Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.

STUDY OBJECTIVE: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach.

BACKGROUND: Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS: A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS: All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS: Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.

Management of the Difficult Airway.

ABSTRACT: Airway management is a fundamental component of care during resuscitation of critically ill and injured children. In addition to predicted anatomic and physiologic differences in children compared with adults, certain conditions can predict potential difficulty during pediatric airway management. This review presents approaches to identifying pediatric patients in whom airway management is more likely to be difficult, and discusses strategies to address such challenges. These strategies include optimization of effective bag-mask ventilation, alternative approaches to laryngoscopy, use of adjunct airway devices, modifications to rapid sequence intubation, and performance of surgical airways in children. The importance of considering systems of care in preparing for potentially difficult pediatric airways is also discussed.

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department.

BACKGROUND: Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting. OBJECTIVE: We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations. DESIGN AND METHODS: We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors. RESULTS: During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy. CONCLUSION: Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.

Virtual Interviewing for Pediatric Emergency Medicine Fellowship-A National Survey.

OBJECTIVE: This study aimed to evaluate both applicant and interviewer satisfaction with the virtual interviewing process for pediatric emergency medicine (PEM) fellowship in hopes to improve the fellowship interviewing process. It was proposed that fellowship programs and applicants would prefer virtual interviews over traditional interviews. METHODS: A survey developed in collaboration with UT Southwestern PEM fellowship leaders and national PEM leaders was sent to all PEM fellowship applicants and programs at the conclusion of the 2020 interview season and rank list submission. The applicant survey obtained information on ease of virtual interviews and whether applicants felt that they obtained adequate information from virtual interviews to make informed program selections. Program director surveys collected data on thoughts and feelings about virtual interviews and obstacles encountered during the recruitment season. Both surveys asked about costs for interviews and interview type preference. RESULTS: A response rate of 49% from applicants and 47% from programs was obtained. Virtual interview days were similar in the amount of time and staff hours used compared with traditional days. Applicants spent less on virtual interviews compared with those who underwent traditional interviews (average $725 vs $4312). Programs received more applications than the prior year and spent less money during the virtual cycle. The majority of the applicants (90%) were comfortable with the virtual interview platform, and most (66%) agreed that virtual interviews provided adequate information to determine program rank. Geography was the number 1 rank determining factor. Programs and applicants preferred a form of in-person interviews. CONCLUSIONS: Virtual interviews provide cost savings for both applicants and programs. Despite this, both parties prefer a form of in-person interviews.

Emergency pediatric radiology imaging trends for non-COVID-19-related illnesses through different stages of the pandemic.

PURPOSE: To evaluate how the COVID-19 pandemic affected the imaging utilization patterns for non-COVID-19-related illness in a pediatric emergency department (ED). METHODS: We retrospectively reviewed radiology reports for ultrasound, CT, MRI, and fluoroscopy studies performed at a pediatric ED in April from 2017 to 2021, excluding studies for respiratory symptoms and trauma. Radiology reports and medical records were reviewed to determine if patients had a positive radiology diagnosis, the type of diagnosis, and whether it required hospital admission. Results from during the pandemic were compared to predicted rates based on pre-pandemic years. RESULTS: A total of 2198 imaging studies were included. During the COVID-19 pandemic, fewer ED imaging studies were performed compared to predicted. The decrease was greater in April 2020 (RR = 0.56, p < 0.001) than in April 2021 (RR = 0.80, p = 0.038). The odds of positive diagnosis was higher during the pandemic than before, and higher in 2020 (OR 2.53, p < 0.001) than in 2021 (OR 1.38, p = 0.008). The expected numbers of positive diagnoses and hospital admittances remained within the predicted range during the pandemic (p = 0.505-0.873). CONCLUSIONS: Although imaging volumes decreased during the studied months of the pandemic, the number of positive findings was unchanged compared to prior years. No differences were demonstrated in the percentage of patients admitted to the hospital with positive imaging findings. This suggests that, at our institution, the pandemic did not lead to a substantial number of missed diagnoses or severely delay the diagnosis of non-COVID-related conditions. While still lower than expected, imaging volumes increased in April 2021 suggesting a return towards baseline patient behavior as the pandemic conditions improved.

