The Pic-Nic Survey

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At Resus at the Harbour 2018 in Sydney we heard from Conor Davis on some of the challenges around paediatric airway management and a few strategies that might lessen the risk of adverse events. Every conference covering acute paediatrics has a talk covering airway management (Ed. note – I think it’s in the contract) and DFTB17 and DFTB18 were no different. But what is the point of all of these leanings if nothing changes?

In this post we are going to take a look at the PIC-NIC survey of paediatric and neonatal intensive care units in the UK.

Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey. Anaesthesia. 2018 Aug 15.

Way back in 2011 the NAP4 report came out. If you haven’t read it, you really should. This National Audit Project looked at the serious complications of airway management in adults. The report recommended that those of us that deal with adult airways should anticipate difficulty, prepare for it, have the equipment to deal with it and have continuous waveform capnography as routine monitoring to help us recognise unanticipated oesophageal intubation amongst other things. Since this report, undetected oesophageal intubation has been declared a ‘Never Event‘ in UK practice and a large number of adult ICUs began to include waveform capnography. Adults are just big children so what are those in paediatric and neonatal practice doing?

The study authors contacted every paediatric (27) and neonatal (143) ICU in the UK and conducted a phone survey between January and October 2016.

Here is a snapshot of the key results. We’ll take a slightly closer look at what they actually mean in a minute.



Difficult airway policy

22% of the PICUs (and 2/3rds of NICUs) would formally mention potential difficult airways at handover. I’d be interested to know what this actually means. My hospitals have hundreds of policies but that does not mean I could tell you what was in each one. For example, most/all of you could tell me that your hospital or department has a policy for what to do in the event of a major incident. But that does not mean that you know what it contains.

I’m also interested in the definition of the term ‘difficult’.  Anaesthetists are pretty bad at determining who has a difficult airway – it’s not the anticipated difficult airways that trip you up after all, but those you do not expect.

It is also important to point out that intubation can also be physiologically challenging, not just anatomically so. Hence the exhortation to resuscitate before you intubate.

Uses an intubation checklist

At Resus at the Harbour 2018 Conor highlighted the combined checklist/kit dump in use at the Royal Children’s Hospital in Melbourne.

There are, of course, many alternatives available just an internet search away.  The mere act of having a checklist out, whether it is followed or not, suggests that at least a cursory look has been cast over potential airway issues.


Has access to a videolaryngoscope

Only 55% of PICUs had access to a videolaryngoscope (VL) of one type on another though in five cases the respondent didn’t know what sort it was. Having said that, a 2017 Cochrane review found that VL took longer than direct view and was associated with an increased number attempts. The heterogeneity of the trials involved means that most evidence was of low or very low quality so this conclusion is open to interpretation.


End tidal CO2 capnography is always available

With shorter airways it is relatively easy for an endotracheal tube to become dislodged during turns and transfers. This leads to a failure to adequately ventilate the patient with potentially disastrous consequences. NAP4 recommended ETCO2 should be routinely used in all intubated and ventilated adults.

Just to remind you of the basics, the capnograph displays the ETCO2 over time with phase 0 being that first part of inspiration. The number we use, the ETCO2, is that at the end of plateau of expiration in phase III. Capnography has been described as the gold standard for the detection of successful tracheal intubation. Whilst you might think that seeing the tube pass through the cords is good enough there have been cases where the tube gets dislodged by the exiting laryngoscope blade.

As well as confirming placement it is also used to confirm maintenance of position of the endotracheal tube. Dislodgement or obstruction of the tube will become apparent very quickly.

A number of reasons that it might be less commonly used in neonates has been suggested including:

Insufficient evidence of effectiveness

Neonates have a high respiratory rate small tidal volume, and thus a shorter inspiratory compared to older children. This leads to a much wider variation in ETCO2.

Potential for continuous capnography to auto-trigger the ventilator

Weight of the ETCO2 module

Concern has been raised that the addition of a small piece of plastic and attendant tubing may just be enough to pull the endotracheal tube out. This may be of concern with mainstream modules that contain the infrared detector within the unit that is attached to the endotracheal tube. It is much less of an issue with sidestream devices that aspirate a small amount of expired air and analyse it within a central device.

Capnography leads to increased dead space

This is issue is of minimal concern with newer sidestream analysers.

So where does this leave us? Looking at the UK data it seems that there is much room for improvement. It would be interesting to see this study repeated elsewhere (Ed. note: Happy to help anyone that wants to take a look at Australasian data). Of course, with any audit project collecting these data is only the first step and, as GI Joe would say, “Knowing is half the battle“. It would be useful to repeat the audit after of years to see what has changed, what has not changed and why.

After the audit was published it hit the more mainstream medical press including the Nursing Times. What’s your experience? Let us know in the comments section below.

Selected references

Abdelgadir IS, Phillips RS, Singh D, Moncreiff MP, Lumsden JL. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates). Cochrane Database of Systematic Reviews. 2017(5).

Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. BJA: British Journal of Anaesthesia. 2016 Jul 20;117(2):182-90.

Eipe N, Doherty DR. A review of pediatric capnography. Journal of clinical monitoring and computing. 2010 Aug 1;24(4):261-8.

Jaffe MB. Infrared measurement of carbon dioxide in the human breath:“breathe-through” devices from Tyndall to the present day. Anesthesia & Analgesia. 2008 Sep 1;107(3):890-904.

Kelly RB, FitzGerald M, Schwartz HP, Bigham MT, Trautman M. The Use of Waveform Capnography During Neonatal and Pediatric Transport.

Kerslake I, Kelly F. Uses of capnography in the critical care unit. BJA Education. 2017 May 1;17(5):178-83.

Kirpalani H, Kechagias S, Lerman J. Technical and clinical aspects of capnography in neonates. Journal of medical engineering & technology. 1991 Jan 1;15(4-5):154-61.

Kugelman A, Golan A, Riskin A, Shoris I, Ronen M, Qumqam N, Bader D, Bromiker R. Impact of continuous capnography in ventilated neonates: a randomized, multicenter study. The Journal of pediatrics. 2016 Jan 1;168:56-61.

Molloy EJ, Deakins K. Are carbon dioxide detectors useful in neonates?. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2006 Jul 1;91(4):F295-8.

Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015 Mar;70(3):272-81.

Riley CM. Continuous capnography in pediatric intensive care. Critical Care Nursing Clinics. 2017 Jun 1;29(2):251-8.

Rozycki HJ, Sysyn GD, Marshall MK, Malloy R, Wiswell TE. Mainstream end-tidal carbon dioxide monitoring in the neonatal intensive care unit. Pediatrics. 1998 Apr 1;101(4):648-53.

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An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew's DFTB posts

Author: Andrew Tagg An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children. @andrewjtagg | + Andrew Tagg | Andrew's DFTB posts