Preemptive airway management planning: A retrospective evaluation of the pediatric difficult airway consultation...

The pediatric Difficult Airway Consultation Service (pDACS) was created in 2017 to identify patients with potentially difficult airways and create airway management plans prior to airway management.

Consults were either nurse-initiated, physician-initiated, or both nurse-and-physician-initiated and were examined for demographic and clinical factors. If a child had difficult airway risk factors, a consult note with airway management recommendations was completed.

We included 419 consults from the 4-year study period for analysis. Sixty-one patients had chronic tracheostomies in place and thus, were analyzed separately. Of the remaining 358 consults, 50% (n = 179) were nurse-initiated, 30.2% (n = 108) physician-initiated, and 19.8% (n = 71) nurse-and-physician-initiated consults. Differences in observed frequency of airway edema (difference, 6.3%; 95%CI 0.1%-12.5%; p = .04), cleft lip/palate (difference, 8.1%; 95%CI 0.07%-16.3%, p = .04), craniofacial abnormalities (difference, 12.3%; 95%CI 1.9%-22.7%, p = .02), and trauma/burn (difference, 6.5%; 95%CI 0.09%-12.8%, p = .04) were calculated. Observed frequencies were higher in physician-initiated compared to nurse-initiated consults. Airway edema was also more prevalent in dual nurse-and-physician-initiated consults (difference, 8.7%; 95%CI 1.6%-15.8%; p = .01). Physician-initiated consults were associated with a greater proportion of high-risk difficult airways than nurse-initiated consults (difference, 26.7%; 95%CI 14.0%-39.4%, p < .001). Approximately 41.9% of patients at high-risk for having a difficult airway were identified by nurse-screening only. Using bag-valve-mask was often the primary ventilation recommendation (89.3%, n = 108) and supraglottic airway placement was the most common tertiary plan (74.2%, n = 83). Direct laryngoscopy (47.1%, n = 65) and videolaryngoscopy (40.6%, n = 56) were the most recommended modes of intubation. Three patients with airway emergencies had previously documented airway management plans and were successfully intubated without complications following the primary intubation technique recommended in their consult note.

In our study, nurse-screening identified patients at high-risk for a difficult airway that would likely not have been identified prior to initiation of a screening protocol. Furthermore, airway management plans outlined prior to an emergent difficult airway event may increase first-attempt success at securing the difficult airway, reducing morbidity and mortality.