Intensive Care Medicine

, Volume 40, Issue 11, pp 1659–1669 | Cite as

Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS

  • Ana Lia Graciano
  • Robert Tamburro
  • Ann E. Thompson
  • John Fiadjoe
  • Vinay M. Nadkarni
  • Akira NishisakiEmail author
Pediatric Original



To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs).


Using the National Emergency Airway Registry for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers.


A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97 % of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9 %. In univariate analysis, patients with difficult TI were younger [median 1 year (0–4) vs. 2 (0–8) years, p = 0.046], and had a reported history of difficult TI (22 vs. 8 %, p < 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58 %, p < 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80 % (48 vs. 15 %, p < 0.001), adverse TI associated events (53 vs. 20 %, p < 0.001), and severe TI associated events (13 vs. 6 %, p = 0.003).


Difficult TI was reported in 9 % of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.


Tracheal intubation Difficult airway Child Pediatric intensive care unit 



We acknowledge Jessica Leffelman for her tireless work as a multicenter coordinator. We also acknowledge Stephanie Tuttle, MBA for her administrative support. We thank Dr. Shults (University of Pennsylvania) for providing guidance for statistical analysis. Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia; Unrestricted funds from the Laerdal Foundation Acute Care Medicine; Agency for Healthcare Research and Quality grant: 1R03HS021583-01.

Conflicts of interest


Supplementary material

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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2014

Authors and Affiliations

  • Ana Lia Graciano
    • 1
  • Robert Tamburro
    • 2
  • Ann E. Thompson
    • 3
  • John Fiadjoe
    • 4
  • Vinay M. Nadkarni
    • 4
  • Akira Nishisaki
    • 4
    Email author
  1. 1.Department of Pediatrics, Division of Critical Care MedicineChildren’s Hospital Central CaliforniaFresnoUSA
  2. 2.Department of Pediatrics, Division of Critical Care MedicinePenn State Hershey Children’s Hospital, Pennsylvania State University College of MedicineHersheyUSA
  3. 3.Department of Anesthesia and Critical CareUniversity of PittsburghPittsburghUSA
  4. 4.Department of Anesthesiology and Critical Care MedicineThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA

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