263 - Identification of the difficult pediatric airway in the emergency department; a modified Delphi approach

Publication Number: 263.5239

Joon Suk Choi, University of Florida College of Medicine, Gainesville, FL, United States; Maritza Plaza-Verduin, University of Florida College of Medicine, Gainesville, FL, United States; Colleen K. Gutman, University of Florida College of Medicine, Gainesville, FL, United States; Sara Kirby, USACS, Lutz, FL, United States; Carolyn K. Holland, University of Florida College of Medicine, Gainesville, FL, United States; Tricia Swan, University of Florida College of Medicine, High Springs, FL, United States; Joshua Nagler, Boston Children's Hospital, Boston, MA, United States; Sakina H. Sojar, Brown Emergency Medicine, Providence, RI, United States; Nicholas Dalesio, Johns Hopkins University School of Medicine, Baltimore, MD, United States; J. Kate Deanehan, Johns Hopkins Children's Center, Baltimore, MD, United States; K. Karisa Walker, University of Florida College of Medicine, Gainesville, FL, United States; Sandra N. Gonzalez, UF Health Shands Children's Hospital, Gainesville, FL, United States; William O.. Collins, University of Florida College of Medicine, Gainesville, FL, United States; Thomas Schrepfer, University of Florida College of Medicine, Gainesvile, FL, United States; Kevin J. Sullivan, University of Florida College of Medicine, Fleming Island, FL, United States; Janice A.. Taylor, University of Florida College of Medicine, Gainesville, FL, United States

Background: Tracheal intubation of critically ill children presenting to the Emergency Department (ED) is potentially lifesaving but often challenging: nearly one-third of encounters require multiple intubation attempts. Intubation checklists draw attention to early identification of potentially difficult airways, but there is no current consensus definition on what constitutes a potentially difficult emergency pediatric airway.

Objective: To develop an expert-consensus based definition of the potentially difficult emergency pediatric airway. Secondarily, we assessed expert opinions regarding an appropriate level of expertise, back-up availability, and necessary equipment for emergency physicians encountering a potentially difficulty emergency pediatric airway.

Design/Methods: We assembled a multi-disciplinary panel of experts in pediatric airway management. Using a modified Delphi approach, we engaged panelists in a three-step process involving two online questionnaires, separated by one series of virtual meetings to discuss results and share expertise. The panel members were tasked to develop consensus on specific pediatric airway scenarios at high risk of first-attempt intubation failure. Panel members reviewed, modified, and added to an initial list of 26 specific anatomical and physiological difficult airway scenarios, using a 9 point scale. Each scenario included follow-on questions related to the need for a backup airway expert (ie anesthesia, otolaryngology, surgery), the role of trainees in initial intubation, and the availability of specific airway equipment (Table 1). Components with a median score 7.0-9.0 and a 25th percentile score ≥ achieved consensus.

Results: Thirteen physicians (6 Pediatric Emergency Medicine, 4 Pediatric Anesthesia, 2 Pediatric Otolaryngology, 1 Pediatric Surgery) were on the panel. Eleven of the panelists (84.6%) practiced in academic settings. All experts participated in the two online questionnaires, and the virtual meetings. Inclusion consensus was achieved on 13 scenarios. Consensus was achieved on 8 original scenarios after the initial online questionnaire; the other 5 were newly suggested or achieved consensus after the follow-on meetings and second questionnaire (Table 2). There was no consensus to support the role of trainees as the initial proceduralist for any scenario. Only one specific piece of airway equipment (video laryngoscopy) achieved inclusion consensus.

Conclusion(s): Through this expert-consensus process, we identified 13 anatomic clinical scenarios at high risk for first-attempt intubation failure in children presenting with the need for an emergency airway.

Identification of the difficult pediatric airway in the emergency department: a modified Delphi approach
Table 1 (Questions).pdfTable 1: Questions, response options, and scoring for consensus surveys

Identification of the difficult pediatric airway in the emergency department: a modified Delphi approach
Table 2 (Scenarios - Consensus).pdfTable 2: Scenarios and survey results