Development of a Multidisciplinary Pediatric Airway Program ......airway management of children. This is a 1-day course held semiannually for faculty, fellows, and residents in anesthesiology,

SPECIAL ARTICLE

Development of a Multidisciplinary PediatricAirway Program: An Institutional ExperienceNicholas M. Dalesio, MD,a,b Natalia Diaz-Rodriguez, MD,a Rahul Koka, MD, MPH,a Sapna Kudchadkar, MD, PhD,a Sara I. Jones, BA,c Lynette J. Mark, MD,a

Renee Cover, BSN, RN, CPHRM,d Vinciya Pandian, PhD, RN,e David Tunkel, MD,b Robert Brown, MD, MPHa

A B S T R A C TRapid response teams have become necessary components of patient care within the hospital community,including for airway management. Pediatric patients with an increased risk of having a difficult airway emergencycan often be predicted on the basis of clinical scenarios and medical history. This predictability has led to thecreation of airway consultation services designed to develop airway management plans for patients experiencingrespiratory distress and who are at risk for having a difficult airway requiring advanced airway management. Inaddition, evolving technology has facilitated airway management outside of the operating suite. Training andcontinuing education on the use of these tools for airway management is imperative for clinicians responding toairway emergencies. We describe the comprehensive multidisciplinary, multicomponent Pediatric Difficult AirwayProgram we created that addresses each component identified above: the Pediatric Difficult Airway Response Team(PDART), the Pediatric Difficult Airway Consult Service, and the pediatric educational airway program.Approximately 41% of our PDART emergency calls occurred in the evening hours, requiring a specialized teamready to respond throughout the day and night. A multitude of devices were used during the calls, obviating theneed for formal education and hands-on experience with these devices. Lastly, we observed that the majority ofPDART calls occurred in patients who either were previously designated as having a difficult airway and/or hadanatomic variations that suggest challenges during airway management. By instituting the Pediatric DifficultAirway Consult Service, we have decreased emergent Difficult Airway Response Team calls with the ultimate goal offirst-attempt intubation success.

aDepartments ofAnesthesiology and

Critical Care Medicineand bOtolaryngology-

Head and Neck Surgery,cSchool of Medicine, and

eNursing, School ofNursing, Johns Hopkins

University, Baltimore,Maryland; and dLegal

Department, The JohnsHopkins Hospital,

Baltimore, Maryland

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2018-0226Copyright © 2019 by the American Academy of Pediatrics

Address correspondence to Nicholas M. Dalesio, MD, Division of Pediatric Anesthesiology and Critical Care Medicine, Department ofAnesthesiology and Critical Care Medicine, Johns Hopkins University, 1800 Orleans St, Suite 6368, Baltimore, MD 21287. E-mail: [email protected]

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Dalesio conceptualized and designed the program and drafted the initial manuscript; Drs Diaz-Rodriguez and Pandian performedinitial data collection and analysis and reviewed and revised the manuscript; Ms Jones reviewed and revised the manuscript andcollected additional data requested by the first set of reviewers; Drs Koka, Kudchadkar, Mark, and Tunkel and Ms Cover contributed tothe creation of the program and reviewed and revised the manuscript; Dr Brown reviewed and revised the manuscript; and all authorsapproved the final manuscript as submitted.

468 DALESIO et al

by guest on June 8, 2021www.aappublications.org/newsDownloaded from

www.hospitalpediatrics.orghttps://doi.org/10.1542/hpeds.2018-0226mailto:[email protected]:[email protected]

The Institute for Healthcare Improvement’sinitial 100 000 Lives Campaign andsubsequent 5 Million Lives Campaign calledfor the establishment of rapid responsesystems.1,2 Although general rapid responseteams are beneficial to patient outcomes,3–5

more specialized teams for specific patientpopulations may be necessary. Emergencyairway management in adults can requirespecialized manpower and equipment.6,7

Furthermore, children needing emergencyairway management pose additionalconsiderations compared with adults.8–11 Inan emergency situation in which a childrequires airway management, highly trainedand experienced personnel should beavailable.

