• Curran Hunter Daigle, John E Fiadjoe, Elizabeth K Laverriere, Benjamin B Bruins, Justin L Lockman, Justine Shults, Conrad Krawiec, Ilana Harwayne-Gidansky, Christopher Page-Goertz, Jamie Furlong-Dillard, Vinay M Nadkarni, Akira Nishisaki, and National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI).
• Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
• Crit. Care Med. 2020 Sep 1; 48 (9): e744-e752.

ObjectivesBag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.DesignA retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.SettingForty-six international PICUs.PatientsChildren receiving bag-mask ventilation as a part of tracheal intubation in a PICU.InterventionsNone.Measurements And Main ResultsThe primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).ConclusionsDifficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.

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