Ducharme-Crevier Laurence, Furlong-Dillard Jamie, Jung Philipp, Chiusolo Fabrizio, Malone Matthew P, Ambati Shashikanth, Parsons Simon J, Krawiec Conrad, Al-Subu Awni, Polikoff Lee A, Napolitano Natalie, Tarquinio Keiko M, Shenoi Asha, Talukdar Andrea, Mallory Palen P, Giuliano John S, Breuer Ryan K, Kierys Krista, Kelly Serena P, Motomura Makoto, Sanders Ron C, Freeman Ashley, Nagai Yuki, Glater-Welt Lily B, Wilson Joseph, Loi Mervin, Adu-Darko Michelle, Shults Justine, Nadkarni Vinay, Emeriaud Guillaume, Nishisaki Akira
Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada.
Department of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, KY USA.
Intensive Care Med Paediatr Neonatal. 2024;2(1):7. doi: 10.1007/s44253-024-00035-4. Epub 2024 Feb 23.
Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted.
We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI.
A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, = 0.759).
In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.
在儿科重症监护病房（PICU）中，鼻气管插管（TI）占所有气管插管的比例较小。鼻气管插管的风险和益处尚未得到充分量化。因此，有必要获取关于这种操作的安全性和描述性数据。
我们在一个前瞻性收集的质量改进数据库（儿童国家紧急气道注册中心：NEAR4KIDS）中评估了2013年至2020年期间气管插管途径与安全结局之间的关联。主要结局是使用NEAR4KIDS的定义，即严重低氧血症（SpO₂较基线下降>20%）和/或严重的气管插管相关不良事件（TIAEs）。为了平衡患者、医护人员和操作协变量，我们使用倾向评分（PS）匹配来比较鼻气管插管与口气管插管的结局。
60个PICU共报告了22,741例气管插管[鼻插管870例（3.8%），口插管21,871例（96.2%）]。鼻气管插管组中婴儿的比例高于口气管插管组（75.9%对46.2%），患有心脏疾病的儿童比例也更高（46.9%对14.4%），两者均P<0.001。严重低氧血症或严重TIAE发生在23.7%的鼻气管插管和22.5%的口气管插管中（未调整P=0.408）。通过PS匹配，严重低氧血症和/或严重不良TIAEs的发生率在鼻气管插管组为23.6%，口气管插管组为19.8%（绝对差异3.8%，95%置信区间（CI）：-0.07，7.7%），P=0.055。首次尝试成功率在鼻气管插管组为72.1%，口气管插管组为69.2%，P=0.072。通过PS匹配，两组成功率无差异（鼻插管72.2%对口插管71.5%，P=0.759）。
在这项大型国际前瞻性队列研究中，围插管期严重并发症的风险并没有显著更高。鼻气管插管在PICU的气管插管中占少数，与口气管插管相比，在患者、医护人员和操作方面存在显著差异。可能有必要进行一项前瞻性多中心试验，以解决潜在的选择偏倚并确认鼻气管插管的安全性。
