Clinical Pathway for Children with Difficult/Critical Airway
- Patient Requiring Urgent/Emergent Intubation on Inpatient Units
- (Outside ED, PICU, NICU, CICU, OR)
- Call 4-CODE
- Code Team will activate Airway Response Team as necessary
Relative Contraindication Neuromuscular Blockage
- Anterior mediastinal masses
- Obstructing airway
- Infiltrative storage diseases (glycogen storage diseases and others)
Sugammadex can be used to reverse the paralytic effects of rocuronium and vecuronium
Critical Airway Known
Difficult Airway
Known/Anticipated
Known/Anticipated
No Airway Issues Identified
- While Awaiting Airway Response Team
- Monitor, Continue O2
- Consider the following based on airway characteristics:
- Bag Mask Ventilation
- Nasal/Oral Airways
- Laryngeal Mask (LMA)
Perform Bag Mask Ventilation
Use Nasal/Oral/Laryngeal Airways as Necessary
Use Nasal/Oral/Laryngeal Airways as Necessary
Routine Airway Management
by Clinical Team
by Clinical Team
Inadequate
Adequate
Failed BVM or Laryngoscopy
- Consider Laryngoscopy
- Most Experienced Practitioner
- Laryngoscopy
- Limit to 2 Attempts
Failure
To Activate the Airway Response Team
- Call Medical Emergency Line, 4-CODE (4-2633)
- or
- Click 4CODE on your smartphone
- then
- State Airway Emergency and give location
Activate
Airway Response Team
Consider Laryngeal Mask Airway
Airway Response Team Arrives
- Airway Team Provides Expert Support to Local Team
- Laryngeal Mask
- Indirect Laryngoscopy
- Considerations for Sedation, Neuromuscular Blockade
- Fiberoptic Laryngoscopy
- Fiberoptic Laryngoscopy through LMA
- Invasive Airway
Posted: January 2014
Revised: June 2022
Authors: A. Nishisaki, MD; R. Giordano, RRT-NPS; J. Lavelle, MD; A. Ades, MD; J. Lioy, MD; L. Javia, MD; K.Y. Tay, MD; A. Costarino, MD; B. Bruins, MD
Revised: June 2022
Authors: A. Nishisaki, MD; R. Giordano, RRT-NPS; J. Lavelle, MD; A. Ades, MD; J. Lioy, MD; L. Javia, MD; K.Y. Tay, MD; A. Costarino, MD; B. Bruins, MD
Evidence
- ASA Practice Guidelines for Management of the Difficult Airway
- A National Emergency Airway Registry for Children: Landscape of Tracheal Intubation in 15 PICUs
- Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation(PeDI) registry: a prospective cohort analysis
- Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies
- Seminars in Neonatal and Fetal Medicine: The Neonatal-Fetal Airway
- A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching
- Management of the Difficult Airway
- Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events
- Neonatal Intubation Practice and Outcomes: An International Registry Study