David Tellez, MD, FCCM
MD
Phoenix Children's Hospital, United States
Disclosure information not submitted.
Natalie Napolitano, MPH, MPH, RRT-NPS (she/her/hers)
Research Clinical Specialist
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Lauren Edwards, MD
MD
Arkansas Children's Hospital, Arkansas, United States
Disclosure information not submitted.
Ronald Sanders, MD, MS, FCCM
Professor of Pediatrics
Arkansas Childrens Hospital, United States
Disclosure information not submitted.
Taiki Kojima, MD
MD
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Justine Shults, PhD
Professor of Biostatistics
Perelman School of Medicine, United States
Disclosure information not submitted.
.jpg "Vinay Nadkarni, MD, MS, FCCM (he/him/his) photo")
Vinay Nadkarni, MD, MS, FCCM (he/him/his)
Professor, Anesthesiology, Critical Care and Pediatrics
University of Pennsylvania Perelman School of Medicine, CHOP
Media, Pennsylvania, United States
Disclosure information not submitted.
Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Severe Peri-Intubation Hypoxemia is More Common in Critically Ill Underweight and Obese Children
Introduction: Extremes of BMI have been associated with difficult intubations in adults. The goal of this study was to determine the relationship of underweight status and obesity with adverse tracheal intubation associated events (TIAEs) and severe peri-intubation hypoxemia (SpO2< 80%).
Method: The NEAR4KIDS database was queried from 2013-2020 for ICU tracheal intubations (TIs) in patients 0-17 years. Patients were categorized as underweight (< 5%ile), normal (5-85%ile), overweight (85-95%ile) and obese (≥95%ile) using age and weight. Primary composite outcome was TIAEs and peri-intubation hypoxemia (SpO2< 80%). Multivariable regression with generalized estimating equation was used to account for confounders and clustering by site. Difficult bag-mask ventilation (BMV) was added as a potential mediator.
Results: A total of 24,349 TIs from 60 ICUs were identified: underweight 27.5%, normal 57.1%, overweight 7.2%, obese 8.2%. Underweight was most common in infants (34%); obesity was most common in children≥8yr (15.1%), p< 0.001. Underweight patients had more oxygenation and ventilation failure as TI indication as well as a history of more difficult airways, p< 0.001. Apneic oxygenation was used more often in overweight and obese patients (19%, 20%) than underweight or normal (14%, 17%), p< 0.001. TIAE/hypoxemia occurred more often in underweight patients at 27%, normal 24%, overweight 24%, obesity 24% (p< 0.001.) Underweight, but not obesity, was significantly associated with TIAE/hypoxemia after adjusting for age, sex, cyanotic heart disease, indication, difficult airway features, apneic oxygenation, device, and site clustering: underweight aOR 1.09, 95% CI 1.02-1.17, p=0.016, obesity aOR 1.11, 95% CI 0.97-1.27, p=0.12. Both underweight and obesity was independently associated with hypoxemia after adjusting for confounders and site clustering: underweight aOR 1.11, 95% CI 1.03-1.21 (p=0.01), obesity aOR 1.22 95% CI 1.08-1.39 (p=0.002). Adding difficult BMV as a mediator did not alter the association between obesity and hypoxemia (aOR 1.17), implying difficult BMV is not in causal pathway.
Conclusions: Tracheal intubation in underweight and obese children is associated with severe peri-intubation hypoxemia, but only underweight was associated with the outcome of adverse TIAEs and severe hypoxemia.