Abstract
Background:
Children's hospitals often care for highly complex infants with severe rare birth defects including airway abnormalities that make standard airway management challenging. Our hospital has established a specialized multidisciplinary airway program that cares for these infants with difficult/critical airways including an emergency airway response team consisting of anesthesia and ENT providers. We also have an ongoing quality improvement database: National Emergency Airway Registry for Neonates (NEAR4NEOS) to capture safety data on all tracheal intubations (TIs) in the special delivery unit (SDU) and neonatal intensive care unit (NICU). We sought to evaluate the current status of emergency airway management in these high-risk difficult/critical airway infants in our hospital.
Methods:
Retrospective review of the all emergency airway activation in NICU and SDU at the Children's Hospital of Philadelphia from January 2016 — April 2018. Both Emergency Airway Response Database and the NEAR4NEOS database were reviewed by a content expert (NN) to describe the safety and outcomes.
Results:
Of the 1,009 intubations that occurred during the study period, 33 (3%) airway emergences were activated. Of these 33 activations (31 in NICU, 2 in SDU), 14 had existing endotracheal tube (8 unplanned extubations), 6 had existing tracheostomies, and 11 had natural airway. 25 required TI, 6 had re-insertion of tracheostomy cannula, and 2 had confirmation of airway placement with no need for adjustment. Of the 22 TIs (3 excluded, 1 taken directly to operating suite and 2 did not have NEAR4NEOS data), 20 were successful (90%), with median 4 (IQR 1-11) attempts and 2 (IQR 1-5) providers. Table 1 shows the advanced resources used for TI. Adverse tracheal intubation associated events occurred in 41% of the cases with 4 having dysrhythmia, 3 having cardiac arrest with return of spontaneous circulation, and 1 died due to failure to establish airway. 77% (17/22) had more than 20% of decline in oxygen saturation level during the intubation procedure.
Conclusions:
Activation of the emergency airway team was uncommon. In patients when it was activated, a high percentage were able to be intubated. However this requires expertise with a number of advanced airway devices and is still associated with a high rate of adverse events. Ongoing hospital wide difficult airway system with multidisciplinary teams and expertise are necessary to continue to improve our current practice.
Tracheal Intubation Advanced Resources (N = 22)
Advanced Resources
Number
Percentage
Equipment
20
91%
CMAC Video Laryngoscope
16
73
Fiberoptic Flexible Bronchoscope
8
36%
Laryngeal Mask Airway
5
23%
Rigid Bronchoscope
2
9%
Glidescope
1
5%
>1 device
9
36%
>2 devices
5
20%
>3 devices
3
13%
Provider
15
68%
ENT
10
66%
Anesthesia
8
53%
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