Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time.

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding: None.

Difficult intubation in syndromic versus nonsyndromic forms of micrognathia in children.

BACKGROUND: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate. METHODS: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. RESULTS: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185). CONCLUSIONS: Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines.

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines.

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

The role of WhatsApp™ in pediatric difficult airway management: A study from the PeDI Collaborative.

BACKGROUND: Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI-C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI-C members. METHOD: Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI-C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI-C WhatsApp™ group. RESULTS: 5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case-sharing 78 (22.2%). The median number of responses to original stems was 9 [2-21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41-1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86-1.45]; p < .0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33-1.40], p < .0016), and clinical case-sharing (regression coefficient 1.2547, 95% CI [0.9401-1.5693] p < .0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice. DISCUSSION: The PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing.

Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry.

BACKGROUND: Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. METHODS: We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. RESULTS: The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. CONCLUSIONS: Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Evaluating the Women's Empowerment and Leadership Initiative: Supporting mentorship, career satisfaction, and well-being among pediatric anesthesiologists.

The Society for Pediatric Anesthesia launched the Women's Empowerment and Leadership Initiative (WELI) in 2018 to empower highly productive women pediatric anesthesiologists to achieve equity, promotion, and leadership. WELI is focused on six career development domains: promotion and leadership, networking, conceptualization and completion of projects, mentoring, career satisfaction, and sense of well-being. We sought feedback about whether WELI supported members' career development by surveys emailed in November 2020 (baseline), May 2021 (6 months), and January 2022 (14 months). Program feedback was quantitatively evaluated by the Likert scale questions and qualitatively evaluated by extracting themes from free-text question responses. The response rates were 60.5% (92 of 152) for the baseline, 51% (82 of 161) for the 6-month, and 52% (96 of 185) for the 14-month surveys. Five main themes were identified from the free-text responses in the 6- and 14-month surveys. Members reported that WELI helped them create meaningful connections through networking, obtain new career opportunities, find tools and projects that supported their career advancement and promotion, build the confidence to try new things beyond their comfort zone, and achieve better work-life integration. Frustration with the inability to connect in-person during the coronavirus-19 pandemic was highlighted. Advisors further stated that WELI helped them improve their mentorship skills and gave them insight into early career faculty issues. Relative to the baseline survey, protégés reported greater contributions from WELI at 6 months in helping them clarify their priorities, increase their sense of achievement, and get promoted. These benefits persisted through 14 months. Advisors reported a steady increase in forming new meaningful relationships and finding new collaborators through WELI over time. All the members reported that their self-rated mentoring abilities improved at 6 months with sustained improvement at 14 months. Thus, programs such as WELI can assist women anesthesiologists and foster gender equity in career development, promotion, and leadership.

Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry.

BACKGROUND: Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of this study was to compare the first-attempt success rate of tracheal intubation during sedated tracheal intubation versus tracheal intubation under general anesthesia. The hypothesis was that sedated intubation would be associated with a lower first-attempt success rate and more complications than general anesthesia. METHODS: This study used data from an international observational registry, the Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. The use of sedation versus general anesthesia for tracheal intubation were compared. The primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and nonsevere and severe complications. Propensity score matching was used with a matching ratio up to 1:15 to reduce bias due to measured confounders. RESULTS: Between 2017 and 2020, 34 hospitals submitted 1,839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation, and 1,764 patients received general anesthesia. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the general anesthesia group. The rate of first-attempt success of tracheal intubation was 28 of 58 (48.3%) in the sedation group and 250 of 522 (47.9%) in the general anesthesia group (odds ratio, 1.06; 95% CI, 0.60 to 1.87; P = 0.846). The median number of intubations attempts was 2 (interquartile range, 1 to 3) in the sedation group and 2 (interquartile range, 1, 2) in the general anesthesia group. The general anesthesia group had 6 of 522 (1.1%) intubation failures versus 0 of 58 in the sedation group. However, 16 of 58 (27.6%) sedation cases had to be converted to general anesthesia for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low. CONCLUSIONS: Sedation and general anesthesia had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to general anesthesia to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.