Pediatric airway anatomy and respiratoryphysiology create unique conditions thatmust be addressed during pediatric airwaymanagement. When the airway is difficult(defined by the American Society ofAnesthesiology Difficult Airway Task Force),12

a specialized skill set to manage the airwayis required to reduce patient morbidity andmortality. Difficult mask ventilation occursin ∼0.02% of pediatric difficult airway cases,and difficult intubation rates range from0.25% to 1.32% of cases.13,14 Despite the lowincidence reported, perioperative airwaymanagement complications are morefrequent in children than adults and remaina major cause for cardiopulmonary arrestin children, as reported by the AmericanSociety of Anesthesiology closed claimsanalysis and perioperative cardiac arrestregistry.15–17 In addition, children withdifficult airways have a higher mortalitywhen .2 direct laryngoscopy attempts aremade,18 making it imperative to havesuccess early on during airwaymanagement.

Our objective was to develop a pediatricdifficult airway program (PDAP) to improvethe safe management of airwayemergencies for the children in ourinstitution. This program consisted of3 components: a pediatric difficult airwayresponse team (PDART), a pediatric difficultairway consult service (PDACS), and amultidisciplinary pediatric airwayeducational program. We provide a detaileddescription of the evidence used to develop

our program beginning in 2012. In contrastto previously published articles focusedonly on emergency response or consultationservices for airway management,6,19–21 wedescribe our implementation and executionof a multifactorial difficult airway programthat we have optimized for children at ourinstitution. Our goal was to adapt the adultdifficult airway response team (DART)6 tooptimize strategies to better managepediatric airway emergencies and expandthe program to include an airwaymanagement consult service that developsplans before respiratory compromise in at-risk children as well as an educationalprogram for continuing education.

PDART

In 2008, our institution created the DART,consisting of a multidisciplinary teamincluding anesthesiologists, otolaryngology-head and neck surgeons (OHNSs), andtrauma surgeons to manage all adult andpediatric patients with difficult airways. Forchildren at our institution, the PICU teamtypically manages the airway initially,whereby the PICU fellow often performs theinitial laryngoscopy. If difficulty occursduring ventilation and/or when securing theairway (defined as $2 laryngoscopyattempts), the DART is activated. If the childwas already designated as having a difficultairway, the DART is called immediatelyshould respiratory distress occur. DARTcarts, stocked with emergency airwaysupplies, were dispersed throughout thehospital floors to provide readily availableequipment during an emergency.6,7 In May2012, our medical center opened a newchildren’s hospital building, increasingseparation between the adult and pediatricservices. This created an opportunity torevise the DART structure and organize apediatric DART for the Children’s Center. TheDART is activated when personnel call theuniversal Lifeline phone number, relayingthe location and emergency response teamthey need (in this case, the DART). The firsttask we initiated was to update the Lifelinequestionnaire script to require callers toalso provide the patient’s age (or closeapproximation). The PDART responds to achild of any age residing in the Children’sCenter and any patient under the age of

15 years throughout the hospital. In additionto the pediatric anesthesiologist responseduring the day, a pediatric respiratorytherapist and pharmacist were included inthe PDART calls.

In July 2015, the Department ofAnesthesiology and Critical Care Medicinemade the decision to have a pediatricanesthesiology faculty remain in-house24 hours per day, 7 days per week in aneffort to optimize safety for our pediatricpatients. With this addition of in-houseexpertise, the PDAP separated from theadult DART. (Fig 1). A pediatricanesthesiologist, in place of an adultanesthesiologist, now responded to DARTcalls after normal business hours forchildren. Pediatric OHNS faculty respondsduring the day; however, because of staffingconstraints, senior-level OHNS residentsrespond at night and call in faculty shouldtheir services be required. Lastly, a specificpediatric airway bag was created, includingintubating supraglottic airways, intubatingstylets, pediatric cuffed and uncuffedendotracheal tubes, as well as equipmentneeded to perform a percutaneous needlecricothyrotomy, which is brought to everyPDART call (Fig 2).

