Airway management outside the operating room: how to better prepare

Operations and outcomes of a Hospital-wide Emergency Airway Response Team (HEART) in a quaternary academic children's hospital

BACKGROUND

To improve pediatric airway management outside of the operating room, a Hospital-wide Emergency Airway Response Team (HEART) program composed of anesthesiology, otorhinolaryngology, and respiratory therapy clinicians was developed.

AIMS

To report processes and outcomes of HEART activations in a quaternary academic children's hospital.

METHODS

A retrospective observational cohort study between January 2017 and December 2019. Local airway emergency database was reviewed for HEART activations. Additional safety data was obtained from patients' electronic health records.

PRIMARY OUTCOME

Adverse airway outcomes, either adverse tracheal intubation-associated events or oxygen desaturation (SpO₂ <80%). We compared airway management by primary teams before HEART arrival and by HEART after arrival.

RESULTS

Of 96 HEART activations, 36 were from neonatal intensive care unit, 35 from pediatric and cardiac intensive care units, 14 from emergency department, and 11 from inpatient wards. 56 (62%) children had airway anomalies and 41/96 (43%) were invasively ventilated. Median HEART arrival time was 5 min (interquartile range, 3-5). 56/96 (58%) required insertion of an advanced airway (supra/extra-glottic airway, endotracheal tube, tracheostomy tube). HEART succeeded in establishing a definitive airway in 53/56 (94%). Adverse airway outcomes were more common before (56/96, 58%) versus after HEART arrival (28/96, 29%; absolute risk difference 29%; 95% confidence interval 16, 41%; p < .001). Oxygen desaturation occurred more frequently before (46/96, 48%) versus after HEART arrival (24/96, 25%; absolute risk difference 23%; 95% confidence interval 11, 35%; p = .02). Cardiac arrests were more common before (9/96, 9%) versus after HEART arrival (3/96, 3%). Multiple (≥3) intubation attempts were more frequent before (14/42, 33%) versus after HEART arrival (9/46, 20%; absolute risk difference -14%; 95% confidence interval -32, 5%; p = .15).

CONCLUSIONS

A multidisciplinary emergency airway response team plays an important role in pediatric airway management outside of the operating room. Adverse airway outcomes were more frequent before compared to after HEART arrival.

Rapid Expansion of the Airway Response Team to Meet the Needs of the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management.

METHODS

A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic.

RESULTS

During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART.

CONCLUSIONS

Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

A Prospective Audit of Airway Code Activations and Adverse Events in Two Tertiary Hospitals

INTRODUCTION

Airway management outside the operating room can be challenging, with an increased risk of difficult intubation, failed intubation and complications. We aim to examine airway practices, incidence of difficult airway and complications associated with airway code (AC) activation.

METHODS

We conducted a prospective audit of AC activations and adverse events in two tertiary hospitals in Singapore. We included all adult patients outside the operating room who underwent emergency intubation by the AC team after AC activation. Adult patients who underwent emergency intubation without AC activation or before the arrival of the AC team were excluded. Data were collected and documented by the attending anaesthetists in a standardised survey form shortly after their responsibilities were completed.

RESULTS

The audit was conducted over a 20-month period from July 2016 to March 2018, during which a total of 224 airway activations occurred. Intubation was successful in 218 of 224 AC activations, giving a success rate of 97.3%. Overall, 48 patients (21.4%) suffered an adverse event. Thirteen patients (5.8%) had complications when intubation was carried out by the AC team compared with 35 (21.5%) by the non-AC team.

CONCLUSION

Dedicated AC team offers better success rate for emergency tracheal intubation. Non-AC team attempted intubation in the majority of the cases before the arrival of the AC team. Increased intubation attempts are associated with increased incidence of adverse events. Equipment and patient factors also contributed to the adverse events. A multidisciplinary programme including the use of supraglottic devices may be helpful to improve the rate of success and minimise complications.

A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

Optimising remote site airway management kit dump using the SCRAM bag-a randomised controlled trial

Background

Emergency airway management may be required at any hospital location. Remote site management is associated with increased airway morbidity and mortality. Poor planning and interrupted workflow are significant contributors. Equipment may be unfamiliar, difficult to locate or inadequate.

