Pediatric adverse tracheal intubation associated events following noninvasive ventilation failure

Objective: To determine if children intubated after failed Noninvasive Ventilation (NIV) have a higher occurrence of Tracheal Intubation Associated Events (TIAEs) compared to those intubated immediately. Methods: We conducted a retrospective study of all Tracheal Intubations (TIs) in a tertiary pediatric intensive care unit from 1/2013 to 12/2015. Data were collected from National Airway Registry for Kids, Virtual PICU System, and chart review. We excluded TI in children on chronic NIV, endotracheal tube exchange, nonemergent TI for procedures, and cases with insufficient documentation. We defined NIV as continuous or bilevel pressure ≥5 cm H2O or high flow nasal cannula ≥4L/min for infants and ≥5L/min for children. NIV failure was defined as TI after >1h of exposure to NIV; it was further characterized as acute (1-4h) or delayed (>4h). Our primary outcome was occurrence of severe TIAEs and/or desaturation (SpO2 drop >20%). Data were analyzed using Fisher’s Exact Test, Chi Square, Mann-Whitney U Test, and logistic regression. Results: One-hundred-forty-four of 192 intubations (75%) were included, of which 48 (33%) were primary TIs and 96 (67%) were after NIV failure. The median duration of NIV prior to failure was 14h (IQR 5, 45). TIAEs/desaturation occurred in 33% of intubations and were not different between the two groups after adjusting for potential confounders (25% vs. 38%; p=0.134, aOR 2.15, 95% CI 0.77-6.03). Additionally, there was no difference between occurrence of severe TIAEs/ desaturation in acute compared to delayed NIV failure (26% vs. 19%; p=0.558). Conclusion: TI after NIV failure is common. However, there was no difference in the occurrence of severe TIAEs/desaturation in primary TI versus TI after NIV failure, suggesting NIV failure does not increase the risk of TIAEs. Correspondence to: Christina Walsh, MD, Yale University, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064, Tel: 203-785-4651; E-mail: [email protected]