Handling Error Traps in Difficult Airway Management in Paediatric Patients With Mandible Tumour: Lessons Learned From Two Cases

doi:10.21203/rs.3.rs-2228551/v1

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Case Report

Handling Error Traps in Difficult Airway Management in Paediatric Patients With Mandible Tumour: Lessons Learned From Two Cases

https://doi.org/10.21203/rs.3.rs-2228551/v1

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Introduction

Various factors can cause difficult airways in the paediatric population, such as congenital anomalies, obstruction, tumours, etc. Failure in managing difficult airways in children is associated with significant morbidity and mortality. We present a case series of how identifying error traps will improve patient care and safety.

Case

We present two similar cases of children with impending airway obstruction due to mandible tumours who were indicated for an urgent tracheostomy. In the first case, there was an airway management failure (cannot intubate, cannot oxygenate). The patient deteriorated rapidly and died in the operating theatre. Aftermath, we conducted a multidisciplinary discussion of experts and analysed this sentinel case. In the first case, there were some error traps related to preparation, performance, and proficiency. Thus, recommendations were advised. The second case occurred 14 days following the first one. This time we delivered the airway management by implementing the recommendation from previous case failures, which were: choosing the appropriate anaesthesia technique and airway device, performing adequate passive oxygenation before an intubation attempt, having a mitigation plan, and communicating it with the surgeon. Also, an airway expert should always be available to be consulted. Lastly, conducting a debriefing with the team involved after the procedure to identify the experienced problems. The team managed to perform the tracheostomy on the second child successfully.

Conclusion

Mortality and morbidity due to airway management failure in paediatric patients with difficult airways could be reduced by averting error traps and following the recommendation to have better preparation in airway management techniques and planning, good inter-team communication and coordination, and consult a more experienced anaesthesiologist to lead the team.

Paediatric

difficult airway management

error traps

Failure of airway management in paediatric patients is a bitter pill to swallow, especially for anaesthesiologists working in tertiary hospitals. This failure may result in morbidity and mortality of patients we have experienced.

Airway management of paediatric patients is a crucial component in an operating theatre, intensive care unit, and emergency room. In paediatric populations, anatomical and physiological differences between children and adults tend to complicate airway management, such as ventilation, direct laryngoscopy, and endotracheal intubation. Short apnoeic time in children further intricates airway management in children. Even paediatric anaesthesiologists and trained emergency paediatricians sometimes have difficulties managing airways in paediatric patients, resulting in morbidity or mortality. (1)

Data from The American Society of Anesthesiologists (ASA) and Perioperative Cardiac Arrest Registry show that respiratory complications are the most common cause of morbidity and mortality in paediatric patients. Incidence of difficult airways in children is 0.28%, 2% of which need surgical airway intervention. Cannot intubate, cannot oxygenate (CICO) is an uncommon complication, but this condition often has an abysmal prognosis. Children with CICO may desaturate rapidly due to high oxygen consumption and low functional residual lung capacit(2) y. Numerous catastrophic accidents on airway management can be anticipated with an adept pre-anaesthetic assessment, thorough planning, and a well-executed plan done by a trained anaesthesiologist. (1, 2, 3)

In this case series, we report two paediatric patients with difficult airways; both were diagnosed with a mandibular tumour that infiltrated the oral cavity and underwent tracheostomy procedures. In the first case, the failure of airway management resulted in rapid desaturation, and the patient died on the surgery table despite a successful tracheostomy procedure. An analysis done by a multidiscipline team consisting of anaesthesiologists, ENT surgeons, paediatricians, nursing team, and hospital management found several factors to be the cause. Thus, recommendations could be devised to improve patient care and safety in the hospital.

1st Case

An 8-year-old boy weighing 19 kg was diagnosed with a threatened airway due to a mandibular tumour. The patient was scheduled to have a secondary tracheostomy procedure. The patient's tumour bled easily. At that time, the patient had an upper respiratory infection causing the patient to cough with yellowish mucopurulent-purulent difficult-to-expectorate sputum. These factors further exacerbate the patient's condition. The patient also experienced anxiety and became uncooperative. We concluded that the patient would be difficult to ventilate and intubate considering these findings.

