Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff

Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial

BACKGROUND

The use of nasal high-flow (NHF) oxygen for apnoeic oxygenation during emergency paediatric intubation is not universally adopted. Although previous studies suggest potential benefits, it remains unclear whether NHF enhances the likelihood of achieving successful first-attempt intubation without oxygen desaturation in children. We aimed to investigate whether the provision of NHF oxygen during paediatric emergency intubation can improve intubation outcomes.

METHODS

We conducted a randomised, controlled, open-label trial at ten hospitals in Australia, New Zealand, and Switzerland (four emergency departments, ten paediatric intensive care units, and one non-maternity neonatal intensive care unit were included). Children younger than 16 years undergoing emergency endotracheal intubation were eligible for inclusion. Participants were randomly assigned (1:1) to receive either NHF apnoeic oxygenation or standard care during intubation. The primary outcomes were the occurrence of hypoxaemic events (defined as oxygen saturation [SpO2] ≤90%) and successful intubation on the first attempt without desaturation in the modified intention-to-treat population (all intubations in participants for whom prospective or retrospective consent was given and a primary outcome was recorded). This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000147381) and is now completed.

FINDINGS

Between May 9, 2017, and Oct 22, 2022, 1069 intubations in 969 children were randomly assigned to the NHF group (535 intubations) or standard care group (534 intubations). The primary analysis comprised 950 intubations in 860 children, with 476 intubations in the NHF group and 474 in the standard care group. In the NHF group, hypoxaemic events occurred in 61 (12·8%) of 476 intubations, compared with 77 (16·2%) of 474 in the standard care group (adjusted odds ratio [aOR] 0·74; 97·5% CI 0·46-1·18; p=0·15). Successful intubation was achieved at the first attempt in 300 (63·0%) of 476 intubations in the NHF group and 280 (59·1%) of 474 intubations in the standard care group (aOR 1·13; 97·5% CI 0·79-1·62; p=0·43). In the per-protocol analysis of 905 intubations, NHF reduced the rate of hypoxaemia (48 [10·8%] of 444) compared with standard care (77 [16·7%] of 461; aOR 0·59; 97·5% CI 0·36-0·97; p=0·017). In this analysis, first-attempt successful intubation was achieved in 284 (64·0%) of 444 intubations in the NHF group versus 268 (58·1%) of 461 intubations in the standard care group (aOR 1·22; 97·5% CI 0·87-1·71; p=0·19).

INTERPRETATION

The use of NHF during emergency intubation in children did not result in a reduction in hypoxaemic events or an increase in the frequency of successful intubation on the first attempt. However, in the per-protocol analysis, there were fewer hypoxaemic events but no difference in successful intubation without hypoxaemia on first attempt. Barriers to the application of NHF during emergency intubation and the reasons for abandoning intubation attempts before physiological compromise should be further investigated to inform future research and recommendations for intubation guidelines and clinical practice.

FUNDING

Thrasher Research Fund (USA), National Health and Medical Research Council (Australia), and the Emergency Medicine Foundation (Australia).

Emergency department management of severely injured children in New South Wales

OBJECTIVE

Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury.

METHODS

The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included.

RESULTS

There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range.

CONCLUSION

A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.