Appropriateness of endotracheal tube size and insertion depth in children undergoing air medical transport

Accuracy of predictive equations in guiding tracheal intubation depth in children: A prospective study

BACKGROUND

Accurate insertion depth of endotracheal tube (ETT) in children has been predicted using the demographic variables, such as age, weight, and height. Middle finger length showed good correlation with ETT depth measurement in children aged 4-14 years.

AIMS

The primary objective was to correlate the actual ETT insertion depth with the depth derived from middle finger length, age, weight, and height formulae in children aged 1-4 years. The secondary objective was to find the most accurate formula for prediction of ETT insertion depth.

METHODS

This prospective parallel group study was done in 50 american society of anesthesiologists 1 or 2 children aged 1-4 years undergoing elective surgery under general anesthesia. Children with difficult airway, finger anomalies, or syndromic associations were excluded. Age, weight, height, and middle finger length of all children were measured. Depth of orally inserted uncuffed ETT and tracheal length was measured by fiberoptic bronchoscopy. The actual ETT depth was correlated with the depth calculated from different formulae.

RESULTS

The mean middle finger length was 4.42 ± 0.50 cm, age was 2.64 ± 1.07 years, weight was 12.28 ± 2.84 kg, and height was 82.89 ± 16.23 cm. The mean tracheal length was 6.42 ± 0.96 cm. The mean depth of ETT was actual depth (12.89 ± 1.09 cm), middle finger depth (13.23 ± 1.53cm; p = .001; 95%CI 0.12-0.50), age-based depth 1(3.31 ± 0.53 cm; 95%CI 0.37-1.44; p = .001), weight-based depth (14.14 ± 1.42 cm; 95% CI 0.10-0.51; p = .004), and height-based depth (13.73 ± 0.94 cm; 95% CI 0.15-0.77; p = .004). Middle finger length and age-based formulae showed higher number of accurate placements (58% each). Weight- (74%) and height (64%)-derived formulae gave a higher number of distal ETT placements.

CONCLUSION

Formulas based on the demographic variables and middle finger length showed good correlation with the actual ETT depth in children aged 1-4 years. The percentage of accurate ETT depth placements was higher with middle finger length and age-based formulae.

“A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children

The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An “A-OK” algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-“A-OK” patients were compared with pre-“A-OK” controls regarding the speed of malpositioned ETTrepositioning. Twenty-eight post-“A-OK” cases and 23 pre-“A-OK” controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-“A-OK” controls than in post-“A-OK” cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.

New decision formulas for predicting endotracheal tube depth in children: analysis of neck CT images

INTRODUCTION

The purpose of this study was to construct a prediction model for endotracheal tube depth using neck CT images.

METHODS

A retrospective image review was conducted that included patients who had undergone neck CT. Using sagittal neck CT images, we calculated the length between upper incisor and mid-trachea and then derived the model via regression analysis. The model was validated externally using chest radiographs of patients who had undergone endotracheal intubation. We compared performance of our model with that of other methods (Broselow tape and APLS formula) via Bland-Altman analysis and the percentage of estimations within 10% of the measured values.

RESULTS

A total of 1111 children were included in this study. The tube depth obtained from CT images was linearly related to body weight (tube depth (cm)=5.5+0.5×body wt (kg)) in children younger than 1 year and to height (tube depth (cm)=3+0.1×height (cm)) in children older than 1 year. External validation demonstrated that our new model showed better agreement with the desired tube depth than Broselow tape and APLS formula. The mean differences in children younger than 1 year were 0.61 cm and -1.24 cm for our formula and Broselow tape, respectively. The mean differences in children older than 1 year were -0.43 cm, -1.98 and -1.64 cm for our formula, Broselow tape and APLS formula, respectively. The percentages of estimates within 10% of the measured values were 52.7% and 35.8% for our formula and Broselow tape in children younger than 1 year, respectively, and 54.3%, 33.8% and 37.2% for our formula, Broselow tape and APLS formula in children older than 1 year, respectively (P<0.01).

