs have
required multiple (more than reported using sedation and/or analgesia only 29% of the
3) attempts and with each additional attempt, the pa-tient is time, and mostly in term neonates. Our data suggest that
at an increased risk for hypoxemia, regur-gitation, and the use of benzodiazepine premedi-cation or
10,15,16
esophageal intubation. In a re-cent study of pediatric benzodiazepine premedication PLUS neuro-muscular
patients, Timmermann et al. found that prehospital blockade favor intubation success. The local pediatric
intubations by anesthesia-trained physicians resulted in transport team intubation protocols delineate the standard
17
infrequent intubation failure (1.7%) and higher hospital use of a sedative and a neuromuscular blocking agent prior
18,19 to intubation. The neonatal intu-bation protocols don’t
survival rates com-pared to published literature. In our
cohort, no pa-tients failed transport team intubation. standardize the use of a sedative and/or a neuromuscular
Most notable in this study is the finding that neona-tal blocking agent, but rather de-fer that decision to the
intubations are associated with higher failure rates. There medical control physician on a case-by-case scenario. This
are inherent anatomic and physiologic features of neonates study supports the AAP position statement favoring
that contribute to difficulty when endo-tracheally premedication and neuro-muscular blockade in neonatal
24
intubating them. Anatomically, the neona-tal airway is intubation.
more complex, with a small orophar-ynx and a high, Our data did not identify an increased risk of intu-bation
anteriorly placed larynx, which makes the vocal cords failure associated with attempts prior to our team’s arrival,
20–22 nor did the total number of intubation attempts correlate
difficult to visualize. In addition, neonates tend to
with success or failure. Connelly et al. found that persistent
have large occiputs, short necks, and relatively large attempts at laryngoscopy were ineffective, but did not draw
tongues compared to adults and older pediatric patients – the conclusion that repeated laryngoscopy increased
20,23
all factors that make intu-bation more challenging. 25
likelihood of further failure. In our study population,
Physiologically, neonates have smaller functional residual intubation attempt failure was not associated with
capacities and are more sensitive to apnea and hypoxemia. increased rates of ICU length of stay, hospital length of
Overall, this amounts to less respiratory reserve than that of stay, duration of mechanical ventilation, or mortality,
4,22,23
their older counterparts. despite other studies linking failed intubation attempts to
Whether due to the emergent nature of tracheal tube 8,26
additional morbidity. Additional morbidities associated
placement, difficulty of successful intubation, or mis- with multiple intubation attempts were not identified, as
conceptions about pain tolerance, many do not ad- our study was not designed to draw conclusions on
 K. A. Smith et al. RISK FACTOR FOR FAILED INTUBATION 21

the clinical and physiologic impact of multiple failed (higher risk intubations), which could have influenced the
intubation attempts prior to transport. Anecdotally, we referring hospital to delay the intubation decision at the
believed that each intubation attempt made it “harder” for referring hospital, resulting in a higher risk cohort
subsequent intubators to intubate. Our data did not support requiring intubation by the transport team.
that.
We suggest utilizing these findings in two ways. First,
patients with one or more of these risk factors should be CONCLUSION
identified in advance of the intubation at-tempt, permitting In our study population, there were higher rates of in-
a higher attention to preparation and mitigation (if tubation failure in transported neonates compared to
possible) of the modifiable risk fac-tors. Second, the transported pediatric patients. The risk seemed to be
intubation risk factors might serve to inform training and increased by the lack of benzodiazepine premedica-tion
simulation strategies for initial and maintenance of and the lack of a neuromuscular blocking agent. The
intubation competencies for criti-cal care transport teams. presence of comorbid conditions, regardless of age, was
associated with a larger risk of failure, al-though we could
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not stratify which specific conditions increased that risk.

LIMITATIONS Inclusion of strategies for recogniz-ing and modifying risks
for failed intubations should be priorities for all critical
Since this was a retrospective study, we were able to care transport teams.
neither obtain direct input from the critical care transport
team caring for each patient nor ensure data accuracy and
completeness. Intubation attempts, success, and peri- References
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A. Characteristics and outcome of prehospital paediatric
For personal use only.