key: cord-0918101-syv8kff1 authors: Peterson, M. B.; Gurnaney, H. G.; Disma, N.; Matava, C.; Jagannathan, N.; Stein, M. L.; Liu, H.; Kovatsis, P. G.; von Ungern‐Sternberg, B. S.; Fiadjoe, J. E.; Arnold, P.; Schindler, E.; Garcia‐Marcinkiewicz, A.; Peyton, J.; Park, R.; Sommerfield, A.; Sommerfield, D.; Griffis, H.; Hu, P.; Caccioppola, A.; Dato, A.; Fernandez, A.; Ortiz, A.; Sheik, A.; Sommerfield, A.; Tutuncu, A.; Gily, B.; Kueppers, B.; Taicher, B.; Dietrich, C.; Gooden, C.; Miller, C.; Neder Neto, C.; Neumann, C.; Ulrichs, C.; Altun Bingöl, D.; Barnes, D.; Cumino, D.; Özcengiz, D.; Pachter, D.; Sommerfield, D.; Wong, D.; Bayliss, E.; Ferrari, E.; Greenwood, E.; Kiss, E.; Ng, E.; Schindler, E.; Izzo, F.; Russo, F.; Chow, G.; Martinez‐Mezo, G.; Petroz, G.; Schälte, G.; Soares de Sousa, G.; Thomas, G.; Wong, G.; Barros, H.; Gill, H.; Lewis, H.; Manley, H.; Pągowska‐Klimek, I.; Major, J.; Zhong, J.; Jonckheer, K.; Rubin, K.; Saracoglu, K.; Bernard, L.; Burgoyne, L.; Sarmiento, L.; Vidaurri, L.; Zamora, L.; Arellano‐Pulido, M.; Brooks Peterson, M.; Clement, M.; Fernández‐Jurado, M.; Hartley, M.; Johansen, M.; Lima, M.; Malavazzi, M.; Matuszczak, M.; Molina Torres, M.; Nemeth, M.; Rodgers McCormick, M.; Stein, M.; Teen, M.; Theroux, M.; Vason, M.; Disma, N.; Hauser, N.; Leister, N.; Singh, N.; Straßberger‐Nerschbach, N.; Thompson, N.; Woodman, N.; Cardoso, P.; Hu, P.; Ingelmo, P.; Kendigelen, P.; Kovatsis, P.; Lane, P.; Olomu, P.; Reynolds, P.; Abujeta Soria, R.; Arellano‐Pulido, R.; Arumainathan, R.; Bonfiglio, R.; Carlos, R.; King, R.; McIntyre, R.; Sant Anna, R.; Abubakra, S.; Bhattacharya, S.; Black, S.; Ferrario, S.; Finamore, S.; Ghamari, S.; Humphreys, S.; Neri, S.; Shaik, S.; Spall, S.; Yücetepe, S.; Ellimah, T.; Engelhardt, T.; Trieschmann, U.; Quintao, V.; Ames, W.; Hatipoglu, Z.; Ustalar Ozgen, Z. title: Complications associated with paediatric airway management during the COVID‐19 pandemic: an international, multicentre, observational study date: 2022-03-23 journal: Anaesthesia DOI: 10.1111/anae.15716 sha: 19fa71d6756ed2bab5d57143a4978e94b6b2b782 doc_id: 918101 cord_uid: syv8kff1 Respiratory adverse events in adults with COVID‐19 undergoing general anaesthesia can be life‐threatening. However, there remains a knowledge gap about respiratory adverse events in children with COVID‐19. We created an international observational registry to collect airway management outcomes in children with COVID‐19 who were having a general anaesthetic. We hypothesised that children with confirmed or suspected COVID‐19 would experience more hypoxaemia and complications than those without. Between 3 April 2020 and 1 November 2020, 78 international centres participated. In phase 1, centres collected outcomes on all children (age ≤ 18 y) having a general anaesthetic for 2 consecutive weeks. In phase 2, centres recorded outcomes for children with test‐confirmed or suspected COVID‐19 (based on symptoms) having a general anaesthetic. We did not study children whose tracheas were already intubated. The primary outcome was the incidence of hypoxaemia during airway management. Secondary outcomes included: incidence of other complications; and first‐pass success rate for tracheal intubation. In total, 7896 children were analysed (7567 COVID‐19 negative and 329 confirmed or presumed COVID‐19 positive). The incidence of hypoxaemia during airway management was greater in children who were COVID‐19 positive (24 out of 329 (7%) vs. 214 out of 7567 (3%); OR 2.70 (95%CI 1.70–4.10)). Children who had symptoms of COVID‐19 had a higher incidence of hypoxaemia compared with those who were asymptomatic (9 out of 51 (19%) vs. 14 out of 258 (5%), respectively; OR 3.7 (95%CI 1.5–9.1)). Children with confirmed or presumed COVID‐19 have an increased risk of hypoxaemia during airway management in conjunction with general anaesthesia. The COVID-19 pandemic caused by the SARS-CoV-2 virus has transformed healthcare and anaesthetic practice globally. However, early in the pandemic, children were thought to be unaffected by the SARS-COV-2 virus and few studies focused on children [1, 2] . Given the paucity of paediatric data, clinicians have relied on expert