Harms Associated with Tracheal Reintubation After Unplanned Extubation: A Retrospective Cohort Study

Objective This study evaluates the clinical harm associated with tracheal intubation (TI) after unplanned extubation (UE) in the pediatric intensive care unit (ICU). We hypothesized that TI after UE is associated with a higher risk of adverse airway outcomes (AAOs), including peri-intubation hypoxia. Methods A total of 23,320 TIs from 59 ICUs in patients aged 0 to 17 years from 2014 to 2020 from the National Emergency Airway Registry for Children (NEAR4KIDS) database were evaluated. AAO was defined as any adverse TI-associated event and/or peri-intubation hypoxia (SpO2 < 80%). UE trends were assessed over time. A multivariable logistic regression model was developed to evaluate the association between UE and AAO, while controlling for patient, provider, and practice confounders. Results UE was reported as TI indication in 373 (1.6%) patients, with the proportion increasing over time: 0.1% in 2014 to 2.8% in 2020 (p < 0.001). TIs after UE versus TIs without preceding UE were more common in infants (62 vs. 48%, p < 0.001), males (63 vs. 56%, p = 0.003), and children with a history of difficult airway (17 vs. 13%, p = 0.03). After controlling for potential confounders, TI after UE was not significantly associated with AAO (adjusted odds ratio [aOR]: 1.26, 95% confidence interval [CI]: 0.99–1.62, p = 0.06). However, TI after UE was significantly associated with peri-intubation hypoxia (aOR: 1.35, 95% CI: 1.02–1.79, p = 0.03). Conclusions UE is increasing as an indication for TI, and is more common in infants and children with a history of difficult airway. As TI after UE was associated with increased peri-intubation hypoxia, future study should focus on identifying causality and mitigating peri-intubation risk.