Difficult/Critical Airway Clinical Pathway, — KOPH | Children's Hospital of Philadelphia

Back to Main Algorithm

Goals and Metrics

Patient Education

Provider Resources

Related Pathways

Relative Contraindication Neuromuscular Blockage

Anterior mediastinal masses
Obstructing airway mass
Infiltrative storage diseases (glycogen storage diseases and others)

Sugammadex can be used to reverse the paralytic effects of rocuronium and vecuronium

Child Requiring Intubation

Admission screening
- Prioritize admitting children with known difficult/critical airways and without stable tracheostomies to
  the PHL campus

Child Requiring Urgent/Emergent Intubation on Inpatient Units
Outside ED, PICU, N/IICU, OR
Call 4-CODE

Child Stabilized, Difficult/Critical
Airway Suspected
Arrange transfer to PHL campus, direct to OR if necessary

Assess Airway

Review Patient Information in Epic

L.E.M.O.N. Method

Critical Airway Known

Difficult Airway
Known/Anticipated

No Airway Issues Identified

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

Activate Resources
- 24 hr availability
  - PICU, N/IICU, ED attending
- 7 a.m. to 5 p.m.
  - Anesthesia Team Lead: KOPH Anes Team Lead 1st Contact
    Call, do not message
    Will know if ENT is on campus
- 5 p.m. to 7 a.m.
  - PHL Campus Anesthesia: PHL Anes Emergency 1st Contact
    Call, do not message

Continue Medical Management
- Consider placement of laryngeal mask airway
  - If unable to intubate but able to ventilate with LMA – arrange transport to PHL OR for ENT/Anesthesia
- Consider reversal of neuromuscular blockade
- If cannot intubate or oxygenate
  - Consider front of neck access (FONA) by trained provider
    - FONA in infants < 1 yr is known
      to be extremely difficult

Posted: July 2024

Authors:
- H. Wolfe, MD;
- B. Bruins, MD;
- S. Cook-Sather, MD;
- K. Martin, MD;
- R. Giordano, RRT

Editors: Clinical Pathways Team

Evidence

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

©2024 by Children's Hospital of Philadelphia, all rights reserved.
Use of this site is subject to the Terms of Use.

The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Find a research study

Innovation and your child

Find research studies

KOPH Clinical Pathway for Unanticipated Difficult/Critical Airway

Evidence