CONCLUSION

Our new formula is useful and more accurate than the currently available methods.

Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study

PURPOSE

Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications.

METHOD

Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as "near miss" intubations.

RESULTS

From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. "Near miss" intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements.

CONCLUSIONS

Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.

Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis

Background

Pre-hospital paediatric airway management is complex. A variety of pitfalls need prompt response to establish and maintain adequate ventilation and oxygenation. Anatomical disparity render laryngoscopy different compared to the adult. The correct choice of endotracheal tube size and depth of insertion is not trivial and often challenged due to the initially unknown age of child.

Methods

Data from 425 paediatric patients (<17 years of age) with any airway manipulation treated by a Swiss Air-Ambulance crew between June 2010 and December 2013 were retrospectively analysed. Endpoints were: 1) Endotracheal intubation success rate and incidence of difficult airway management in primary missions. 2) Correlation of endotracheal tube size and depth of insertion with patient’s age in all (primary and secondary) missions.

Results

In primary missions, the first laryngoscopy-guided endotracheal intubation attempt was successful in 95.3% of cases, with an overall success rate of 98.6%. Difficult airway management was reported in 10 (4.7%) patients. Endotracheal tube size was frequently chosen inadequately large (overall 50 of 343 patients: 14.6%), especially and statistically significant in the age group below 1 year (19 of 33 patients; p < 0.001). Tubes were frequently and distinctively more deeply inserted (38.9%) than recommended by current formulae.

Conclusion

Difficult airway management, including cannot intubate and cannot ventilate situations during pre-hospital paediatric emergency treatment was rare. In contrast, the success rate of endotracheal intubation at the first attempt was very high. High numbers of inadequate endotracheal tube size and deep placement according to patient age require further analysis. Practical algorithms need to be found to prevent potentially harmful treatment.

Three-finger tracheal palpation to guide endotracheal tube depth in children

BACKGROUND

Accurate endotracheal tube (ETT) depth is critical, especially in children. The current tools used to guide appropriate ETT depth have significant limitations.

OBJECTIVES

To evaluate the utility of tracheal palpation in the neck to guide appropriate ETT placement in children.

METHODS

A prospective observational study with a convenience sample of 50 children was conducted. During intubation, an investigator palpated the trachea with three fingertips side-by-side extending upward from the suprasternal notch. The anesthesiologist advanced the ETT slowly until palpated at the sternal notch. The investigator stated ETT palpation certainty as 'strongly felt', 'weakly felt', or 'not felt.' Final ETT position was determined by bronchoscopy and categorized as 'ETT too shallow' (tip in proximal ¼ of trachea), 'ETT too deep' (tip in distal ¼ of trachea), or 'ETT placement satisfactory' (between those extremes).

RESULTS

Thirty boys and 20 girls undergoing dental surgery with nasal intubation were recruited (median age 4.4 years; range 2.0-10.8). The ETT (all ≥4 mm ID) was palpable at the sternal notch in all patients: 46 of 50 strongly palpable and 4 of 50 weakly palpable. The experimental methods led to satisfactory ETT placement in 49 of 50 patients, too deep in 1 of 50 patients. Compared with the Pediatrics Advanced Life Support (PALS) predictive formula, satisfactory placement would have been 41 of 50 patients (P < 0.008). Number needed to treat is 6.3 for improvement over the PALS method.

CONCLUSIONS

The use of tracheal palpation to guide ETT placement has excellent clinical performance and better guides appropriate ETT depth than the PALS formula in our study population.

