title: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.
abstract: BACKGROUND
  Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications.
  
  
  METHODS
  The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe.
  
  
  RESULTS
  Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication.
  
  
  CONCLUSIONS
  More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety.
  
  
  BACKGROUND
  None.
authors.affiliation: Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA. Electronic address: FIADJOEJ@email.chop.edu.
authors.forename: John Edem
authors.initials: JE
authors.lastname: Fiadjoe
authors.affiliation: Children's Hospital of Philadelphia, Philadelphia, PA, USA.
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
authors.affiliation: Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Illinois, IL, USA.
authors.forename: Narasimhan
authors.initials: N
authors.lastname: Jagannathan
authors.affiliation: Seattle Children's Hospital, Seattle, WA, USA; University of Washington Medical School, Seattle, WA, USA.
authors.forename: Agnes I
authors.initials: AI
authors.lastname: Hunyady
authors.affiliation: The Johns Hopkins Medical Insitutions, Baltimore, MD, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Greenberg
authors.affiliation: University of Michigan Medical School, Michigan, MI, USA.
authors.forename: Paul I
authors.initials: PI
authors.lastname: Reynolds
authors.affiliation: University of Texas Health Science Center Houston, Texas, TX, USA; Children's Memorial Herman Hospital, Houston, TX, USA.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Matuszczak
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA.
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Rehman
authors.affiliation: The Children's Hospital Denver, Denver, CO, USA; University of Colorado School of Medicine, Denver, CO, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Polaner
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX, USA; Dallas and Children's Medical Center at Dallas and Outcome Research Consortium, Cleveland, OH, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Szmuk
authors.affiliation: Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA.
authors.forename: Vinay M
authors.initials: VM
authors.lastname: Nadkarni
authors.affiliation: Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA.
authors.forename: Francis X
authors.initials: FX
authors.lastname: McGowan
authors.affiliation: Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA.
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Litman
authors.affiliation: Children's Hospital Boston, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
authors.forename: Pete G
authors.initials: PG
authors.lastname: Kovatsis
mesh_terms: D000293:Adolescent; D058109:Airway Management; D001999:Bronchoscopy; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology*; D006801:Humans; D000860:Hypoxia / Q000453:epidemiology*; D015994:Incidence; D007223:Infant; D007442:Intubation, Intratracheal; D007828:Laryngoscopy; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D014132:Trachea / Q000293:injuries; D014481:United States / Q000453:epidemiology; D020535:Video-Assisted Surgery