Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020)

Pediatr Crit Care Med. 2024 Feb 1;25(2):147-158. doi: 10.1097/PCC.0000000000003387. Epub 2023 Oct 31.


Objectives: Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children.

Design/setting: Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020.

Patients: Critically ill children, 0 to 17 years old, undergoing TI in PICUs.

Interventions: None.

Measurements and main results: Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002).

Conclusions: In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Critical Illness*
  • Humans
  • Hypoxia / epidemiology
  • Hypoxia / etiology
  • Infant
  • Infant, Newborn
  • Intubation, Intratracheal / adverse effects
  • Intubation, Intratracheal / methods
  • Overweight / etiology
  • Pediatric Obesity* / complications
  • Pediatric Obesity* / epidemiology
  • Registries
  • Retrospective Studies
  • Thinness / complications
  • Thinness / epidemiology