A priority of the PDART is to move stablepediatric patients to the operating suite(OR) as opposed to the adult DART priorityto manage the airway at the bedside. Bybringing children to the OR, we can usespecialized equipment and medications tooptimize spontaneous ventilation forintubation. Advanced pediatric airwayequipment (including rigid and flexiblefiber-optic bronchoscopes) for both OHNSsand anesthesiologists are housed only inthe OR. Pediatric-specific airway carts werenot dispersed throughout the Children’sCenter primarily because of cost for airwaycarts and the frequency with which theywould be used. It is the responsibility of theOHNS resident to bring the cart, only ifneeded, to the patient’s bedside.

MULTIDISCIPLINARY AIRWAYCOURSE

In 2014, a continuing medicaleducation–accredited multidisciplinarycourse was created focusing solely on

HOSPITAL PEDIATRICS Volume 9, Issue 6, June 2019 469


airway management of children. This is a1-day course held semiannually for faculty,fellows, and residents in anesthesiology,pediatrics, emergency medicine, andsurgery as well as OHNSs, nursepractitioners, and respiratory therapistscaring for children. Didactic courseworkfocuses on induction of anesthesia,pediatric airway anatomy and physiology,basic and advanced airway management,neonatal airway management, supraglotticairway placement, and airway managementfor the critically ill child. Faculty in theDivision of Pediatric Anesthesiology andCritical Care Medicine and the Departmentof Otolaryngology-Head and Neck Surgeryteach the courses. In addition, hands-onpractice stations were created for using themost common devices employed duringPDART responses, such as videolaryngoscopy and supraglottic airwayplacement on pediatric mannequins. Thecourse participants also practiceperforming cricothyrotomy in pig tracheas.

The course concludes with several pediatricairway simulation scenarios modeled fromtrue PDART calls, which tie together theskills learned throughout the day.

PDACS

Although rare, the difficult airway scenarioin children is often predictable.21 Riskfactors that are commonly associated withdifficult airway management includephysical attributes, genetic syndromes, and/or clinical scenarios (such as head andneck trauma). Many syndromes havephysical attributes commonly associatedwith a difficult airway, including craniofacialabnormalities such as micrognathia,macroglossia, and midface hypoplasia.22 Thephysical attributes and historical featuresof children who required PDART suggestthat the majority of children with difficultairways can be identified through screeningduring hospital admission. The idea for adifficult airway consult service has beendescribed by Nykiel-Bailey et al20 at the St

Louis Children’s Hospital, and on the basis ofthe experience of our PDART, we created thePDACS at our institution.

The PDACS was first instituted in 2016 in thePICU and has since expanded to cover allunits in the hospital, including theemergency department (ED) and NICU. Theprimary providers may request a consult ifan admitted patient has a history or riskfactors associated with a difficult airway;however, not all pediatric clinicians focus onairway pathology. To automate theidentification of children at risk for having adifficult airway, we created a 2-itemscreening questionnaire administered bythe triage nurse when a child is beingadmitted to the Children’s Center. Thesequestions inquire (1) whether there is ahistory of a difficult airway and (2) whetherthe child has any head or neck abnormalitythat may change airway anatomy. If either ofthese 2 questions is answered affirmatively,an automatic consultation to the PDACS ismade. Consults are either indicated asurgent, in which an anesthesiologistcompletes the consult within 1 to 2 hours,or routine, whereby the consult iscompleted within 24 hours.