The airway management was planned with non-apnoeic sleep using a video laryngoscope and a no.2 McGrath blade. After inhalation of 40 mg lidocaine and 0.1 mg epinephrine, the anaesthesiologist would perform endotracheal intubation. Before induction, there was copious secretion from the patient's mouth, and the patient was more comfortable in a sitting position. The patient was hemodynamically stable with a heart rate of 130–140 beats per minute and blood pressure of 100 mmHg over 62 mmHg. Induction was performed using 10 mg of intravenous Ketamine and 20 mcg of intravenous Fentanyl. The anaesthesia was further deepened using inhalation of 6 vol% sevoflurane by spontaneous breathing. The patient began to desaturate after losing consciousness, and there was blood gushing from the patient's mouth. Peripheral oxygen saturation was 70%, and the anaesthesiologist decided to attempt to intubate using a video laryngoscope.

The anaesthesiologist’s field of view was not improving despite blood and oral secretions suctioning. Consequently, the intubation attempt failed, and the patient's oxygen saturation dropped to 46%. The patient began to be bradycardic, and then needle cricothyroidotomy was attempted, but to no avail. The ENT surgeon took charge of the airway and performed a tracheostomy. The situation became chaotic as the patient was categorised as CICO (cannot intubate, cannot oxygenate) patient. While the tracheostomy was being performed, suctioning blood, oral secretions, and oxygen delivery via face mask were done alternately. Tracheostomy cannula insertion was hard, and the patient had cardiac arrest, and cardiac, pulmonary resuscitation was performed. At the first tracheostomy cannula insertion attempt, the etCO₂ reading was not detectable. A bronchoscopy confirmed that the cannula was not visible in the tracheal lumen; therefore, it was decided to attempt another tracheostomy cannula insertion. At the second insertion attempt, the cannula was confirmed to be in the tracheal lumen with fibreoptic bronchoscopy. The patient was still in cardiac arrest while CPR was being performed. Since ROSC (return of spontaneous circulation) had not been attained, another bronchoscopy was performed via the tracheostomy cannula. It was found that there was a mass obstructing the left main bronchus. The patient was pronounced deceased after a 30-minute CPR.

The team reported this incident to the Patient Safety and Quality Committee, and it was classified as a sentinel event. All the involved team and experts were gathered to discuss the cause of airway management failure in this case. The analysis was done using a fishbone diagram, and the result is shown below (Diagram 1)

The discussion resulted in several recommendations:

Perform adequate assessments using necessary workups to identify potentially difficult airway
Option for appropriate anaesthesia techniques and airway devices to increase the chance of first-pass intubation
Form a paediatric difficult airway team consisting of experts to manage similar cases
Give training and education about difficult airway management to residents, anaesthesiologists, and ENT surgeons.
Choosing a more appropriate time to manage a difficult airway case so experts consult can be more easily obtained
Devise a pre-formulated airway plan for every difficult airway case and brief the plan with the involved teams before the induction.

A similar case was presented two weeks after the first case.

2nd Case

A 7-year-old boy weighing 16 kg was admitted to the hospital with hypovolemic shock due to bleeding from a mandibular tumour. The patient had an impending airway obstruction due to his tumour; hence he was scheduled to have a secondary tracheostomy. We conducted a COVID-19 screening for surgery using a nasopharyngeal PCR swab test, and the result came back positive. The patient also had moderate-degree pneumonia due to COVID-19. After performing a pre-surgery assessment, we determined that the patient would be difficult to ventilate and intubate, and the patient's COVID-19 pneumonia and history of hypovolemic shock due to haemorrhage from the tumour further sophisticated the case. The patient was anxious and uncooperative, which made awake intubation impossible to perform on the patient.

The anaesthesia team opened a discussion with the ENT team regarding actual and potential problems during anaesthesia induction. Taking into account the patient's emergency situation, the discussion was done in a timely fashion. It was decided that the induction would be done with a sleep non apnoea technique using dexmedetomidine combined with fentanyl and inhalation anaesthesia. Fibreoptic bronchoscopy would be used to intubate the patient. The surgery team was also notified to prepare to perform surgical airway intervention: from needle cricothyroidotomy to tracheostomy with front of neck access. Thus, the most experienced member was chosen to be the operator. The patient's family was informed about the risk and how the procedure would be done, and the consent was obtained. The patient was connected to a vital signs monitor in the operating theatre and administered beta 2 agonists via inhalation; then, the patient was pre-oxygenated with a no. 5 face mask. The induction agents used in this procedure were intravenous Fentanyl 25 mcg, intravenous drip of 1 mcg/kg/hour Dexmedetomidine, and inhalation of Sevoflurane 6 vol%. Additional airway block was performed using local anaesthetic Lidocaine 2%. Endotracheal intubation was successful after the second attempt using fibreoptic bronchoscopy. Throughout the procedure, the patient was hemodynamically stable and admitted to PICU.

