SPA Annual Meeting Reviews

Session III: Pedx Talks: Error Traps in Airway Management

Reviewed by Sharon A. Ashley MD, MPH, MBA, FASA
Professor, University of California, Davis

Dr. Ashley

Error Traps in Airway Management
Narasimhan “Sim” Jagannathan, MD, MBA

Narasimhan Jagannathan, MD, MBA (Vice Chair and Division Head, Professor, Ann and Robert H. Lurie Children’s Hospital of Chicago) presented an outline for the lecture on "Error Traps in Airway Management" which included difficult airway management in children as well as identifying and resolving error traps in airway management. He discussed an article by John Fiadjoe1 from the Pediatric Difficult Intubation Registry which stated that the most common difficult airway complication is hypoxia and the most common major complication is cardiac arrest. Risk factors associated with airway complications were identified as; weight < 10 kg, short thyromental (TM) distance (micrognathia), and more than two attempts at intubation.1

Dr. Jagannathan emphasized that the clinical translation from the article is: intubation in infants and children is associated with time pressure because they have decreased oxygen reserve. The caveat is to consider oxygenating during the apneic period. Oxygen desaturation forces the anesthesiologist to abandon the intubation attempt in order to mask ventilate which may lead to multiple attempts at intubation. Keeping this concept at the forefront, it is beneficial to use an advanced alternative technique if early direct laryngoscopy fails. Advanced techniques include; fiberoptic techniques, video laryngoscopy and supraglottic techniques.

Error Trap #1 Communication – Case Scenario
Dr. Jagannathan presented the case of a 2-day old in the NICU with severe upper airway obstruction

The NICU attending attempts laryngoscopy x 2 and fails; he calls you for help.  Your pediatric anesthesiology fellow, otolaryngology (ENT) attending and fellow, and you arrive to the NICU. The ENT attending wants to try with a Phillips blade. Dr. Jagannathan posed the question, “what would you do?” He further explained that the error traps in this scenario are: Authority bias – which is described as declining to disagree with an “expert” and the Dunning-Krueger effect which involves unskilled individuals overestimating their abilities and experts underestimating theirs.

The Solution: Perform a time out. In the chart below, Dr. Jagannathan identifies a scenario that allows for evaluation of the clinical status of the patient and to delineate roles and expectations.

Error Trap #2 – Iatrogenic Difficulty
In this scenario, Dr. Jagannathan stated that we should aim for first pass success at intubation. He reminded the audience to avoid the error of unnecessary attempts by not employing early use of advanced airway devices. Dr. Jagannathan went further to state that each attempt over two attempts is a critical attempt, and we must remember multiple trials may produce airway trauma and other complications. He shared the below chart which shows the comparative success rate, in children < 10 kg and > 10 kg, with Direct Laryngoscopy, Video Laryngoscopy, Flexible Bronchoscopy and Fiberoptic with Supra Glottic Airway.

Dr. Jagannathan explained that the intubation success rate using direct laryngoscopy was quite low; however, use of the video laryngoscope, specifically, the glide scope provided a higher success rate of tracheal intubation than direct laryngoscopy.2 He also discussed an article by Nicholas E. Burjek3 which provided an analysis from the Multicenter Pediatric Difficult Intubation Registry. The two main concepts he highlighted were:

1. In older children, there are similar first attempt success rates for fiberoptic intubation via supraglottic airway (SGA) and video laryngoscopy.
2. In infants – fiberoptic intubation via a supraglottic airway was more successful than the use of video laryngoscopy.

Thus, in the case of the patient with Pierre Robin, the decision must be made regarding the mechanism of airway securement: direct laryngoscopy vs video laryngoscopy vs flexible bronchoscopy.

The solutions for Error Trap #2 included the following:

1. Set the narrative with your trainee, nurse anesthetist, anesthesia assistant.
2. Aim for 1st pass success.
3. Consider different devices remembering smaller children with micrognathia may have limited mouth opening.
4. Flexible bronchoscopy via SGA may be a better choice in infants < 10 kg.
5.  Simple nasal prongs can be used on every patient during intubation,
   – NASAL PRONGS ARE UNDERUTILIZED.
6. Oxygenate passively. Oxygen desaturation forces the anesthesiologist to interrupt the attempt to in order to ventilate.

Error Trap: Oxygenation During Attempts. Dr. Jagannathan described perceived cultural biases that can exists such as “it takes an extra step to place the nasal prongs” and “nobody else in the practice does it.” He also explained that confirmational biases include a tendency to interpret, favor and recall information in a way that confirms or supports one’s prior beliefs or values. Several potential solutions included changing the culture, changing expectations, changing beliefs and changing habits. This can be achieved with education and adoption into routine practice.4,5

Error Trap #3 – Bandwagon Effect
Dr. Jagannathan presented the same infant with Pierre Robin, and asked, “should the provider allow for respirations to be spontaneous or controlled?” He emphasized that “It is hard to kill a spontaneously breathing patient!” With the spontaneous technique he suggested that we have a “Bandwagon effect “– if everyone else thinks it, it must be right!  Interestingly, when considering spontaneous vs. controlled ventilation, a retrospective analysis from the Pediatric Difficult to Intubate Registry by Garcia Marinkiewicz in Anesthesia Analgesia6 states there were more complications (hypoxemia/laryngospasm) with spontaneous ventilation versus controlled ventilation group.6  

With regard to the solutions for Error Trap #3; Dr. Jagannathan urged us to consciously decide to do either a spontaneous vs. a controlled technique independent of the labels applied by others and to always ensure adequate anesthetic depth.

In conclusion, Dr. Jagannathan stated that the Pediatric Difficulty Airway is always challenging with added stress from time pressure and desaturation. He suggested that we recognize and mitigate the error traps by ensuring a clear line of communication, identifying the roles and expectations of each person present, aiming for first pass success, and minimizing cognitive biases.

References:

1. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (peDI)registry: a prospective cohort analysis. Dec 2015. The Lancet Respiratory Medicine 4(1): John E. Fiadjoe, et al.
2. Clinical Investigation: The efficacy of Glide scope video laryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the Paediatric Difficult Intubation Registry. R. Park et al, BJA 2017.
3. Nicholas E. Burjek3, et al Anesthesiology Sept 2017.
4. Fiadjoe JE, et al, Oxygen supplementation during prolonged tracheal intubation should be the standard of care. BJA 117 (4): 417-8, 2016.
5. Sohn, Lisa MS Apneic oxygenation as a Standard of Care in Children: How Do We Get There?
6. A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Garcia Marcinkiewicz AG et al A&A 2019.