It is the responsibility of the pediatricanesthesiologist to evaluate the patient,conduct a physical evaluation and chartreview, and create plans for ventilation,intubation, and sedation (if necessary and/or requested). Each consult is documentedby using a preformed PDART consultationnote (Fig 3), in which the provider describesairway history, successful and unsuccessfulattempted techniques for ventilation, andintubation described in the past. On thebasis of the patient’s pathophysiology andairway management history, first-, second-,and third-line recommendations areoutlined for both ventilation and intubationmanagement. Recommendations for whereintubation should occur, such as the OR ifadvanced techniques and equipment areneeded and the child is hemodynamicallystable for transfer, as well as for sedation,extubation, and whether OHNSs should bepresent during airway management arealso described. The child receives a difficultairway designation in the medical record,an identifying bracelet, as well as a card on

FIGURE 1 Components of the PDART. Activation of the PDART is via a group page from the Lifelineservice. If the patient is a child (age ,15 years), a pediatric OHNS will also respondduring the daytime.

470 DALESIO et al


the hospital room door labeled DART. Ifworsening respiratory distress does occur,execution of the prepared airwaymanagement plan is performed, reducingthe need for an emergency response. If thechild is unlikely to be designated as havinga difficult airway, the consultation willdenote that, and identifiers are not placed.Figure 4 illustrates the time line when keyelements of the PDAP were initiated.

METHODS

Data were collected prospectively inpatients for whom a DART call was madebetween July 2008 and December 2018. Dataregarding intubation techniques used, thenumber of attempts made using eachtechnique, techniques that were ultimatelysuccessful, the location of the intubation, aswell as the time of day the DART call wasmade were included. These data wereentered by the responding anesthesiologyresident or attending on the DART.

RESULTS

Before the implementation of the PDAP inJuly 2015, there were 51 pediatric difficultairway emergencies from July 2008 to June2015 (Table 1). The techniques mostcommonly attempted to secure the airwayinclude direct laryngoscopy (41.3%), OHNSlaryngoscopy (18.8%), flexible fiber-opticscope (16.3%), and video laryngoscopy(13.7%). The 3 most common successfultechniques at securing the airway weredirect laryngoscopy (51.4%), OHNSlaryngoscopy (25.5%), and flexible fiber-optic scope (15.6%). In addition, 47% of thecalls were initiated during the day (7 AM–7 PM), 43% of the calls took place at night(7 PM–7 AM), and 9.8% of the calls did nothave a time recorded in our database. Mostof the pediatric airway emergency callsoriginated from the NICU or PICU (60.8%),whereas the ED and OR had 23.5% and11.8% of the emergencies, respectively.

Since the implementation of the PDART,there has been activation of the PDART for19 pediatric airway emergencies. Thetechniques used to secure the airwayduring these calls include directlaryngoscopy, video laryngoscopy, andsurgical tracheostomy performed by OHNSs.There are fewer airways secured by OHNSsas well as fewer PDART emergency callson average (∼11 per year pre-PDARTcompared with 7 per year post-PDARTinitiation).

From January 2018 to December 2018, wereceived both physician-initiated andautomatic nurse-initiated difficult airwayconsultation requests with means of 8.1 (SD3.9) and 14.3 (SD 5.4) requests per month,respectively.

DISCUSSION

Children needing emergency airwaymanagement pose several unique concerns.We created a multidisciplinary group tomanage emergency pediatric difficultairways in our institution. Our results fromDART calls before the implementation of thePDART show that a variety of devices andtechniques were used to secure the airwayduring those events. Direct laryngoscopy,for example, was used in 67.5% of all DARTcalls before the implementation of thePDART. This implies that standard directlaryngoscopic techniques and commonlyused laryngoscopy blades can be used tosecure the airway in the majority of patientsdeemed difficult during an emergency, andemphasis on optimizing routine intubationtechniques of nonanesthesia providers isrequired during educational coursework.Overall, other techniques that werecommonly used include video laryngoscopy(15.7%) and placement of supraglotticairways (8.9%). These findings provideevidence for our multidisciplinary educationinitiative to teach first responders tochildren in respiratory distress (ie,pediatricians, intensivists, nursepractitioners, emergency physicians, andrespiratory therapists) how to use thesealternative methods. In addition, our datashow that the most common locations forPDART calls were the NICU and PICU (58.5%)as well as the ED (21.4%). Our educationalinitiative primarily focuses on teaching