According to a study conducted by The Anaesthesia Practice in Children Observational Trial (APRICOT) on children under 15-year-old who underwent 31,127 procedures with anaesthesia in 261 hospitals in Europe, the incidence of the critical airway is 5.2%. The events ranged from laryngospasms, bronchospasms, bronchial aspirations, and post-anaesthesia stridor. Patients predicted to be difficult to intubate experience critical airway events more frequently. The Paediatric Difficult Intubation Collaborative's study showed a similar finding – critical airway events happened to 20% of 1018 paediatric patients with difficult airways in 13 hospitals. The complications recorded in the study mentioned above were cardiac arrest, hypoxemia, laryngospasm, and airway trauma. (4)

Comprehension of various factors that might contribute to difficult airways in paediatric patients can minimise and prevent events that might lead to morbidity or mortality of the patients. Several potential errors (error traps) in paediatric airway management can be categorised into preparation errors, performance errors, and proficiency errors. (5)

Preparation Errors

Paediatric patients with difficult airways can be divided into three categories, as shown in Table 1. Patients with facial tumours fall into patients with difficult airways; therefore, treatments and procedures done on the patients have to be done in a well-equipped hospital with experienced personnel to ensure patients' safety. The presence of a surgical operator when induction is being performed is an essential factor because, often, a tracheostomy procedure is the only reliable option to rescue a patient's airway.

Table 1

Classification of Difficult Airways in Paediatric Patients
Unexpected difficulties in normal airways	Anatomical obstruction Functional obstruction
Disturbances of normal paediatric airways	Inflammation Foreign bodies Allergy Trauma
Difficult airways	Abnormality of head, neck, or airway morphology Congenital malformations associated with syndromes Acquired malformation (burn injuries, scars) Mass or tumour Abnormality in the subglottic or tracheal region Anterior mediastinum mass

Table 1. Difficult Airways Classification

Source: Krishna SG, Bryant JF, Tobias JD. Management of the Difficult Airway in the Paediatric Patient. J Paediatr Intensive Care. 2018

In this case series, both of the patients planned to have a tracheostomy to rescue their airways since there had been signs of obstruction – inspiratory and expiratory stridor when the patients were awake. The patients were both categorised as patients with difficult airways. Hence, it is not recommended to sedate the patients in a facility without a multidisciplinary team with experts in paediatric airway management. Performing tracheostomy procedures without sedation in these patients was very difficult because the patients were not cooperative, unlike adults. Preparation to anticipate a difficult airway can be done with preoperative assessment (Table.2) (1)

Table 2

Anticipation for Difficult Airway
1. Is the procedure or surgery elective or urgent or emergent?
2. In the event of failure to secure the airway, can the patient be awakened and can an alternative airway strategy be planned for a later time?
3. Are any further evaluations necessary to define the airway?
4. Can the airway be optimized further before anaesthesia or sedation?
5. What is the level of sedation that will be required: awake (rare in paediatric patients), sedated, or anaesthetized?
6. If sedation or anaesthesia is attempted, can a patent airway and spontaneous ventilation be preserved?
7. Should a surgical airway be electively performed?
8. What is the preferred route for endotracheal intubation: oral or nasal?
9. What is the method of securing the airway: FOB intubation, use of a supraglottic airway (e.g., LMA) or indirect video laryngoscopy?
10. Is the difficult airway cart accessible and what equipment will be utilized to secure the airway?
11. If there is a loss of airway control at any point, what is the rescue route and pathway?
12. Is there a need for emergency surgical access? If so, would it be prudent to have an ENT surgeon in the room?
13. Is there a need to be prepared for complex advanced rescue procedures, such as emergency tracheostomy, emergency sternotomy, or vascular access for extracorporeal membrane oxygenation?

