D. Kerrigan, N. Rousseau, M. Lawlor, A. Walsh

CHI Temple Street, Dublin, Ireland

Intubation is a common procedure carried out on critically ill children in Paediatric Intensive Care Units (PICU). Difficult intubation in children has been quantified at 9% in PICU and 0.9% in paediatric Anaesthesia 1,2.  The incidence of difficult intubation has not yet been studied in PICU in Ireland.

1 To quantify difficult intubation in children admitted to PICU

2 To quantify the incidence of adverse events which occur in these cases

3 To identify risk factors for difficult intubation

This was a retrospective chart review of electronic medical records for patients admitted to the PICU of Children’s Health Ireland at Temple St (CHIT), from April 2020-April 2023. Database search terms included; Difficult + airway, Difficult + intubation, Failed + Intubation, Grade 3 + View, Grade 4+ view, Grade 3 + intubation, Grade 4 + intubation, CL +3, CL +4, C&L +3, C&L +4, Multiple + attempts + intubation, Difficult + BMV. Inclusion criteria were a documented history of “difficult intubation” or “difficult airway”, 3 or more attempts at intubation or a C&L view of 3 or 4. Data collected included; age, sex, reason for intubation, weight, location of intubation, co-morbidities, if bag mask ventilation (BMV) was difficult, number of intubation attempts, Cormack & Lehane (C&L) Grade, laryngoscope used, size of endotracheal tube , if a supraglottic airway device or fiberoptic scope was used, desaturation episodes, haemodynamic instability or any other adverse events during intubation and the speciality and grade of the intubating Doctor(s). Data analysis involved descriptive statistics.

809 intubated patients were admitted to PICU during this period.10 cases met inclusion criteria. The difficult airway rate  was 1.24 %. The median weight was 4.6 Kg (2.7-19), median age was 37 months (19 -193) . 70% were Male. 20% of patients had no co-morbidities. 40% had syndromes involving craniofacial abnormalities.  None had difficulty in BMV. The median number of intubation attempts was 4 (2-6). 40% of cases had a C&L grade documented. One C&L 1, one C&L 3, one C&L 4 and one case had more than one grade documented. One case used  a parsons laryngoscope and rigid bronchoscope . In 50% of cases a video laryngoscope was successfully used to intubate. There were no cases in which a child successfully intubated with direct laryngoscopy.20% used an LMA, 20% used a fiberoptic scope. 40% had a desaturation episode and 40% had haemodymanic instability.

The incidence of difficult intubation in this study is lower than previously published in PICU. Children with craniofacial abnormalities were relatively over represented, reflecting the fact that they are known to be more likely to have a difficult airway 3. The high success rate with videolaryngoscopy in paediatric difficulty in this study is consistent with previous studies 4.


1      Graciano AL, Tamburro R, Thompson AE, Fiadjoe J, Nadkarni VM, Nishisaki A. Incidence and associated factors of difficult tracheal intubations in pediatric icus: A report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Medicine. 2014 Aug 27;40(11):1659–69. doi:10.1007/s00134-014-3407-4

  1. Engelhardt T, Virag K, Veyckemans F, Habre W. Airway management in paediatric anaesthesia in Europe—insights from Apricot (anaesthesia practice in children observational trial): A prospective multicentre observational study in 261 hospitals in Europe. British Journal of Anaesthesia. 2018 Jul;121(1):66–75. doi:10.1016/j.bja.2018.04.013
  2. Garcia‐Marcinkiewicz AG, Stricker PA. Craniofacial Surgery and specific airway problems. Pediatric Anesthesia. 2019 Dec 31;30(3):296–303. doi:10.1111/pan.13790
  3. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the pediatric difficult intubation (pedi) registry: A prospective cohort analysis. The Lancet Respiratory Medicine. 2016 Jan;4(1):37–48. doi:10.1016/s2213-2600(15)00508-1
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