FIGURE 2 The contents of the pediatric difficult airway bag carried to the PDART calls by theresponding pediatric anesthesiologist. ETCO2, end-tidal carbon dioxide; ETT,endotracheal tube; IV, intravenous; LMA, laryngeal mask airway.



basic and advanced airway techniquesand the use of commonly used devicesto providers in these units. Not allhospitals and facilities across the UnitedStates have pediatric anesthesiologists onstaff, and education on basic airwaytechniques as well as supraglottic airwayplacement and video laryngoscopy fornonanesthesia pediatric providers may benecessary. Other findings that support theimplementation of a PDART programincluded the timing of the events. The

number of DART calls during daytime hourswere approximately equal to the number ofovernight calls, which is consistent withrecently published data showingperioperative cardiac arrest in childrenoccurred at all hours, with higher mortalityduring after-hour emergencies.23 These datasupport the need for airway emergencyresponse personnel, including pediatricanesthesia, OHNSs, respiratory therapists, intertiary pediatric hospitals to be available24 hours per day.

The initiation of the PDAP has providedmany benefits to our institution, and eacharm of the program is currently beingformally evaluated. Briefly, having expertson the PDART in-house has decreasedmorbidity associated with pediatric airwaymanagement, especially in children with adifficult airway. The PDACS has allowed forearly identification of children at risk fordifficult airway so that formal airwaymanagement plans can be placed beforerespiratory failure. This early recognition

FIGURE 3 An example of the PDART Consultation Note. Each topic has dropdown menus that allow for easy completion of the note. After completion,ventilation and intubation plans can be copied and pasted into the Problem List under the Overview of the Difficult Airway Problem. Bydoing this, all practitioners caring for the patient can easily access and follow airway management recommendations in an emergency.BVM, bag-valve mask; CP, cerebral palsy; ETT, endotracheal tube; LMA, laryngeal mask airway; s/p, status post.

472 DALESIO et al


and preplanning has decreased the need foremergency airway management andallowed for a more controlled approachwhen the need to secure the airway arose.Lastly, our multidisciplinary airway coursehas provided continuing hands-on trainingand simulation for our first responders,improving their first-attempt success atsecuring an airway in an otherwise routineintubation. This has also contributed tofewer PDART calls and optimized first-attempt success.

Implementation of the PDAP in ourinstitution provided many benefits but wasnot without several hurdles. To have asuccessful PDART, it was necessary forpediatric-trained personnel to be in-houseand immediately available for emergencycalls around the clock. Before having thepediatric anesthesiologist in-house, childrenwere managed by adult anesthesiologists,who may not have had the optimal skill setto care for difficult airway emergencies inyoung children. Institutions that care for

small children but do not have a pediatricanesthesiologist or OHNS in-house aroundthe clock should consider regular andfrequent airway training courses for facultywho will be responding to pediatric airwayemergencies. Having readily availableintubation and ventilation equipment werealready components of our operatingrooms. However, institutions that do nothave pediatric-specific video laryngoscopes,flexible fiber-optic scopes, and/or specialtylaryngoscopes should make available these

FIGURE 4 A time line of events during the development of the PDAP. Air-Q is a type of LMA. LMA, laryngeal mask airway; RT, respiratory therapist.



devices if caring for children in theirfacilities. Another limitation was identifyingat-risk patients when initiating the PDACS.Automatic screening during admissiondrastically reduced this issue, identifyingmany patients with potential difficult airway,allowing for the implementation of airwayplans in patients who may not have beenidentified otherwise. Lastly, we have manyresources at our disposal, including apediatric anesthesiology coordinator or on-call attending, who can conduct theconsultations, and a fully equippedsimulation center with all the airwaydevices used and state-of-the-art simulationlaboratories equipped with mannequinsrepresenting all ages. Our primary hurdle

regarding the educational component wasthe difficulty our clinical faculty facedfinding the time to participate. To avoid thisissue, courses can be offered on theweekends.