Helicopter EMS: Research Endpoints and Potential Benefits

Patients, EMS systems, and healthcare regions benefit from Helicopter EMS (HEMS) utilization. This article discusses these benefits in terms of specific endpoints utilized in research projects. The endpoint of interest, be it primary, secondary, or surrogate, is important to understand in the deployment of HEMS resources or in planning further HEMS outcomes research. The most important outcomes are those which show potential benefits to the patients, such as functional survival, pain relief, and earlier ALS care. Case reports are also important "outcomes" publications. The benefits of HEMS in the rural setting is the ability to provide timely access to Level I or Level II trauma centers and in nontrauma, interfacility transport of cardiac, stroke, and even sepsis patients. Many HEMS crews have pharmacologic and procedural capabilities that bring a different level of care to a trauma scene or small referring hospital, especially in the rural setting. Regional healthcare and EMS system's benefit from HEMS by their capability to extend the advanced level of care throughout a region, provide a "backup" for areas with limited ALS coverage, minimize transport times, make available direct transport to specialized centers, and offer flexibility of transport in overloaded hospital systems.

Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU

OBJECTIVE

To describe the current practice of pediatric airway management at referring hospitals and the associated adverse events compared to a receiving tertiary pediatric ICU.

METHOD

Retrospective chart and transport record review of all emergency critical care transports to our Pediatric ICU over 3 years. Data regarding tracheal intubation procedure, pre-defined adverse Tracheal Intubation Associated Events (TIAEs), and airway events before, during, and after the inter-hospital transport were collected using a standard National Emergency Airway Registry for children (NEAR4KIDS) definition. Tracheal intubation outcomes were compared to in-hospital P ICU intubations.

RESULTS

253/1489 (17%) of critical care transports had airway management, all by tracheal intubation. The most common condition was seizure (34%), followed by pulmonary/lower airway disease (16%). 49 (19%) had TIAEs; the most common event was mainstem bronchial intubation (13%). Incidence of TIAEs was similar to PICU (p=0.69). Thirteen had an inappropriate tracheal tube position upon PICU arrival, but none experienced accidental extubation during transport. An uncuffed tracheal tube was used in 108/172 (63%) of patients<8 years, significantly higher than PICU (20%, p<0.0001). 124 (49%) were extubated within 24 h, 153 (60%) within 48 h. Two patients had the tracheal tube changed to cuffed from uncuffed due to air leak.

CONCLUSION

Provider reported adverse TIAEs are common during airway management in children requiring critical care transport, but not higher compared to PICU intubations. Most inter-hospital transport patients are intubated with an uncuffed tracheal tube. Subsequent tracheal tube change from uncuffed to cuffed tube is rarely required.

Assessment of airway length of Korean adults and children for otolaryngology and ophthalmic surgery using a fiberoptic bronchoscope

Background

Knowledge regarding normal upper airway anatomy is essential for airway management and is required to prevent malpositioning of endotracheal tubes. We evaluated the length of the upper airway in Korean children and adults who had no abnormality of the upper airway using a fiberoptic bronchoscope.

Methods

Eighty seven patients aged 5 to 81 years undergoing noninvasive elective surgery were included in this study. After induction of anesthesia was complete, we measured the distance from the upper incisor to various components of the upper airway by fiberoptic bronchoscopy.

Results

In adults, the mean length between the upper incisor and midtrachea was found to be 21.8 ± 1.8 cm in males and 19.9 ± 1.3 cm in females, while the mean length of the trachea was 10.1 ± 1.3 cm in males and 10.3 ± 1.6 cm in females. The length between the upper incisor and midtrachea (IT) were correlated with height both in children (IT [cm] = 2.531 + 0.109 × height [cm]) and adults (IT [cm] = 0.167 + 0.127 × height [cm]), which shows that they differ from the western standard (length of tube [cm] = 5 + 0.1 × height [cm]).

Conclusions

In adults and children, the length from the incisor to the midtrachea was significantly different when compared with western standards. Therefore, re-evaluation of the proper and precise depth of endotracheal tube in Koreans should be considered.

