AET-22
The impact of ventilation technique on complications in the PeDI difficult airway registry
1Garcia-Marcinkiewicz A, 1Fiadjoe J, 2Adams H, 3Patel V, 1Gurnaney H, 1Peeples K, 1Lockman J, 4Kovatsis P
1The Children's Hospital of Philadelphia, Philadelphia, PA, USA; 2Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA; 3Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA; 4Boston Children's Hospital, Boston, MA, USA
The optimal ventilation approach in children with difficult airways remains controversial. Traditional teaching is to maintain spontaneous ventilation during tracheal intubation (TI) of a challenging airway because it maintains oxygen saturation and airway tone during TI and allows the patient to continuously ventilate and recover quickly if TI fails. Coughing, laryngospasm, and movement may hinder TI and is why some anesthesiologists paralyze patients after confirming easy facemask ventilation. This retrospective study of prospectively collected data in the PeDI registry compares the complication rates of patients with difficult airways managed with spontaneous vs. controlled ventilation. The Pediatric Difficult Intubation (PeDI) registry is a multicenter quality improvement database containing TI data about children with difficult direct laryngoscopy.1 Ventilation approaches in the registry are categorized as controlled ventilation with muscle relaxant; controlled ventilation without muscle relaxant or spontaneous ventilation (with or without CPAP). We reviewed 1,404 encounters of anticipated difficult airways. For each encounter in the registry, we documented the attending anesthesiologist's a priori ventilation plan. We categorized our results based on this plan and categorized complications as Severe and Non-Severe. Thirty-three percent of the Spontaneous Ventilation Group had complications, which was significantly higher than the Controlled Ventilation with muscle relaxant (20%) and the controlled ventilation without muscle relaxant groups (20%). We examined complications in multivariate negative binomial regression with robust estimation (GEE) with similar results.
In children with anticipated difficult TI controlled ventilation techniques are associated with fewer non-severe complications than spontaneous ventilation techniques and similar severe complications. Limitations of our study include the potential for selection bias. We do not know why anesthesiologists planned a particular ventilation approach, it may be that the sicker more fragile patients were in the spontaneous group, however, both groups had similar ASA physical status and we used the planned ventilation approach before induction for our analysis to reduce the selection bias effect. Our data is retrospective and is subject to unknown confounders. Our results should be interpreted with caution; we believe that there are clearly patient populations with difficult airways that should not receive paralysis such as patients with large airway masses, profuse bleeding, and others. The judgment of the clinicians remains critical in these cases. We believe that spontaneously ventilating patients can be as safely intubated as controlled patients by maintaining an adequate depth of anesthesia using continuous administration of inhalational or intravenous anesthesia during TI. Controlled ventilation in children with difficult airways may play a role in securing the airway with few complications.
1.Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4:37-48
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