Source: Krishna SG, Bryant JF, Tobias JD. Management of the Difficult Airway in the Paediatric Patient. J Paediatr Intensive Care. 2018

Preparation of the airway device

Ventilation device: face mask, nasal cannula (HFNC, LFNC), supraglottic airway (6, 7, 8)
Intubation device: direct laryngoscopy, angulated video laryngoscopy, hyperangulated video laryngoscopy, fiberoptic bronchoscopy. (6, 7, 8)
Front of neck airway device. (6, 7, 8)

Endotracheal tubes with various numbers, suction catheter, stylet, and emergency trolley are available and easy to reach before starting the induction. (6, 7, 8)

Inter-team Communication

Awareness of risk factors for difficult airways and preparation to address those are essential components in dealing with children with difficult airways. It is not uncommon that the difficult airways are caused by not only anatomical factors but also physiological factors, cardiopulmonary reserve, airway secretions, blood in the airway, etc. Communicating with more experienced anaesthesiologists, including a team of surgeons, such as ENT surgeons, to devise a plan for airway management; using a standardized checklist during a time out could result in a favourable outcome when facing a child with a difficult airway. These actions may also improve the level of care provided for the next surgeries since effective communication has been built, and every team member has been given a specific task according to their area of expertise. The number of paediatric airway complications, morbidity, and mortality also can be decreased if the actions mentioned above are implemented. (5)

Table 3

Airway Management Time-out Checklist
Example of a Structured Airway Management Time-out
Introduction and Roles	- Intubation - Assistance for adjunct maneuvers - Monitoring patient and medication administration - Equipment setup
Approach	- Awake or after induction - Consider patient status (cardiopulmonary reserve, resuscitation needs)
Ventilation Strategy	- Spontaneous or controlled - Passive oxygenation plan
Airway Plan	- Plan A, B, C delineated, including device to be used - Appropriate equipment available and set up, including backup plans - Availability of appropriate experienced help and list of phone numbers of: other anesthesiologists, otolaryngologists, ECMO team

Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N. Error traps in paediatric difficult airway management. Paediatr Anaesth. 2021

In the first case, after the intubation attempts failed, we experienced difficulties in finding front neck access. Learning from that incident, we conducted a pre-surgery briefing led by anaesthesiologists to decide the course of action for airway management if there were any difficulties in the second case's surgery. Difficult airway management guidelines (Picture 3) were very accommodating in aiding each team member in understanding their role. (1)

Pre-formulated Airway Management Plan for the 2nd Patient

Performance Errors

To minimize the risks of airway complications, endotracheal intubation should be successful in the first attempt. There are several ways to achieve that, such as:

1. Adequate passive oxygenation before an endotracheal intubation attempt

Adequate oxygen supplementation can reduce the risk of hypoxemia. There are a few means to give passive oxygenation: using a nasal cannula, modified nasopharyngeal airway, modified Ring-Adair-Elwyn (RAE) TT, and high flow nasal cannula, as shown in Figs. 3 and 4. (9)

We performed a face mask simulation on the 2nd patient to fit the face mask accommodating to the patient's anatomical difference and conduct passive oxygenation via the face mask, as shown in Fig. 5 (4, 10)

2. Implementing an advanced airway technique as an initial attempt and choosing medications according to the patient's condition.

In a potentially difficult airway case, a child's uncooperativeness often hinders an awake FOB intubation attempt. On that condition, FOB intubation with sedation or anaesthesia could be an option. (11) Complications that often arise with sedation and anaesthesia are airway obstruction due to loss of consciousness and respiratory depression. Intravenous sedation agents, such as Ketamine, Dexmedetomidine, or Midazolam, are several agents that have minimal effect on respiratory control and can be used in such cases.

In the 2nd case, we used a combination of 1 mcg/kg/hour of intravenous Dexmedetomidine and 1.5 mcg/kg of intravenous Fentanyl. To further deepened the anaesthesia, inhalation of 6%vol of Sevoflurane was used. During the process of FOB, the depth of anaesthesia was preserved, and the patient kept breathing spontaneously without airway obstruction.

When the depth of the anaesthesia is adequate, airway management can be done with:

Indirect video laryngoscopy (9, 11)
Intubation using FOB (9, 11)
Intubating LMA (4, 10)

Video laryngoscopy has advantages over direct laryngoscopy: better field of view in patients with difficult airways without having to align oral, pharyngeal, and laryngeal axes; better view of the anterior portion of glottis; lower risk of injuring intraoral soft tissues, although there have been some reports regarding this; and often tongue displacement is not necessary. However, there are several setbacks to indirect video laryngoscopy: Good hand-eye coordination is needed; it cannot be used in patients with limited mouth opening and/or copious intraoral secretion or blood as secretion and blood will obstruct the lens. (12, 13)

In patients potentially difficult to ventilate, awake FOB can be a choice if there are no other safer options, especially for special populations, such as infants and neonates. Airway block can be performed on cooperative patients if local anaesthetic nebulization is impossible. Airway block has to avoid toxic doses of local anaesthetics. (5)

Airway Ultrasonography (USG)

Airway USG can be used to (a) determine the correct tracheal tube (TT) size; (b) confirm TT placement; (c) identify the cricothyroid membrane before anaesthesia induction on patients with difficult airways; (d) qualitatively or quantitatively determine gastric contents before induction. (14, 15). Figure 6, 7, and 9 shows the ultrasound of the trachea on a patient.

