Authors: Stein ML et al.
eClinicalMedicine, Volume 69
Summary
This propensity score–matched analysis from the Paediatric Difficult Intubation Registry evaluated whether longitudinal quality improvement initiatives were associated with improved airway management outcomes in children with difficult tracheal intubations. The study compared an early cohort enrolled between 2012 and 2015 (785 patients across 13 centers) with a contemporary cohort enrolled between 2017 and 2023 (3,925 patients across 43 centers). Children under 18 years of age with difficult direct laryngoscopy were included based on predefined registry criteria. A 5:1 propensity score match was used to account for differences between cohorts. The primary outcome was first-attempt intubation success, with secondary outcomes including total number of attempts, use and persistence of direct laryngoscopy, complications, and severe complications.
First-attempt intubation success was significantly higher in the contemporary cohort compared with the early cohort. Children in the current cohort required fewer total intubation attempts and had fewer attempts using direct laryngoscopy. Persistence with direct laryngoscopy beyond two attempts was substantially reduced over time. While the overall rate of complications remained similar between cohorts, severe complications were significantly lower in the current cohort, including a notable reduction in cardiac arrest events.
The analysis identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. The observed improvements over time coincided with registry-driven efforts to reduce repeated attempts and encourage earlier transition to advanced airway techniques, suggesting that these practice changes may have contributed to improved safety in pediatric difficult airway management.
Key Points
• First-attempt intubation success improved significantly over time in children with difficult airways.
• Total intubation attempts and direct laryngoscopy attempts decreased in the contemporary cohort.
• Persistence with direct laryngoscopy beyond two attempts was reduced by nearly half.
• Severe complications, including cardiac arrest, declined substantially over time.
What You Should Know
This large registry-based analysis demonstrates that systematic efforts to limit repeated direct laryngoscopy attempts and promote early use of advanced airway techniques can meaningfully improve outcomes in pediatric difficult intubations. Persistence with direct laryngoscopy remains a key modifiable risk factor for severe complications and represents an important target for ongoing airway safety initiatives.
Thank you for allowing us to highlight this important contribution published in eClinicalMedicine.