Interfacility transport of the critically ill pediatric patient

Care of the critically ill and injured child has evolved over the last 20 years, with growth of regional pediatric critical care services, attendant subspecialties, and the proliferation of pediatric critical care training programs nationally. Concurrent with this evolution has been recognition of the need for specialty care of the critically ill child during air or ground transport to a regional pediatric center. The American Academy of Pediatrics Section on Transport Medicine has provided standards that have been adopted by many neonatal and pediatric transport teams. Team composition varies, but all share the mission of specialized transport for critically ill and injured children in a safe and expeditious process while ultimately improving patient outcome. Specialized pediatric transport teams are costly to maintain. Declining reimbursement for specialized care and reduced profit margins have resulted in extended roles for transport team members within children's hospitals. More stringent budgetary constraints have created challenges for pediatric transport teams in our constantly changing medical environment.

Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements

STUDY OBJECTIVE

To evaluate a new method of endotracheal tube (ETT) positioning relative to carina, based on external topographic landmarks.

DESIGN

Prospective, randomized, crossover study.

SETTING

Operating room, university hospital.

PATIENTS

200 American Society of Anesthesiologists (ASA) physical status I-II patients (100 women and 100 men) scheduled for elective surgery with general anesthesia.

INTERVENTIONS

ETT insertion depth was topographically determined by adding the distance measured (in cm) from the right mouth corner to right mandibular angle to the distance measured from the right mandibular angle to a point situated on the center of a line running transversally through the middle of the sternal manubrium. This method was compared to the 21/23 cm insertion depth method.

MEASUREMENTS

ETT position was assessed fiberoptically. The main end point was considered the percentage of ETT tips situated more than 25% higher or lower than a predetermined "best" tip position (4 cm above the carina).

MAIN RESULTS

There were 58.5% ETT tips positioned too closely (<3 cm above the carina) to the carina with the control method and 24% with the study method (P=0.0001). No ETT tip was too high (>5 cm above the carina). The tip-carina distance was shorter in women (2.7+/-2.5 vs 3.6+/-2.2 cm in men P=0.0001) and in those aged more than 65 years (2.8+/-2.4 vs 3.4+/-2.4 cm with age less than 65 years; P=0.012) only with the 21/23 cm method.

CONCLUSIONS

With our new ETT positioning method, there were fewer ETTs positioned outside the desired range of distance to carina. Our method may be especially valuable in women and in patients older than 65 years.

New formulae for predicting tracheal tube length

BACKGROUND

The aim of this study was to determine the accuracy of standard techniques for estimating oral and nasal tracheal tube length in children and to devise more accurate predictive formulae that can be used at the bedside.

METHODS

Data were collected from 255 children who required tracheal intubation whilst on the Pediatric Intensive Care Unit over a period of 1 year. Age, weight, the final length of the tracheal tube and the internal diameter were documented. Patients with a tracheostomy were excluded from the study.

RESULTS

Using linear regression the following formulae best predicted final tracheal tube length. For children over 1 year of age: Insertion depth (cm) for orotracheal intubation = age/2 + 13 Insertion depth (cm) for nasotracheal intubation = age/2 + 15 For children below 1 year of age: Insertion depth of orotracheal tube (cm) = weight/2 + 8 Insertion depth of nasotracheal tube (cm) = weight/2 + 9

CONCLUSIONS

Current Advanced Paediatric Life Support guidelines underestimate the appropriate tracheal tube lengths for orotracheal intubation in children over 1 year of age. Similarly, the novel weight-based formulae for tracheal tube lengths in children below the age of 1 year proved more accurate than standard reference charts. We therefore recommend that these new formulae are prospectively evaluated.

Air versus ground transportation of artificially ventilated neonates: comparative differences in selected cardiopulmonary parameters

OBJECTIVE

To assess if cardiopulmonary interventions and abnormal CO2 tension are more likely in intubated neonates transported by air versus ground.

METHODS

We reviewed the transport records of all ventilated neonates retrieved to a pediatric teaching hospital in the United States within a 12-month period. Demographic data, underlying diagnosis, pretransport and posttransport ventilation settings and blood gas data, and transport data were recorded.

