Pediatric Difficult Airway Simulation Day

This small-group simulation workshop is designed for pediatric emergency medicine fellows but can also be offered to emergency medicine residents or faculty.

Pediatric intubation is a high-acuity, low-frequency event. Specific patient scenarios that may lead to a difficult pediatric airway, such as airway edema, airway contamination (hemorrhage, emesis), prematurity, obesity, shock, and inhalational injuries, compound an already challenging and emergent situation. Previous studies have investigated simulation-based airway education for emergency medicine (EM), anesthesia, and critical care trainees. To our knowledge, there has been no study reporting the development and outcomes of a difficult airway course for pediatric emergency medicine (PEM) fellows covering emergency department (ED)-specific pediatric difficult airway content.

The objective of this one-day simulation workshop is to increase learner confidence and skills necessary to perform critical pediatric airway procedures. PEM fellows of all training levels at our institution completed a three-hour "PEM Difficult Airway Day," which consisted of six 30-minute stations focusing on airway scenarios critical for PEM fellow training: five high- and low-fidelity simulations (premature neonate, inhalational injury, contaminated airway, obese patient, and failed airway) and one discussion-based station on the physiologically difficult intubation. By the end of this workshop, learners will be able to: 1) identify various clinical situations in which a pediatric patient may have a difficult airway, 2) successfully intubate mannequins with simulated difficult airways using direct laryngoscopy (DL), video laryngoscopy (VL), laryngeal mask airway (LMA) placement, bougie-assisted intubation, and a hyper-angulated VL blade, and 3) recognize and describe the management of physiologically difficult airways and failed airways.

Small group activity combining procedural high- and low-fidelity simulations, as well as case-based learning.

The PEM fellows completed pre- and post-workshop surveys to assess their airway knowledge and confidence regarding intubation using DL, VL, LMA placement, bougie-assisted intubation, intubation using a hyper-angulated VL blade, managing the anatomically difficult airway, managing the physiologically difficult airway, and managing the failed airway. In addition, learners were asked to identify any areas with continued knowledge gaps and low procedural confidence that they wished to be addressed in a future "PEM Difficult Airway Day."

Our findings suggest that the "PEM Difficult Airway Day" significantly improved PEM fellow knowledge and confidence in infrequently performed critical pediatric EM scenarios, such as bougie-assisted intubation and use of a hyper-angulated VL blade, and knowledge of options and techniques for managing the anatomically difficult, physiologically difficult, and failed airway. There was no statistically significant improvement in confidence in DL and VL intubation and LMA placement. Additionally, fellows identified management of airway foreign bodies as an area with a continued knowledge gap and low procedural confidence.

A workshop dedicated to increasing the confidence and procedural skills necessary to perform critical airway procedures can be successfully offered to PEM fellows as a single-day, focused, small-group simulation workshop.

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