title: Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS.
abstract: OBJECTIVE
  To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs).
  
  
  METHODS
  Using the National Emergency Airway Registry for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers.
  
  
  RESULTS
  A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97% of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9%. In univariate analysis, patients with difficult TI were younger [median 1 year (0-4) vs. 2 (0-8) years, p = 0.046], and had a reported history of difficult TI (22 vs. 8%, p < 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58%, p < 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80% (48 vs. 15%, p < 0.001), adverse TI associated events (53 vs. 20%, p < 0.001), and severe TI associated events (13 vs. 6%, p = 0.003).
  
  
  CONCLUSIONS
  Difficult TI was reported in 9% of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.
authors.affiliation: Department of Pediatrics, Division of Critical Care Medicine, Children's Hospital Central California, 6235 N Fresno St Ste 103 (OS43), Fresno, 93710, CA, USA.
authors.forename: Ana Lia
authors.initials: AL
authors.lastname: Graciano
authors.forename: Robert
authors.initials: R
authors.lastname: Tamburro
authors.forename: Ann E
authors.initials: AE
authors.lastname: Thompson
authors.forename: John
authors.initials: J
authors.lastname: Fiadjoe
authors.forename: Vinay M
authors.initials: VM
authors.lastname: Nadkarni
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
mesh_terms: D001999:Bronchoscopy; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D007828:Laryngoscopy; D008297:Male; D011446:Prospective Studies; D058996:Quality Improvement; D012042:Registries; D012307:Risk Factors; D016896:Treatment Outcome