RESULTS

Seventy-five intubated neonates were transported by ground (n = 43), helicopter (n = 29) and by fixed-wing aircraft (n = 3). Thirty-nine patients (52%) received interventions, including adjustments of ventilator settings (36 patients) and increase in the rate of dopamine infusion or boluses infusion (volume expanders or sodium bicarbonate) in 9 patients. There were no overt pneumothoraces, endotracheal tube complications, arrhythmias, or cardiopulmonary resuscitation en route. The posttransport blood gas analysis revealed 7 patients with hypercapnia greater than 55 mm Hg and 17 patients with hypocapnia of less than 30 mm Hg. When compared with patients with Pco2 30 to 55 mm Hg, all patients with posttransport Pco2 greater than 55 mm Hg had interventions en route (P = 0.01). No significant difference between the mode of transport and stabilization time, return time, diagnostic groups, interventions, or the occurrence of hypercapnia and hypocapnia was identified. Additional adjustments of ventilatory settings were retrospectively considered necessary in many of these patients with Pco2 greater than 55 mm Hg or less than 30 mm Hg.

CONCLUSIONS

There were no cardiopulmonary disasters (such as overt pneumothoraces, endotracheal tube complications, arrhythmias, or cardiopulmonary resuscitation en route) in the various modes of neonatal transport. Adjustments of ventilation, inotropes, and volume infusion are often required for stabilization of patients during the dynamic process of transport. When compared with ground transport, there is no increase in the risk of cardiopulmonary interventions or abnormal CO2 tension in air transport of intubated neonates. Additional adjustments of ventilatory settings were retrospectively considered necessary in many of these patients with significant hypercapnia or hypocapnia.

Hyperventilation at referring hospitals is common before transport in intubated children with neurological diseases

OBJECTIVE

To assess if cardiopulmonary complications and abnormal carbon dioxide tension are more likely in intubated children with neurological diseases undergoing transport.

METHODS

We reviewed the transport records of all ventilated children retrieved to a pediatric teaching hospital in the United States within a 12-month period.

RESULTS

Twenty-seven children were transported by ground (n = 11), helicopter (n = 10), and fixed-wing aircraft (n = 6). Adjustments of ventilator settings were made in 17 (63%). There were no pneumothoraces, endotracheal tube complications, arrhythmias, or cardiopulmonary resuscitation en route. Twelve patients (44%) had a primary neurological condition. In the neurological category, the pretransport blood gases revealed 7 patients with hyperventilation (Pco2, 20-29 mm Hg), and the posttransport blood gases showed 4 patients with hyperventilation (Pco2, 15-28 mm Hg). In the nonneurological category, hyperventilation occurred only in one patient before and another after transport. No significant difference between the mode of transport, stabilization time, return time, and the occurrence of hypercapnia and hypocapnia was identified. Patients who had a neurological condition were more likely to be hyperventilated at the referring hospitals (P = 0.007). Additional maneuvers were considered necessary in 3 of the 6 neurological patients and 2 of the 5 nonneurological patients with DeltapH greater than +/-0.1, whereas the management of all but one patient with DeltapH less than +/-0.1 was considered appropriate (DeltapH defined as the difference between posttransport and pretransport pH values).

CONCLUSION

There is no cardiopulmonary disaster in the various modes of pediatric transport. When compared with ground transport, there is no significant increase in the risk for cardiopulmonary complications or abnormal CO2 tension in air transport of intubated children. DeltapH, in conjunction with clinical data and PCO2 values, may be a simple index for evaluation of cardiopulmonary management during transport.

Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children

OBJECTIVE

To determine whether multiplying the internal diameter of the endotracheal tube (ETT) by 3 (3x ETT size) is a reliable method for determining correct depth of oral ETT placement in the pediatric population.

DESIGN

Prospective, observational.

SETTING

University-affiliated, 12-bed pediatric intensive care unit.

PATIENTS

Orally intubated pediatric intensive care unit patients of < or =12 yrs of age.

INTERVENTIONS

Demographics, ETT size, and depth of ETT placement measured from the lip were obtained. Correct placement, defined as the tip of the ETT below the thoracic inlet and > or =0.5 cm above the carina, was determined by chest radiograph.

