title: Ease and difficulty of pre-hospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Anaesthesiology, University Children's Hospital, Zurich, Switzerland.
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Schmidt
authors.affiliation: Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
authors.forename: Lea
authors.initials: L
authors.lastname: Ulrich
authors.affiliation: Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
authors.forename: Burkhardt
authors.initials: B
authors.lastname: Seifert
authors.affiliation: Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland.
authors.forename: Roland
authors.initials: R
authors.lastname: Albrecht
authors.affiliation: Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
authors.forename: Donat R
authors.initials: DR
authors.lastname: Spahn
authors.affiliation: Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. philipp.stein@usz.ch.|Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland. philipp.stein@usz.ch.
authors.forename: Philipp
authors.initials: P
authors.lastname: Stein
mesh_terms: D000293:Adolescent; D017732:Air Ambulances; D058109:Airway Management / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services; D006801:Humans; D007223:Infant; D007442:Intubation, Intratracheal; D012189:Retrospective Studies; D013557:Switzerland