CONCLUSIONS

The development and implementation of thePDART, a difficult airway consultationservice, and a multidisciplinary educationinitiative should substantially improvepediatric airway management within thehospital setting. We described ourexperience developing an all-encompassingprogram to optimize the response to andcare of children needing emergent airwaymanagement. Buy in and participation from

multiple shareholders was crucial for thesuccessful implementation of the PDAP.

ACKNOWLEDGMENTS

We thank the members of the PediatricDifficult Airway Committee, including Dr J.Kate Deanehan, Linda Foreman, AileenMendez, CRNA, and Amy Fritges, for theircontinued efforts in developing andoptimizing the PDAP. In addition, Dr LaurenBerkow contributed to the framework onwhich to build through her work on theadult DART educational program. Finally, weacknowledge the late Dr Mark Rossberg,who was instrumental in creating the initialpediatric educational airway program andwho emulated the ideal educator.

TABLE 1 Airway Techniques Used, Location of Airway Management, and Time of Day of Emergent DART Calls

Overall, July 2008–December2018

Pre-PDART Initiation, July 2008–June2015

Post-PDART Initiation, July 2015–December2018

Airway equipment and techniquesattempted, n (%)a

n 5 104 n 5 80 n 5 24

Direct laryngoscopy 45 (43.3) 33 (41.3) 12 (50.0)

OHNS laryngoscopy 20 (19.2) 15 (18.8) 5 (20.9)

Flexible fiber-optic 13 (12.5) 13 (16.3) 0

Video laryngoscopy 14 (13.4) 11 (13.7) 3 (12.5)

Supraglottic airway 8 (7.7) 6 (7.5) 2 (8.3)

Eschmann 1 (1.0) 1 (1.2) 0

Aintree 1 (1.0) 1 (1.2) 0

Tracheostomy replacementb 2 (1.9) 0 2 (8.3)

Final successful technique, n (%) n 5 70 n 5 51 n 5 19

Direct laryngoscopy 24 (34.3) 16 (51.4) 8 (42.1)

OHNS laryngoscope 16 (22.9) 13 (25.5) 3 (15.8)

Flexible fiber-optic 8 (11.4) 8 (15.6) 0

Video laryngoscopy 9 (12.9) 6 (11.8) 3 (15.8)

Supraglottic airway 3 (4.3) 2 (3.9) 1(5.3)

Surgical airways 10 (14.2) 6 (11.8) 4 (21.1)

To OR to secure airway, n (%) 29 (41.4) 25 (49.0) 4 (21.1)

Timing of events, n (%)

7:00 AM–7:00 PM 36 (51.4) 24 (47.1) 12 (63.2)

7:00 PM–7:00 AM 29 (41.4) 22 (43.1) 7 (36.8)

Unknown 5 (7.2) 5 (9.8) 0

Location and frequency, n (%)

ICU 41 (58.6) 31 (60.8) 10 (52.6)

ED 15 (21.4) 12 (23.5) 3 (15.8)

Floor 3 (4.3) 2 (3.9) 1 (5.3)

OR 11 (15.7) 6 (11.8) 5 (26.3)

PDART Initiation, July 2015.a Attempts include those made before the DART arrived; several different devices and techniques can be attempted on 1 patient.b Two patients had their tracheostomy come out and presented to the ED, where personnel could not replace it. A DART was called, and the tracheostomy wasreplaced successfully by OHNSs.

