Nasotracheal intubations in the pediatric intensive care unit (picu): maybe not that risky?

Introduction: Nasotracheal intubation represents the minority of tracheal intubation (TI) in the PICU. The choice of the nasal route is determined by physician’s experience and clinical context. Limited evidence exists for the safety of nasal TI, although the oral route is recommended for rapid sequence intubation. We hypothesize that patients receiving primary nasal TI have higher risk of severe peri-intubation hypoxia (SpO2 < 80%) and/or severe tracheal intubation-associated events (TIAEs) (e.g. cardiac arrest, hypotension, emesis with aspiration), compared to those receiving oral TI. Methods: We evaluated the association between TI route and safety outcomes in a prospectively collected QI database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013-2020. Primary outcome: occurrence of either severe hypoxia (SpO2 < 80%) and/or severe TIAEs. Given unbalanced patient, provider, and practice covariates, we used propensity score (PS) matching of 1:1 without replacement. Our sensitivity analysis included logistic regression. p< 0.05 as significant. Results: 20,991 TI [nasal 894 (3.9%), oral 22,097 (96.1%)] were reported from 60 PICUs. Nasal TIs were more common in infants [6.2% vs 2.3% (1-7 y) vs 1.3% (8-17y),p< 0.001] and in children with cardiac conditions (11.4%). Patients receiving nasal TI were least among those intubated for hypoxia or hemodynamic instability (2.3%, 2.2%) and greatest among those with procedural indication (6.6%), p< 0.001. Nasal TIs were performed more often by attending physicians [35% vs 18%(oral)] than fellows [29% vs 48%(oral)], p< 0.001. Nasal TI utilized less video laryngoscopy [13% vs 32%(oral)] and apneic oxygenation [5% vs 18%(oral)], p< 0.001, than oral. In univariate analysis, nasal TI was associated with higher primary outcome (nasal 24.2% vs oral 22.5%, p=0.254). With PS matching, nasal TI was not associated with primary outcome (nasal 24% vs oral 20% in matched samples, 95% CI of difference: 0 to 7%, p=0.153). The estimate from standard logistic regression for nasal (vs oral) was OR 1.06, 95% CI: 0.896-1.247, p=0.509. Conclusions: Children receiving primary nasal TI do not have higher risk of severe peri-intubation hypoxia and/or severe TIAEs compared to those receiving oral TI, with substantial differences in patient, provider, and practice differences.