Proficiency Errors

All airway management techniques require team proficiency to be executed well. Declining performance and skill could happen if one does not constantly learn and train. Knowing and being able to execute various techniques are musts when facing an unusual case. Recognizing every piece of equipment that will be used is crucial. Pressure and stress when facing a difficult airway can lead to a significant increase in errors. (3, 12, 16, 17)

Not all airways devices can be used in every different situation. Recognizing the advantages and disadvantages of every device used before a procedure could help the operator to arrange a plan. Acknowledging one's limitation in performing certain procedures will give realization to consult the experts and call for help earlier.³ Technicians and assistants to assist in operating machinery also need to be prepared. To improve the skill of handling cases with difficult airways, individual and team training and simulation need to be conducted. (18, 19)

In the 2nd case, expert consults were obtained earlier, and a preoperative briefing was also performed to ensure each team member knew their role, ability, and limitation. After the procedure, a debriefing with anaesthesiologists, ENT surgeons, surgical nurses, anaesthetists, residents, and technicians was carried out to review the process and as a lesson for future improvement of patient care and safety

Difficult airway management in paediatric patients with mandibular tumours can generate high pressure and stress for anaesthesiologists. Failure to do so can result in fatal complications resulting in death. To avoid error traps that might happen in the limited time and high-pressure environment, several steps can be done:

Good preparation: thorough assessment, build an effective intra- and inter-team communication, devise mitigation plans
During the "performance": perform adequate preoxygenation, and opt for a suitable anaesthesia technique and airway device.
Proficiency: acknowledge own limitations, keep learning and improving from past experiences.

APRICOT The Anaesthesia Practice in Children Observational Trial

ASA The American Society of Anesthesiologists

BW body weight

CICO cannot intubate, cannot oxygenate

COVID-19 coronavirus disease 2019

CPR cardiopulmonary resuscitation

ENT ear, nose, and throat

etCO2 end-tidal carbon dioxide

FOB fiberoptic bronchoscopy

HFNC high flow nasal cannula

LFNC low flow nasal cannula

LMA laryngeal mask airway

PCR polymerase chain reaction

PICU pediatric intensive care unite

RAE TT Ring-Adair-Elwyn tracheal tube

ROSC return of spontaneous circulation

USG ultrasonography

Ethics approval and consent to participate

Not applicable

Consent for publication

Consents for publication were obtained from both patient’s parents/guardian prior to publication.

Availability of data and materials

Not applicable

Competing interests

The authors declare that they have no competing interests

Funding Declaration

This study received no fund from any funding agency in the public, commercial, or not-for-profit sectors

Authors’ contribution

Raihanita Zahrah, Arie Untari, Bintang Pramodana, Andi Ade Wijaya Ramlan, and Melvin Dikwan Bernaldi Kwa have made a substantial contribution to the conception and design of the study. Each author has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements

Not applicable

Third party submissions

The manuscript was submitted by Corresponding Author. There was no third party involved.

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Diagrams 1 and 2 are available in the Supplemental Files section.

No competing interests reported.

Diagram1.jpg
Diagram 1: Fishbone diagram for the first case
Diagram11.jpg
Diagram 1. Guidelines for Unanticipated Difficult Airway Management Source: Krishna SG, Bryant JF, Tobias JD. Management of the Difficult Airway in the Paediatric Patient. J Paediatr Intensive Care. 2018
Diagram2.jpg
Diagram 2. Pre-formulated Airway management plan for the 2^nd patient

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Handling Error Traps in Difficult Airway Management in Paediatric Patients With Mandible Tumour: Lessons Learned From Two Cases

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Abstract

Introduction

Case

Conclusion

Figures

Introduction

Case Presentation

1st Case

2nd Case

Discussion And Conclusion

Preparation Errors

Performance Errors

Proficiency Errors

List Of Abbreviations

Declarations

References

Diagram

Additional Declarations

Supplementary Files

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