Noninvasive Ventilation and Outcomes in Bronchiolitis.

OBJECTIVES: Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest. DESIGN: Multicenter retrospective cross-sectional study. SETTING: Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database. PATIENTS: Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0). CONCLUSIONS: In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.

The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team.

INTRODUCTION: Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT). Methods: We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors. Results: Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period. Conclusion: We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

BACKGROUND: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. OBJECTIVES: Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. METHODS: A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. RESULTS: 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. CONCLUSION: BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings.

BACKGROUND: First-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children. METHODS: We performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS. RESULTS: Intubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen. CONCLUSIONS: Placement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.

Cognitive Errors in Pediatric Emergency Medicine.

ABSTRACT: Fundamental to the practice of pediatric emergency medicine is making timely and accurate diagnoses. However, studies have shown errors in this process are common. A number of factors in the emergency department environment as well as identifiable errant patterns of thinking can contribute to such challenges. Cognitive psychologists have described 2 types of thinking: system 1 (fast) relies primarily on intuition and pattern recognition, whereas system 2 (slow) is more deliberative and analytical. Reviewing how these 2 styles of thinking are applied in clinical practice provides a framework for understanding specific cognitive errors. This article uses illustrative examples to introduce many of these common errors, providing context for how and why they occur. In addition, a practical approach to reducing the risk of such errors is offered.

Use of the C-MAC Macintosh 0 Blade for Intubation of Infants in the Emergency Department.

ABSTRACT: First-pass success rates during intubation of infants in the emergency department have been shown to be low. Video laryngoscopy is being increasingly used during advanced airway management in the emergency department, but available data have not supported improved outcomes with use in pediatrics. The newly available Macintosh size 0 (curved) blade for the C-MAC video laryngoscope offers a narrower blade for use in infants. We describe the use of the new C-MAC Macintosh 0 blade for intubation of 2 infants with apnea secondary to respiratory syncytial virus bronchiolitis. The included video recording demonstrates the favorable glottic view and improved maneuverability offered by the narrower blade but also highlights the limitation in use beyond young infants given the short blade length.

Maintenance of Certification Pediatrics: Pediatric Emergency Medicine (PEM): The New Part 3 Maintenance of Certification Assessment Option.

ABSTRACT: Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

BACKGROUND: Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. METHODS: Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. RESULTS: Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. CONCLUSIONS: Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

Research Interest in Pediatric Emergency Medicine Fellows.

OBJECTIVE: Factors predictive of research career interest among pediatric emergency medicine (PEM) fellows are not known. We sought to determine the prevalence and determinants of interest in research careers among PEM fellows. METHODS: We performed an electronically distributed national survey of current PEM fellows. We assessed demographics, barriers to successful research, and beliefs about research using 4-point ordinal scales. The primary outcome was the fellow-reported predicted percentage of time devoted to clinical research 5 years after graduation. We measured the association between barriers and beliefs and the predicted future clinical research time using the Spearman correlation coefficient. RESULTS: Of 458 current fellows, 231 (50.4%) submitted complete responses to the survey. The median predicted future clinical research time was 10% (interquartile range, 5%-20%). We identified no association between sex, residency type, and previous research exposure and predicted future research time. The barrier that most correlated with decreased predicted clinical research time was difficulty designing a feasible fellowship research project (Spearman coefficient [ρ], 0.20; P = 0.002). The belief that most correlated with increased predicted clinical research time was excitement about research (ρ = 0.69, P < 0.001). CONCLUSIONS: Most fellows expect to devote a minority of their career to clinical research. Excitement about research was strongly correlated with career research interest.

Preferred learning modalities and practice for critical skills: a global survey of paediatric emergency medicine clinicians.