A prospective observational study of video laryngoscopy-guided coaching in the pediatric intensive care unit.

BACKGROUND: There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. AIM: Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation-associated events. METHODS: This is a pre-post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single-center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation-associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured. RESULTS: Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation-associated events between the two phases (pre- 9% vs. post- 5%, absolute difference -3%, CI95 : -8% to 1%, p = .11), oxygen desaturations <80% (pre- 13% vs. post- 13%, absolute difference 1%, CI95 : -6% to 5%, p = .75), or first attempt success (pre- 73% vs. post- 76%, absolute difference 4%, CI95 : -3% to 11%, p = .29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95 : 23% to 51%, p < .001). CONCLUSIONS: Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation-associated events and oxygen desaturation.

Practice what you teach: An approach to integrate airway education for experienced anesthesia clinicians.

BACKGROUND: The COVID-19 pandemic has disrupted clinician education. To address this challenge, our divisional difficult airway program (AirEquip) designed and implemented small-group educational workshops for experienced clinicians. Our primary aim was to test the feasibility and acceptability of a small-group, flexible-curriculum skills workshop conducted during the clinical workday. Secondary objectives were to evaluate whether our workshop increased confidence in performing relevant skills and to assess the work-effort required for the new program. METHODS: We implemented a 1:1 and 2:1 (participant to facilitator ratio) airway skills workshop for experienced clinicians during the workday. A member of the AirEquip team temporarily relieved the attendee of clinical duties to facilitate participation. Attendance was encouraged but not required. Feasibility was assessed by clinician attendance, and acceptability was assessed using three Likert scale questions and derived from free-response feedback. Participants completed pre and postworkshop surveys to assess familiarity and comfort with various aspects of airway management. A work-effort analysis was conducted and compared to the effort to run a previously held larger-format difficult airway conference. RESULTS: Fifteen workshops were conducted over 7 weeks; members of AirEquip were able to temporarily assume participants' clinical duties. Forty-seven attending anesthesiologists and 17 CRNAs attended the workshops, compared with six attending anesthesiologists and five CRNAs who attended the most recent larger-format conference. There was no change in confidence after workshop participation, but participants overwhelmingly expressed enthusiasm and satisfaction with the workshops. The number of facilitator person-hours required to operate the workshops (105 h) was similar to that required to run a single all-day larger-format conference (104.5 h). CONCLUSION: It is feasible and acceptable to incorporate expert-led skills training into the clinical workday. Alongside conferences and large-format instruction, this modality enhances the way we are able to share knowledge with our colleagues. This concept can likely be applied to other skills in various clinical settings.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Empowering Women as Leaders in Pediatric Anesthesiology: Methodology, Lessons, and Early Outcomes of a National Initiative.

Research has shown that women have leadership ability equal to or better than that of their male counterparts, yet proportionally fewer women than men achieve leadership positions and promotion in medicine. The Women's Empowerment and Leadership Initiative (WELI) was founded within the Society for Pediatric Anesthesia (SPA) in 2018 as a multidimensional program to help address the significant career development, leadership, and promotion gender gap between men and women in anesthesiology. Herein, we describe WELI's development and implementation with an early assessment of effectiveness at 2 years. Members received an anonymous, voluntary survey by e-mail to assess whether they believed WELI was beneficial in several broad domains: career development, networking, project implementation and completion, goal setting, mentorship, well-being, and promotion and leadership. The response rate was 60.5% (92 of 152). The majority ranked several aspects of WELI to be very or extremely valuable, including the protégé-advisor dyads, workshops, nomination to join WELI, and virtual facilitated networking. For most members, WELI helped to improve optimism about their professional future. Most also reported that WELI somewhat or absolutely contributed to project improvement or completion, finding new collaborators, and obtaining invitations to be visiting speakers. Among those who applied for promotion or leadership positions, 51% found WELI to be somewhat or absolutely valuable to their application process, and 42% found the same in applying for leadership positions. Qualitative analysis of free-text survey responses identified 5 main themes: (1) feelings of empowerment and confidence, (2) acquisition of new skills in mentoring, coaching, career development, and project implementation, (3) clarification and focus on goal setting, (4) creating meaningful connections through networking, and (5) challenges from coronavirus disease 2019 (COVID-19) and the inability to sustain the advisor-protégé connection. We conclude that after 2 years, the WELI program has successfully supported career development for the majority of protégés and advisors. Continued assessment of whether WELI can meaningfully contribute to attainment of promotion and leadership positions will require study across a longer period. WELI could serve as a programmatic example to support women's career development in other subspecialties.

