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

  • Joshua Nagler
    Correspondence
    Corresponding author at: Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
    Affiliations
    Boston Children's Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA

    Pediatric Emergency Care Applied Research Network (PECARN), USA
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  • Marc Auerbach
    Affiliations
    Yale University School of Medicine, New Haven, CT, USA

    Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA
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  • Michael C. Monuteaux
    Affiliations
    Boston Children's Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA
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  • John A. Cheek
    Affiliations
    Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia

    Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia

    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand
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  • Franz E. Babl
    Affiliations
    Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia

    Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia

    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    University of Melbourne, Melbourne, Australia
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  • Ed Oakley
    Affiliations
    Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia

    Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia

    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    University of Melbourne, Melbourne, Australia
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  • Lucia Nguyen
    Affiliations
    Peninsula Health, Frankston, Victoria, Australia
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  • Arjun Rao
    Affiliations
    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    Sydney Children's Hospital (Randwick), NSW, Australia

    University of New South Wales, Australia

    Health Education Training Institute (HETI), New South Wales, Australia
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  • Sarah Dalton
    Affiliations
    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    The Children's Hospital at Westmead, Westmead, NSW, Australia
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  • Mark D. Lyttle
    Affiliations
    Emergency Department, Bristol Royal Hospital for Children, Bristol, UK

    Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK

    Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI), UK
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  • Santiago Mintegi
    Affiliations
    Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain

    University of the Basque Country, Spain

    Research in European Pediatric Emergency Medicine (REPEM), Spain

    Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG), Spain
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  • Rakesh D. Mistry
    Affiliations
    Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA

    Children's Hospital Colorado, Aurora, CO, USA
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  • Andrew Dixon
    Affiliations
    University of Alberta, Edmonton, Alberta, Canada

    Stollery Children's Hospital, Edmonton, Alberta, Canada

    Women's and Children's Health Research Institute, Canada

    Pediatric Emergency Research Canada (PERC), Canada
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  • Pedro Rino
    Affiliations
    Universidad de Buenos Aires, Argentina

    Hospital de Pediatría “Prof. Dr. Juan P. Garrahan”, Buenos Aires, Argentina

    Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
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  • Guillermo Kohn-Loncarica
    Affiliations
    Universidad de Buenos Aires, Argentina

    Hospital de Pediatría “Prof. Dr. Juan P. Garrahan”, Buenos Aires, Argentina

    Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
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  • Stuart R. Dalziel
    Affiliations
    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    Starship Children's Hospital, Auckland, New Zealand

    Department of Surgery, University of Auckland, Auckland, New Zealand
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  • Simon Craig
    Affiliations
    Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand

    Paediatric Emergency Department, Monash Medical Centre, Melbourne, Australia

    Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Australia
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  • the Pediatric Emergency Research Networks (PERN)
    Author Footnotes
    1 Participating networks include: the Pediatric Emergency Care Applied Research Network (PECARN), the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM-CRC), Pediatric Emergency Research Canada (PERC), Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), Pediatric Research in Emergency Departments International Collaborative (PREDICT), Research in European Pediatric Emergency Medicine (REPEM), and Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoaméricana (RIDEPLA).
  • Author Footnotes
    1 Participating networks include: the Pediatric Emergency Care Applied Research Network (PECARN), the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM-CRC), Pediatric Emergency Research Canada (PERC), Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), Pediatric Research in Emergency Departments International Collaborative (PREDICT), Research in European Pediatric Emergency Medicine (REPEM), and Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoaméricana (RIDEPLA).
Published:December 30, 2020DOI:https://doi.org/10.1016/j.ajem.2020.12.075

      Abstract

      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.
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