Failure of invasive airway placement and correlated severe complications : dealing with inappropriate training and related medico-legal issues

Acquiring the necessary skills to ensure pulmonary ventilation through hand-operated devices (such as self-inflating and flow-inflating ventilation bags) is the foundation of the appropriate management of respiratory insufficiency among adult and pediatric patients. Failure to ensure airway patency and oxygenation is causative in conditions that may lead to cardiac arrest and patient death and/or adverse neurologic outcomes in cases when adequate oxygenation cannot be established and maintained. Appropriate airway management represents a highly important step in the treatment of the patient in critical care, and the ability to achieve airway control through intubation is the hallmark of the specialist. The maneuver, which is not particularly difficult in itself, requires adequate training if it is to be performed properly and in a timely manner. If the maneuver to ensure airway patency has to be repeated several times either because of incompetence or an impossibility to achieve unobstructed airways speedily, hypoxic and/or anoxic injury may follow because of the failure to maintain oxygenation during the procedure. Intubation, correctly carried out, even if complicated, should not compromise oxygenation and, therefore, the final outcome. The study published by Stinson et al. in this issue of Pediatric Critical Care Medicine is of interest, addressing as it does (not for the first time, but from the standpoint of an analysis of a large caseload) the question of why failure of the first attempt at intubation is attended by such a high frequency of cardiac arrest. Distinct from these results and general considerations, however, is the clear significance this study evinces on the issue of the acquisition of skills through the practical experience of intubation. These problems correlate with potential medicolegal issues of which PICU providers should be aware.