The SCRAM (Structured CRitical Airway Management) bag aims to provide a portable, structured and reproducible approach to airway management preparation. We hypothesised that SCRAM bag use reduces equipment preparation time, the rate of error and operator cognitive load.

Methods

Fifty experienced anaesthetists were randomised into two groups and asked to prepare (kit dump) for and manage a simulated remote site difficult airway scenario. The control group (n = 25) used a standard resuscitation trolley while the experimental group used the SCRAM bag (n = 25). The primary outcome was time taken to kit dump completion (seconds). Secondary outcomes were the number of errors and self-reported difficulty (100 mm visual analogue scale).

Results

Using the SCRAM bag, a 29% reduction in kit dump time (111.7 ± 29.5 vs 156.7 ± 45.1, p = 0.0001) was noted. Participants using the SCRAM bag reported it to be less challenging to use (18.36 ± 16.4 mm vs 50.64 ± 22.9 mm, p < 0.001), and significantly fewer errors were noted (1 (IQR 1–3) vs 8 (IQR 5–9), p = 0.03) (87.5% reduction in the total number of errors).

Conclusion

The SCRAM bag facilitates a quicker, less challenging kit dump with significantly fewer errors. We propose that this would reduce delay to airway management, reduce cognitive load and provide an improved capability to manage anticipated and unanticipated airway events.

Emergency intubation of children outside of the operating room

Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.

Difficult airway management algorithms: a directed review

The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.

Non-operating room anaesthesia in children

Administration of sedation and/or anaesthesia to patients undergoing painful or uncomfortable procedures at off-site locations is referred to as non-operating room anaesthesia (NORA). Sedating/anaesthetising children in an unfamiliar environment, with the lack of support staff, nonavailability of choice of medication and equipment is often challenging. Studies have shown an increased risk of airway-related adverse events, complications, and even death outside the operating room locations. It is crucial to be familiar with the anatomical and physiological variations in children, well versed with the difficult airway algorithm and call for help early. The most common event in NORA claims was inadequate oxygenation/ventilation, which are preventable with vigilant monitoring. English language articles were searched in Pubmed, Google Scholar, and Academic using 'sedation in children', 'remote location anaesthesia', 'peadiatric sedation', and 'nonoperating room anaesthesia' as the mesh words. Full text of the relevant articles was obtained and this review article was synthesised. The article outlines various safety guidelines, sedation techniques, drugs used for sedation, environmental concerns, procedure-specific risks, and complications associated with NORA in children.

Utility of the laryngeal handshake method for identifying the cricothyroid membrane

BACKGROUND

The cricothyroid membrane is the most commonly accessed location for invasive surgical airway. Although the laryngeal handshake method is recommended for identifying the cricothyroid membrane, there is no clinical data regarding the utility of the laryngeal handshake method in cricothyroid membrane identification. The objective of this study was to compare the accuracy of cricothyroid membrane identification between the laryngeal handshake method and simple palpation.

METHODS

After anaesthesia induction, the otorhinolaryngology resident and anaesthesia resident identified and marked the needle insertion point for cricothyroidotomy using simple palpation and the laryngeal handshake method, respectively. The cricothyroid membrane was confirmed with ultrasonography. Identification was determined successful if the marked point was placed within the longitudinal area of the cricothyroid membrane and within 5 mm from midline transversely. The accuracy of cricothyroid membrane identification using the laryngeal handshake method and simple palpation was compared.

RESULTS

A total of 123 patients were enrolled. The cricothyroid membrane was correctly identified in 87 (70.7%, 95% confidence interval 61.8-78.6%) patients using the laryngeal handshake method compared to 78 (63.4%, 95% confidence interval 54.3-71.9%) patients using simple palpation (P = .188). The time required to identify the cricothyroid membrane was longer when using the laryngeal handshake method (15 [3-48] seconds vs 10.9 [3-55] seconds, P = .003).

CONCLUSION

The success rate of identifying the cricothyroid membrane was similar among the anesthesiologists who performed the laryngeal handshake method and also among otorhinolaryngologists who used simple palpation.