A Coronavirus Disease 2019 Pandemic Pivot: Development of the American Board of Anesthesiology's Virtual APPLIED Examination.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic interrupted the administration of the APPLIED Examination, the final part of the American Board of Anesthesiology (ABA) staged examination system for initial certification. In response, the ABA developed, piloted, and implemented an Internet-based "virtual" form of the examination to allow administration of both components of the APPLIED Exam (Standardized Oral Examination and Objective Structured Clinical Examination) when it was impractical and unsafe for candidates and examiners to travel and have in-person interactions. This article describes the development of the ABA virtual APPLIED Examination, including its rationale, examination format, technology infrastructure, candidate communication, and examiner training. Although the logistics are formidable, we report a methodology for successfully introducing a large-scale, high-stakes, 2-element, remote examination that replicates previously validated assessments.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

BACKGROUND: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. METHODS: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. RECOMMENDATIONS: In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. REFLECTION: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. CONCLUSIONS: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Operations and outcomes of a Hospital-wide Emergency Airway Response Team (HEART) in a quaternary academic children's hospital.

BACKGROUND: To improve pediatric airway management outside of the operating room, a Hospital-wide Emergency Airway Response Team (HEART) program composed of anesthesiology, otorhinolaryngology, and respiratory therapy clinicians was developed. AIMS: To report processes and outcomes of HEART activations in a quaternary academic children's hospital. METHODS: A retrospective observational cohort study between January 2017 and December 2019. Local airway emergency database was reviewed for HEART activations. Additional safety data was obtained from patients' electronic health records. PRIMARY OUTCOME: Adverse airway outcomes, either adverse tracheal intubation-associated events or oxygen desaturation (SpO2 <80%). We compared airway management by primary teams before HEART arrival and by HEART after arrival. RESULTS: Of 96 HEART activations, 36 were from neonatal intensive care unit, 35 from pediatric and cardiac intensive care units, 14 from emergency department, and 11 from inpatient wards. 56 (62%) children had airway anomalies and 41/96 (43%) were invasively ventilated. Median HEART arrival time was 5 min (interquartile range, 3-5). 56/96 (58%) required insertion of an advanced airway (supra/extra-glottic airway, endotracheal tube, tracheostomy tube). HEART succeeded in establishing a definitive airway in 53/56 (94%). Adverse airway outcomes were more common before (56/96, 58%) versus after HEART arrival (28/96, 29%; absolute risk difference 29%; 95% confidence interval 16, 41%; p < .001). Oxygen desaturation occurred more frequently before (46/96, 48%) versus after HEART arrival (24/96, 25%; absolute risk difference 23%; 95% confidence interval 11, 35%; p = .02). Cardiac arrests were more common before (9/96, 9%) versus after HEART arrival (3/96, 3%). Multiple (≥3) intubation attempts were more frequent before (14/42, 33%) versus after HEART arrival (9/46, 20%; absolute risk difference -14%; 95% confidence interval -32, 5%; p = .15). CONCLUSIONS: A multidisciplinary emergency airway response team plays an important role in pediatric airway management outside of the operating room. Adverse airway outcomes were more frequent before compared to after HEART arrival.