Survey highlights variations in practice of airway management in pediatric intensive care units

Recommendations to implement standardized monitoring of breathing in intensive care units have not been put into practice consistently following a 2011 landmark study

A new survey published today, Thursday 16 August 2018, in the journal Anesthesia, highlights that variations in the practice of airway management in intensive care units across the UK are putting children and particularly newborn babies at risk. The PIC-NIC survey, led by doctors at the Royal United Hospitals Bath NHS Foundation Trust, found that lessons from a landmark study in 2011 have not been put into practice in all pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Most respondents (98% of NICUs and 75% of PICUs) reported that they were unaware of the study (titled the 4th National Audit Project or NAP4).

Professor Tim Cook, Consultant in Anesthesia and Intensive Care Medicine at the Royal United Hospital Bath NHS Foundation Trust, and co-author

The NAP4 study, by the Royal College of Anesthetists (RCoA) and the Difficult Airway Society (DAS), studied major complications of airway management (establishing and maintaining a patient on a ventilator). It found that the absence of a simple method of monitoring breathing, called capnography, contributed to 74% of deaths from these events. The NAP4 authors recommended universal use of capnography in intensive care units together with changes in policy, equipment provision and training to improve airway safety. These recommendations have been largely adopted in adult intensive care units in the UK.

Key findings from the PIC-NIC survey team, who interviewed staff from all of the UK's PICUs and 90% of the NICUs, include:

• The recommendations from NAP4 have not been widely implemented in NICUs. Despite capnography now being used in almost 100% of adult ICUs, as a direct result of the 2011 study, only 47% of NICUs have capnography available and it is rarely used.

• Some of the recommendations from NAP4 have been implemented in PICUs but not all. For example, 78% of PICUs and 34% NICUs do not formally identify patients with a difficult airway at staff handover. This is reflected by the relatively low number of units (40% of NICUs and 67% of PICUs) with protocols for high risk patients in place compared to 90% of adult ICUs.

• Of the 129 NICUs and 27 PICUs who responded to the survey, 34 of the NICUs and 5 of the PICUs reported death or serious harm in their unit as a result of complications of airway management in the last five years.

Speaking about the PIC-NIC survey findings, Dr Fiona Kelly, a consultant in Anesthesia and Intensive Care Medicine at the Royal United Hospitals Bath NHS Foundation Trust, and one of the report authors, said:

The findings of this survey indicate that the NAP4 recommendations have been adopted into routine practice by many paediatric intensive care units, but into only a small number of neonatal intensive care units. There are many differences between adult, paediatric and especially neonatal practice but monitoring the breathing of a patient who is dependent on a ventilator is fundamental to safe practice in any ICU. Capnography, which detects exhaled carbon dioxide breath by breath, is a simple tool and can detect misplaced tubes or disconnections from a ventilator. It is of concern that this technology is only used in a few NICUs. This variation in practice, which is potentially putting lives at risk, merits further investigation."

Prof Tim Cook, a Consultant in Anesthesia and Intensive Care Medicine at the Royal United Hospital Bath NHS Foundation Trust, and another report author, said:

We recommend that lessons from adult ICUs are shared widely with our NICU and PICU colleagues and hope that this survey will prompt discussion about the feasibility of routine capnography monitoring. In particular we hope that the NICUs where capnography is already being used can share best practice with other colleagues to help implement this important technology more widely. In the case of low weight neonates, more research is needed to establish the utility of capnography and improve reliability of care. The current situation of half of UK NICUs using capnography and it not being available in the other half needs addressing."

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