Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events

Crit Care Med. 2020 Sep;48(9):e744-e752. doi: 10.1097/CCM.0000000000004425.


Objectives: Bag-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.

Design: A 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.

Setting: Forty-six international PICUs.

Patients: Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.

Interventions: None.

Measurements and main results: The 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).

Conclusions: Difficult 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.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adolescent, Hospitalized
  • Age Factors
  • Child
  • Child, Hospitalized
  • Child, Preschool
  • Critical Illness*
  • Female
  • Humans
  • Infant
  • Intensive Care Units, Pediatric / statistics & numerical data*
  • Intubation, Intratracheal / adverse effects
  • Male
  • Oxygen / blood
  • Respiration, Artificial / adverse effects*
  • Respiration, Artificial / methods*
  • Retrospective Studies
  • Risk Factors
  • Young Adult


  • Oxygen