Authors: Garcia-Marcinkiewicz AG et al.
Anesthesia & Analgesia 131(2):469–479, August 2020
Summary
This retrospective analysis from the Pediatric Difficult Intubation (PeDI) Registry evaluated the association between ventilation technique, use of neuromuscular blocking drugs (NMBDs), and peri-intubation complications in children with anticipated difficult airways. Data were analyzed from 1,289 difficult intubations recorded between 2012 and 2016 across 16 children’s hospitals. Ventilation strategies were categorized as spontaneous ventilation, controlled ventilation with NMBD administration, or controlled ventilation without NMBDs. The analysis used generalized estimating equations to account for clustering by site, followed by propensity score matching to balance baseline characteristics among groups.
Spontaneous ventilation was used in 39% of cases, controlled ventilation with NMBDs in 35%, and controlled ventilation without NMBDs in 26%. Overall complications occurred in 18.8% of patients, with the majority classified as nonsevere; severe complications were uncommon. Nonsevere complications were significantly more frequent in the spontaneous ventilation group compared with either controlled ventilation approach. After propensity score matching, spontaneous ventilation remained associated with significantly higher odds of complications than controlled ventilation strategies.
The most common nonsevere complications included hypoxemia and laryngospasm. The authors suggest that inadequate anesthetic depth during spontaneous ventilation may contribute to increased airway reactivity and subsequent complications. These findings challenge the assumption that maintaining spontaneous ventilation is inherently safer during pediatric difficult airway management.
Key Points
• Spontaneous ventilation was associated with higher rates of nonsevere complications during difficult pediatric intubation.
• Controlled ventilation, particularly with NMBD use, was associated with fewer complications.
• Severe complications were rare across all ventilation strategies.
• Inadequate anesthetic depth during spontaneous ventilation may increase airway reactivity and complications.
What You Should Know
In children with anticipated difficult airways, spontaneous ventilation during intubation may increase the risk of nonsevere airway complications compared with controlled ventilation techniques. Thoughtful use of controlled ventilation and adequate anesthetic depth, including NMBDs when appropriate, may improve safety during pediatric difficult airway management.
Thank you for allowing us to highlight this important study published in Anesthesia & Analgesia.