opinion to guide airway management. A review of children with COVID-19 who had a general anaesthetic reported one peri-operative death in nine symptomatic cases [3] . Studies have reported anaesthesiarelated complications in adults with COVID-19 [3] [4] [5] . One such study found that pulmonary complications occurred in 50% of adults having a general anaesthetic and identified male sex, age ≥ 70 y, ASA physical status ≥3 and emergency/major surgery as risk-factors for complications [5] . Children with COVID-19 may have more airway-related complications due to the pulmonary effects of the illness or the use of novel personal protective equipment (PPE) such as barriers during airway management [6] . On the other hand, the mild symptoms experienced by many children may mean that general anaesthesia might not be associated with more adverse events. During the early stage of the pandemic, anecdotal data suggested barriers such as plastic drapes or boxes could protect clinicians from droplets containing SARS-CoV-2 [7] [8] [9] . Recent literature has challenged the efficacy of this practice; however, there are few data about the impact of using barriers on outcomes in children. Videolaryngoscopy is recommended in people with COVID-19 to increase the distance from the patient's airway to the clinician ('mouth-to-mouth' distance) [10, 11] and probability of successful tracheal intubation on the first attempt [12] . The Pediatric Difficult Intubation Collaborative is an international multicentre group that focuses on research, quality improvement and difficult airway management education. Members of the collaborative created the Pediatric AirWay complicationS during COVID-19 (PAWS- registry to capture data about anaesthesiarelated airway management of children during the COVID-19 pandemic [13] . The collaborative aimed to determine whether children with confirmed or suspected COVID-19 having a general anaesthetic had a higher incidence of complications such as hypoxaemia during airway management. Our primary aim was to compare the incidence of hypoxaemia in children with proven or suspected COVID-19 (COVID-19 group) with those who were COVID-19 negative. This was defined as mild (oxygen saturation (S p O 2 ) < 90% or 10% decrease from baseline), moderate (S p O 2 < 80% or 20% decrease from baseline) or severe (S p O 2 < 50% or 50% decrease from baseline). Secondary outcomes included: incidence of airway management complications; firstattempt success rate of tracheal intubation; and incidence of failed tracheal intubation. In addition, we aimed to describe the airway devices, induction techniques used, determine risk-factors associated with complications and the impact of having COVID-19 symptoms (dyspnoea, headache, sore throat, cough, myalgia, fever, anosmia and/ or diarrhoea) on outcome. We analysed non-normally distributed variables using Wilcoxon rank-sum tests and the incidence of hypoxaemia and other complications using Chi-square and Fisher's exact tests. Based on a previous study [12] , we assumed that the incidence of hypoxaemia during tracheal intubation for children without COVID-19 was 3% (SD 3). We estimated the incidence of hypoxaemia in children with COVID-19 to be 33% higher, that is, an incidence of 4%. Using a t-test for two independent groups and assuming equal variance in the incidence of hypoxaemia during airway management for both groups, a sample size of 191 participants per group (382 total) was required (a = 0.05, b = 0.90). We performed a post-hoc sub-group analysis of patients who underwent tracheal intubation in conjunction with a protective barrier. We compared complications by barrier use at tracheal intubation and extubation using Chi-square and Fisher's exact tests. Where applicable, multiple comparisons were performed for outcomes and complications, and we adjusted p-values for false discovery rate correction. All analyses were conducted in SAS (version 9.4; SAS Institute, Cary, NC, USA). Table 4 ). The difference between the two groups was most notable for mild and moderate hypoxaemia during airway device removal. A post-hoc sub-group analysis of children whose tracheas were intubated