A consultation service to plan management of pediatric patients with difficult airways before problems arise is an effective use of resources, according to a recent study.
The study described findings from the Pediatric Difficult Airway Program, implemented in two stages in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine, in Baltimore. In 2015, the institution created the Pediatric Difficult Airway Response Team (DART) to manage pediatric patients with difficult airways, and in the following year, they established a consultation service—consisting of an attending pediatric anesthesiologist and a fellow—to provide sedation, ventilation, intubation and extubation plans for patients with a potentially difficult airway.
To determine which physical attributes were predictive of DART calls, and therefore of difficult airways, the investigators compared data between 56 patients in the DART registry and 60 patients requiring intubation during a code where no difficulty securing the airway was documented. They could then identify specific medical and physical risk factors that predispose pediatric patients to airway difficulties, and might help providers predict patients with potentially difficult airways (Table). The findings were presented at the 2017 meeting of the Society for Pediatric Anesthesia/American Academy of Pediatrics Section on Anesthesiology and Pain Medicine (abstract AIR-17).
|Table. Characteristics of Children Requiring Intubation for Difficult Airways (DART Patients) and Children Who Required Intubation During a Code but Without a Difficult Airway|
|Total Patients||DART Patients, n (%)||Code Patients, n (%)||P Value|
|Musculoskeletal disease||12||11 (19.6)||1 (1.7)||0.002|
|Craniofacial abnormalities||18||16 (28.6)||2 (3.3)||<0.001|
|Airway swelling||16||14 (25)||2 (3.3)||<0.001|
|Airway bleeding||13||10 (17.9)||3 (5)||0.04|
|Genetic syndrome||35||23 (41.1)||12 (20)||0.02|
|>1 characteristic||32||28 (50)||4 (6.7)||<0.001|
|>2 characteristics||17||16 (28.6)||1 (1.7)||<0.001|
|DART, difficult airway response team|
“Unlike in adults, children with difficult airways are often predictable; however, there has been little focus on creating a consultation service to preemptively identify children with potentially difficult airways and describe ventilation and intubation plans prior to these children experiencing respiratory distress,” said Nicholas Dalesio, MD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University and director of the Pediatric DART. “The ideal way to alleviate errors and stress during an emergency is to have extensive, well-thought-out plans, and what better patient population to institute this idea than in children with difficult airways?
“The goal is to do that—to create this kind of consult service throughout academic institutions caring for medically complex children,” Dr. Dalesio added.
Keys to Success
Dr. Dalesio said the keys to success of a program for predicting and managing difficult airways are threefold:
“The first component is having an emergency response team of experts, ideally composed of a multidisciplinary team of anesthesiologists, otolaryngologists, pediatric surgeons, respiratory therapists, nurses and pharmacists.
“The second component is to have a consultation service to investigate successful ventilation and intubation plans that fit individual patients’ airway pathology before they have airway emergencies, so when they do have respiratory distress, these plans can be confidently and calmly executed.
“The third component of a successful program includes basic airway education of all members caring for children. Good mask ventilation technique and learning how to place a supraglottic airway can be lifesaving, and practitioners caring for children should be proficient at these skills.
“Basic airway management education for any practitioner that takes care of children needs to be emphasized and should be implemented at any institution,” Dr. Dalesio said. “Pediatricians and emergency physicians, as well as nurse practitioners and pediatric respiratory therapists—for anybody that is doing airway management, it’s important to have an educational program where basic airway management is taught.”
Nicholas Burjek, MD, a pediatric anesthesiology fellow at Northwestern University’s Feinberg School of Medicine and the Ann & Robert H. Lurie Children’s Hospital of Chicago, said the study revealed some predictors he wasn’t familiar with, such as musculoskeletal disease, and provided a potentially useful template for similar programs. “Beyond just identifying predictors, I thought that the quality improvement process that forced those predictors to be acted upon clinically was very good,” he said. “I thought of it as two different studies. One was identifying features that predict difficult airways, and the other was a system for implementing that knowledge. The system was automated, getting information that would be useful for potential intubations to people who needed it.”