MEASUREMENTS AND MAIN RESULTS

Suggested ETT size based on the Pediatric Advanced Life Support (PALS) age-based formula and the Broselow tape-length-based guidelines were determined. A total of 174 of 226 ETTs (77%) were correctly positioned. If practitioners utilized the 3x ETT size for the actual tubes chosen, 170 of 226 (75%) would have been accurately placed. More accurate were the 3x PALS-based ETT size (81%) and 3x Broselow-suggested ETT size (85%). The use of the Broselow ETTs to determine the depth would have led to a significantly improved ETT position (p = .009) compared with the actual ETT.

CONCLUSION

The commonly used formula of 3x tube size for ETT depth in children results in 15-25% malpositioned tubes. Practitioners can improve the reliability of this formula by utilizing the recommended ETT size as suggested by the Broselow tape. A more reliable method is necessary to avoid ETT malposition.

Helicopter transport of sick neonates: a 14-year population-based study

BACKGROUND

The Norwegian Helicopter Emergency Medical Service (HEMS) employs anesthesiologists and paramedics who are not formally trained in neonatology to provide stabilization and transport of sick neonates. We describe neonatal transport by HEMS in central Norway and report the outcome.

METHODS

Retrospective analysis of HEMS missions during the 14-year period 1988-2001.

RESULTS

A total of 252 neonates were transported, indicating a prevalence of 0.90 per 100 newborn. Median response time was 42 min, on-scene stabilization time 38 min and transportation time 30 min. Median gestational age (GA) was 38 weeks and 4.8% of the neonates were <1000 g and/or <28 weeks. Main clinical problems were respiratory disease, asphyxia and malformations; 30 neonates (12%) died within 1 year. No deaths were transport-related. Tube or ventilator problems were noted in seven out of 66 transports of ventilated neonates. Other technical problems were few. Regarding ventilation, oxygenation and circulation, the clinical condition of most neonates improved during transport and the median temperature rose from 36.5 degrees C to 37.0 degrees C. Hypoglycemia (<2 mmol l(-1)) was documented in 19 missions after transport; of these, eight received a glucose infusion. Four neonates might have profited from HEMS-delivered surfactant therapy.

DISCUSSION

Helicopter Emergency Medical Service in central Norway provides rapid medical assistance in a wide spectrum of neonatal problems, but more attention should be paid to proper ventilation and prevention of hypothermia and hypoglycemia.

Success rates of pediatric intubation by a non-physician-staffed critical care transport service

OBJECTIVES

Previous researchers have found that institution of an endotracheal intubation (ETI) protocol into a large urban paramedic program resulted in low success rates and had no beneficial effects. The primary goal of the current study was to assess ETI success rates achieved by a small cadre of nonphysician critical care transport (CCT) providers. A secondary objective was to assess for association between ETI success and factors such as age group or ETI setting (eg, in-hospital, in-aircraft).

DESIGN

This retrospective study analyzed transport records of consecutive pediatric patients (younger than 13 years) in whom ETI was attempted by a nurse/paramedic (RN/EMTP) CCT crew working under protocols which included neuromuscular blockade (NMB)-facilitated ETI. The CCT service performs scene and interfacility transports in helicopter, fixed-wing (airplane), and ground critical care vehicles; pediatric patients are transferred to 4 receiving tertiary care centers. Chi2 test, Fisher exact test, and logistic regression analysis (P = 0.05) examined ETI success rates and assessed for association between ETI success and various characteristics (eg, age group, ETI setting).

RESULTS

The CCT crew attempted ETI in 143 patients, with success in 136 cases (95.1%). There were no unrecognized esophageal intubations. ETI success was of similar likelihood across pediatric age groups (P = 0.19) and in different ETI settings (P = 0.57).

CONCLUSIONS

CCT crew airway management success was very high in all practice settings. These data support contentions that, with a high level of initial and ongoing training, nonphysician CCT crew can successfully manage pediatric airways in a variety of circumstances.