Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020).

OBJECTIVES: Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. DESIGN/SETTING: Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. PATIENTS: Critically ill children, 0 to 17 years old, undergoing TI in PICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). CONCLUSIONS: In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

Outcomes in patients who received ECMO and/or volatile anesthetics as rescue therapies for status asthmaticus☠.

BACKGROUND: In the state of Kentucky, many status asthmaticus (SA) patients require care in the Pediatric Intensive Care Unit (PICU) and a fraction of these patients may receive "rescue therapies" with inhaled volatile anesthetics (IVA) and/or Extracorporeal Membrane Oxygenation (ECMO). We present a series of such patients with the objective of comparing the clinical parameters of individual patients who received inhaled volatile anesthesia and subsequently the need for ECMO. METHODS: Children between 2 and 18 years of age admitted to our PICU from January 2014 to July 2020 with SA were reviewed and categorized as 1) patients who received IVA alone, 2) patients who received IVA and then subsequently ECMO, and 3) patients on ECMO alone. RESULTS: A total of 1772 children with SA episodes were identified with a mortality of 13 patients. Seven children with SA were identified who received either IVA, ECMO, or both. One patient received only IVA, 5 received both IVA and ECMO and one received only ECMO. All received standard asthma therapies of steroids, albuterol, magnesium sulphate, and aminophylline prior to escalation. Six out of seven refractory SA received IVA, and five (83%) of those were subsequently escalated to ECMO. There was an improvement in mean pH after cannulation compared to IVA. pCO2 levels had no improvement after IVA administration but decreased by an average of 20 points after ECMO. Patients peak inspiratory pressures decreased within the 1st 24 h of ECMO cannulation from a mean of 30 to 18. There were no other complications related to ECMO placement. CONCLUSION: While we cannot decisively draw any conclusions from our study due to the small sample, it was noted that there was no clear advantage of using IVA prior to ECMO in our patients. Most patients who received IVA were escalated to ECMO indicating that early ECMO cannulation may be beneficial. Given the high cost and potential complications of both, there is a need for the development of well-defined guidelines for severe SA management in the PICU.

Enteral Feeding for Children on Bilevel Positive Pressure Ventilation for Status Asthmaticus.

A retrospective data analysis was conducted to evaluate enteral nutrition practices for children admitted with status asthmaticus in a single-center pediatric intensive care unit. Of 406 charts, 315 were analyzed (63% male); 135 on bilevel positive airway pressure ventilation (BIPAP) and 180 on simple mask. Overall median age and weight were 6.0 (interquartile range [IQR]: 6.0) years and 24.8 (IQR: 20.8) kg, respectively. All children studied were on full feeds while still on BIPAP and simple mask; 99.3 and 100% were fed per oral, respectively. Median time to initiation of feeds and full feeds was longer in the BIPAP group, 11.0 (IQR: 20) and 23.0 hours (IQR: 26), versus simple mask group, 4.3 (IQR: 7) and 12.0 hours (IQR: 15), p = 0.001. The results remained similar after adjusting for gender, weight, clinical asthma score at admission, use of adjunct therapy, and duration of continuous albuterol. By 24 hours, 81.5% of patients on BIPAP and 96.6% on simple mask were started on feeds. Compared with simple mask, patients on BIPAP were sicker with median asthma score at admission of 4 (IQR: 2) versus 3 (IQR: 2) on simple mask, requiring more adjunct therapy (80.0 vs. 43.9%), and a longer median length of therapy of 41.0 (IQR: 41) versus 20.0 hours (IQR: 29), respectively, p = 0.001. There were no complications such as aspiration pneumonia, and none required invasive mechanical ventilation in either group. Enteral nutrition was effectively and safely initiated and continued for children admitted with status asthmaticus, including those on noninvasive bilevel ventilation therapy.