474 DALESIO et al


REFERENCES

1. Berwick DM. Overview of the100000 Lives Campaign. In: IHI 16thAnnual National Forum on QualityImprovement in Health Care; December14–15, 2004; Winnipeg, Canada

2. Institute for Healthcare Improvement.Initiatives: 5 Million Lives Campaign.Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspx. Accessed April 8, 2019

3. Jones D, Rubulotta F, Welch J. Rapidresponse teams improve outcomes: yes.Intensive Care Med. 2016;42(4):593–595

4. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139–146

5. Winters BD, Weaver SJ, Pfoh ER, Yang T,Pham JC, Dy SM. Rapid-responsesystems as a patient safety strategy: asystematic review. Ann Intern Med. 2013;158(5, pt 2):417–425

6. Mark LJ, Herzer KR, Cover R, et al. Difficultairway response team: a novel qualityimprovement program for managinghospital-wide airway emergencies. AnesthAnalg. 2015;121(1):127–139

7. Hillel AT, Pandian V, Mark LJ, et al. Anovel role for otolaryngologists in themultidisciplinary Difficult AirwayResponse Team. Laryngoscope. 2015;125(3):640–644

8. Weiss M, Engelhardt T. Proposal for themanagement of the unexpected difficultpediatric airway. Paediatr Anaesth. 2010;20(5):454–464

9. Henderson JJ, Popat MT, Latto IP, PearceAC; Difficult Airway Society. DifficultAirway Society guidelines formanagement of the unanticipated

difficult intubation. Anaesthesia. 2004;59(7):675–694

10. Carroll CL, Spinella PC, Corsi JM, Stoltz P,Zucker AR. Emergent endotrachealintubations in children: be careful if it’slate when you intubate. Pediatr Crit CareMed. 2010;11(3):343–348

11. Nishisaki A, Ferry S, Colborn S, et al;National Emergency Airway Registry;National Emergency Airway Registry forKids Investigators. Characterization oftracheal intubation process of care andsafety outcomes in a tertiary pediatricintensive care unit. Pediatr Crit CareMed. 2012;13(1):e5–e10

12. Apfelbaum JL, Hagberg CA, Caplan RA,et al; American Society ofAnesthesiologists Task Force onManagement of the Difficult Airway.Practice guidelines for management ofthe difficult airway: an updated reportby the American Society ofAnesthesiologists Task Force onManagement of the Difficult Airway.Anesthesiology. 2013;118(2):251–270

13. Lee-Jayaram JJ, Yamamoto LG.Alternative airways for the pediatricemergency department. Pediatr EmergCare. 2014;30(3):191–199; quiz 200–202

14. Heinrich S, Birkholz T, Ihmsen H,Irouschek A, Ackermann A, Schmidt J.Incidence and predictors of difficultlaryngoscopy in 11,219 pediatricanesthesia procedures. PaediatrAnaesth. 2012;22(8):729–736

15. Jimenez N, Posner KL, Cheney FW, CaplanRA, Lee LA, Domino KB. An update onpediatric anesthesia liability: a closedclaims analysis. Anesth Analg. 2007;104(1):147–153

16. Morray JP, Geiduschek JM, Caplan RA,Posner KL, Gild WM, Cheney FW. A

comparison of pediatric and adultanesthesia closed malpractice claims.Anesthesiology. 1993;78(3):461–467

17. Bhananker SM, Ramamoorthy C,Geiduschek JM, et al. Anesthesia-relatedcardiac arrest in children: update fromthe Pediatric Perioperative CardiacArrest Registry. Anesth Analg. 2007;105(2):344–350

18. Fiadjoe JE, Nishisaki A, Jagannathan N,et al. Airway management complicationsin children with difficult trachealintubation from the Pediatric DifficultIntubation (PeDI) registry: a prospectivecohort analysis. Lancet Respir Med.2016;4(1):37–48

19. Bai W, Golmirzaie K, Burke C, et al.Evaluation of emergency pediatrictracheal intubation by pediatricanesthesiologists on inpatient units andthe emergency department. PaediatrAnaesth. 2016;26(4):384–391