showed that the risk of hypoxaemia at extubation was significantly higher in the COVID-19 group (19 out of 232 (8%) vs. 162 out of 4241 (4%), OR 2.25 (95%CI 1.33-3.59); Table 4 ). The occurrence of any complication was more common in the COVID-19 group (39 out of 329 (12%) vs. 463 out of 7567 (6%), OR 2.06 (95%CI 1.44-2.88); Table 5 ). The complications which occurred are detailed in Table 6 . p < 0.001), with the most common barrier being a plastic drape over the child or a transparent shield (Table 3) . Clinicians used a barrier more often at tracheal extubation for children in the COVID-19 group (100 out of 329 (30%) vs. 418 out of 7567 (6%); p < 0.001). The most common barriers used during extubation of the trachea were a plastic drape over the child or a transparent shield, alone or in combination ( Table 3 ). The use of a barrier during tracheal Our prospective, international, multicentre observational study showed that children with COVID-19 had a higher incidence of hypoxaemia and overall complications during airway management for general anaesthesia. Children with COVID-19 were 2.7 times more likely to [14] . Mild hypoxaemia: oxygen saturation < 90% (or 10% decline from baseline); moderate hypoxaemia: oxygen saturation < 80% (or 20% decline from baseline); severe hypoxaemia: oxygen saturation < 50% (or 50% decline from baseline). SAD, supraglottic airway device. There are limitations to our study. First, although we analysed close to 8000 anaesthetics, we had only a small number of COVID-19 cases (4.4%), limiting our ability to detect differences in outcomes. In addition, the low rate of adverse events prevented us from analysing risk factors associated with complications, one of our a priori goals. Finally, as we wanted to collect data quickly, we collected anonymised data and did not collect personal health information. We, therefore, could not assess patient outcomes beyond the immediate peri-operative period. Additionally, under-reporting of complications and adverse events is likely in this type of self-reporting registry. There were more emergency cases in the COVID-19 group, potentially confounding our results; however, the ASA physical status was similar in the two groups. In summary, our study found that children with COVID-19 have a greater incidence of mild hypoxaemia and more complications during airway management than children without the disease; however, these were not lifethreatening adverse events. Incidence of COVID-19 in pediatric surgical patients among 3 US Children's hospitals Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention Unique challenges in pediatric anesthesia created by COVID-19 The plural of anecdote is not data, please mind the gap between virtual and real life Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study Aerosol barriers in pediatric anesthesiology: clinical data supports FDA caution Adaptation to the plastic barrier sheet to facilitate intubation during the COVID-19 pandemic Enhanced draping for airway procedures during the COVID-19 pandemic Aerosol boxes and barrier enclosures for airway management in COVID-19 patients: a scoping review and narrative synthesis Videolaryngoscopy increases 'mouth-to-mouth' distance compared with direct laryngoscopy The role of videolaryngoscopy in airway management of COVID-19 patients Firstattempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial response Anesthetic complications associated with severe acute respiratory syndrome coronavirus 2 in pediatric patients Quantitative evaluation of aerosol generation during manual facemask ventilation Barrier system for airway management of COVID-19 patients What's inside the box? Or shall we think outside the box? Pediatric Anesthesia 2020 Use of a high-flow extractor to reduce aerosol exposure in tracheal intubation A quantitative evaluation of aerosol generation during tracheal intubation and extubation A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal Risk of hypoxemia by induction technique among infants and neonates undergoing pyloromyotomy Additional supporting information may be found online via the journal website.Appendix S1. List of study collaborators.