The Difficult Pediatric Airway: Lessons from the PeDI Registry
Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Fiadjoe, J., et al. The Lancet, 2015.
Create a registry to characterize complications and identify risks for bad outcomes with difficult pediatric airways. Use the results to suggest strategies to make pediatric airway management successful.
This study was a prospective observational study carried out at multiple US academic children’s hospitals that evaluated the characteristics and complications of difficult pediatric airways in a variety of clinical settings, managed by anesthesiologists.
Any child was included if they met one or more of the inclusion criteria: Cormack and Lehane Grade greater than or equal to 3, direct laryngoscopy impossible due to patient anatomy, or attending discretion.
Of the 1,018 difficult airways, there was a 20% overall complication rate and a 3% incidence of severe complications such as cardiac arrest, severe airway trauma, death, or aspiration. The most common non severe complications were hypoxia, minor airway trauma, esophageal intubation with immediate recognition, or laryngospasm.
Anticipated difficult airways typically involved patients with conditions affecting airway anatomy, such as Pierre Robin sequence or Goldenhar syndrome. Unanticipated difficult airways occurred more frequently in younger children and in locations outside the operating room. In unanticipated difficult airways, the most successful rescue device was the Glidescope.
Cardiac arrest was the most common severe complication, and all were preceded by hypoxia. Importantly, only 10% of patients received apneic oxygenation by nasal cannula or other method during intubation attempts.
Despite a high incidence of complications securing the airway, most of the patients were able to be mask ventilated with or without the use of airway adjuncts.
Most Emergency Physicians infrequently intubate pediatric patients. Have a reliable rescue method that you feel comfortable using should direct laryngoscopy fail. Provide apneic oxygenation during intubation attempts. Data from the PeDI registry suggest that implementing these two techniques can reduce complications during pediatric airway management. If you practice in a location with specialty backup, consider whether it is feasible to temporize with mask ventilation while awaiting assistance for securing a definitive airway.