20. Nykiel-Bailey SM, McAllister JD, SchrockCR, Molter DW, Marsh JK, Murray DJ.Difficult airway consultation service forchildren: steps to implement andpreliminary results. Paediatr Anaesth.2015;25(4):363–371

21. Russo SG, Becke K. Expected difficultairway in children. Curr OpinAnaesthesiol. 2015;28(3):321–326

22. Nargozian C. The airway in patients withcraniofacial abnormalities. PaediatrAnaesth. 2004;14(1):53–59

23. Christensen RE, Lee AC, Gowen MS,Rettiganti MR, Deshpande JK, MorrayJP. Pediatric perioperative cardiacarrest, death in the off hours: areport from wake up safe, thepediatric quality improvementinitiative. Anesth Analg. 2018;127(2):472–477



http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspxhttp://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspxhttp://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspxhttp://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspx

DOI: 10.1542/hpeds.2018-0226 originally published online May 14, 2019; 2019;9;468Hospital Pediatrics

BrownI. Jones, Lynette J. Mark, Renee Cover, Vinciya Pandian, David Tunkel and Robert Nicholas M. Dalesio, Natalia Diaz-Rodriguez, Rahul Koka, Sapna Kudchadkar, Sara

ExperienceDevelopment of a Multidisciplinary Pediatric Airway Program: An Institutional

ServicesUpdated Information &

http://hosppeds.aappublications.org/content/9/6/468including high resolution figures, can be found at:

Supplementary Material Supplementary material can be found at:

Referenceshttp://hosppeds.aappublications.org/content/9/6/468#BIBLThis article cites 21 articles, 0 of which you can access for free at:

Subspecialty Collections

rovement_subhttp://www.hosppeds.aappublications.org/cgi/collection/quality_impQuality Improvementnary_teams_subhttp://www.hosppeds.aappublications.org/cgi/collection/interdiscipliInterdisciplinary Teamson:practice_management_subhttp://www.hosppeds.aappublications.org/cgi/collection/administratiAdministration/Practice Managementfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

mlhttp://www.hosppeds.aappublications.org/site/misc/Permissions.xhtin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.hosppeds.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://hosppeds.aappublications.org/content/9/6/468http://hosppeds.aappublications.org/content/9/6/468#BIBLhttp://www.hosppeds.aappublications.org/cgi/collection/administration:practice_management_subhttp://www.hosppeds.aappublications.org/cgi/collection/administration:practice_management_subhttp://www.hosppeds.aappublications.org/cgi/collection/interdisciplinary_teams_subhttp://www.hosppeds.aappublications.org/cgi/collection/interdisciplinary_teams_subhttp://www.hosppeds.aappublications.org/cgi/collection/quality_improvement_subhttp://www.hosppeds.aappublications.org/cgi/collection/quality_improvement_subhttp://www.hosppeds.aappublications.org/site/misc/Permissions.xhtmlhttp://www.hosppeds.aappublications.org/site/misc/Permissions.xhtmlhttp://www.hosppeds.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/hpeds.2018-0226 originally published online May 14, 2019; 2019;9;468Hospital Pediatrics

BrownI. Jones, Lynette J. Mark, Renee Cover, Vinciya Pandian, David Tunkel and Robert Nicholas M. Dalesio, Natalia Diaz-Rodriguez, Rahul Koka, Sapna Kudchadkar, Sara

ExperienceDevelopment of a Multidisciplinary Pediatric Airway Program: An Institutional

http://hosppeds.aappublications.org/content/9/6/468located on the World Wide Web at:

The online version of this article, along with updated information and services, is

All rights reserved. Print ISSN: 1073-0397. Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics.Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Hospital Pediatrics is an official journal of the American Academy of Pediatrics. Hospital

http://hosppeds.aappublications.org/content/9/6/468

Documents

Development of a Multidisciplinary Pediatric Airway Program ......airway management of children. This is a 1-day course held semiannually for faculty, fellows, and residents in anesthesiology,