Practice Patterns and Performance of Pediatric Air Medical Tracheal Intubation: A National Multisite Cohort Study

OBJECTIVES: Pediatric prehospital advanced airway management is high-stakes and low-frequency. Prior analyses have been limited to single-agency air medical groups or ground emergency medical services cohorts. National air medical performance is not well described. The aim of this study is to characterize practice patterns and outcomes of pediatric air medical intubation across a national multisite cohort. METHODS: This was a retrospective cohort study of pediatric (< 18 years) intubation encounters performed by air medical crews and recorded in ImageTrend Collaborate, a multisite prehospital clinical data repository, from 2021-2025. First-pass success, overall intubation success, and post-attempt physiology defined as a composite of hypoxia, age-adjusted hypotension, and age-adjusted bradycardia within 10 minutes after index attempt were summarized as n(%) or median (IQR) and compared across four age groups (<1, 1-5, 6-10, 11-17 years) using chi-square or Fisher's exact tests. Site-level medication use was summarized among sites contributing 10 or more encounters. RESULTS: Among 1,040 encounters from 39 contributing sites across four United States regions, median age was 13 years (IQR 5-16) and 57.7% involved trauma or burn. A sedative-plus-paralytic strategy was used in 77.8% (809/1,040) with ketamine the most common induction agent (43.5% ketamine-only, 31.9% etomidate-only). Video laryngoscopy was documented in 8.6% of intubations. First-pass success was 86.5% (898/1,038) and overall success was 93.3% (968/1,038). Performance varied significantly by age with first-pass success at 69.1% (47/68) in infants under 1 year versus 88.7% (535/603) in adolescents (p < 0.001), overall success 80.9% (55/68) versus 93.9% (566/603) respectively (p < 0.001), and post-attempt physiologic instability 53.6% (30/56) versus 31.3% (175/560) respectively (p = 0.008). Post-attempt ETCO2 within 10 minutes was documented in 82.8% (861/1,040) overall, and 60.0% (42/70) in infants (p < 0.001). Among the 13 sites with 10 or more encounters, peri-attempt ketamine share ranged from 9% to 84% and succinylcholine share from 0% to 91%. CONCLUSIONS: In this national multisite air medical cohort, overall airway performance was favorable, but infants younger than 1 year had lower first-pass success, lower overall intubation success, and less frequent post-intubation ETCO2 documentation. Substantial practice variation across contributing sites suggests opportunity for both targeted training in the infant subgroup and benchmarking across sites.