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

Assess Airway

Review Patient Information in Epic

Epic Screenshots

L.E.M.O.N. Method

Relative Contraindication Neuromuscular Blockage
  1. Anterior mediastinal masses
  2. Obstructing airway
  3. 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
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
Routine Airway Management
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)
    • State “Airway Emergency” and give location
  • ASCOM Phone
    • Double press button on top of phone
    • State "Airway Emergency"
    • Give patient 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: April 2017, June 2019 (Reviewed), June, 2021, July 2021
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