OBJECTIVE: To describe senior paediatric emergency clinician perspectives on the optimal frequency of and preferred modalities for practising critical paediatric procedures. METHODS: Multicentre multicountry cross-sectional survey of senior paediatric emergency clinicians working in 96 EDs affiliated with the Pediatric Emergency Research Network. RESULTS: 1332/2446 (54%) clinicians provided information on suggested frequency of practice and preferred learning modalities for 18 critical procedures. Yearly practice was recommended for six procedures (bag valve mask ventilation, cardiopulmonary resuscitation (CPR), endotracheal intubation, laryngeal mask airway insertion, defibrillation/direct current (DC) cardioversion and intraosseous needle insertion) by at least 80% of respondents. 16 procedures were recommended for yearly practice by at least 50% of respondents. Two procedures (venous cutdown and ED thoracotomy) had yearly practice recommended by <40% of respondents. Simulation was the preferred learning modality for CPR, bag valve mask ventilation, DC cardioversion and transcutaneous pacing. Practice in alternative clinical settings (eg, the operating room) was the preferred learning modality for endotracheal intubation and laryngeal mask insertion. Use of models/mannequins for isolated procedural training was the preferred learning modality for all other invasive procedures. Free-text responses suggested the utility of cadaver labs and animal labs for more invasive procedures (thoracotomy, intercostal catheter insertion, open surgical airways, venous cutdown and pericardiocentesis). CONCLUSIONS: Paediatric ED clinicians suggest that most paediatric critical procedures should be practised at least annually. The preferred learning modality depends on the skill practised; alternative clinical settings are thought to be most useful for standard airway manoeuvres, while simulation-based experiential learning is applicable for most other procedures.

Reexpansion Pulmonary Edema in Pediatrics.

Reexpansion pulmonary edema is a rare complication that may occur after drainage of pneumothorax or pleural effusion. A number of factors have been identified that increase the risk of developing reexpansion pulmonary edema, and pathophysiologic mechanisms have been postulated. Patients may present with radiographic findings alone or may have signs or symptoms that prompt evaluation and diagnosis. Clinical presentations range from mild cough to respiratory failure and hemodynamic compromise. Treatment strategies are supportive, and should be tailored to match the severity of the condition.

Teaching Incision and Drainage: Perceived Educational Value of Abscess Models.

OBJECTIVES: Incision and drainage (I&D) of skin abscesses is an important procedural skill for pediatric emergency medicine providers. Practical skills training using simulation provides an opportunity to learn and gain confidence with this invasive procedure. Our objective was to assess the perceived educational value of 2 versions of an abscess model as part of an educational workshop for teaching I&D. METHODS: A combined didactic and practical skills workshop was developed for use at 2 national conferences. The didactic content was created through an iterative process. To facilitate hands-on training, 2 versions of an abscess model were created: 1 constructed from a negative mold and the other using a 3-dimensional printer. Participants were surveyed regarding prior experience with I&D, procedural confidence, and perceptions of the educational utility of the models. RESULTS: Seventy physicians and 75 nurse practitioners participated in the study. Procedural confidence improved after training using each version of the model, with the greatest improvements noted among novice learners. Ninety-four percent of physicians, and 99% of nurse practitioners rated the respective models as either "educational" or "very educational," and 97% and 100%, respectively, would recommend the abscess models to others. CONCLUSIONS: A combined didactic and practical skills educational workshop using novel abscess models was effective at improving learners' confidence. Our novel models provide an effective strategy for teaching procedural skills such as I&D and demonstrate a novel use of 3-dimensional printers in medical education. Further study is needed to determine if these educational gains translate into improvement in clinical performance or patient outcomes.

High-flow nasal cannula therapy beyond the perinatal period.

PURPOSE OF REVIEW: High-flow nasal cannula (HFNC) is emerging as a means of oxygen delivery and respiratory support for a range of conditions outside the perinatal period. We aim to review the mechanisms of action and advantages of HFNC and to summarize current findings regarding clinical benefit in specific pediatric disease processes and in patients with significant respiratory distress. RECENT FINDINGS: Currently published studies outside the neonatal population demonstrate both safety and efficacy of this mode of respiratory support. Retrospective and prospective observational trials have shown improvements in oxygenation and respiratory distress, as well as reductions in the need for intubation in select patient populations. Randomized controlled trials are ongoing. SUMMARY: HFNC is emerging as a means of oxygen delivery and respiratory support across a wide range of pediatric conditions. Available data suggest that it is well tolerated by children and can have a favorable effect on clinical outcomes. Future research will better define optimal patient populations and best practices for use.