Difficult Airway Response Team

Abstract

Background Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. Methods We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had three core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. Results Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index > 40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which more than 200 providers were trained. Conclusions DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Discrimination ability of the endotracheal tube location using real-time palpation during intubation using an endotracheal tube with a preloaded stylet

“…Confirmation of endotracheal intubation is an essential and life-saving step during airway management. 26 , 27 Therefore, the palpation method should not be substituted for fail-safe or almost fail-safe methods, such as direct visualization of vocal cords, quantitative carbon dioxide waveform on capnography, and fiberoptic bronchoscopic inspection of the tracheal ring and carina. Instead, the real-time palpation method during intubation has major implications to prevent such consequences.…”

Coping with airway emergencies: Get, Set, Go!

“…[ Table 2 ] Preparation: A dedicated trained difficult airway response team or DART (multidisciplinary team of anaesthesiologists and ENT surgeons) should be available round the clock for prompt action in case of an airway emergency. [ 4 ] All the emergency intubations are difficult, and a difficult airway cart should be ready[ 3 ] Patient positioning: During airway emergency, it may not be always possible to place the patient in supine or lateral position, rendering airway management difficult. In such circumstances, the aim should be to provide ventilation, using the immediately available, appropriate equipment.…”

“…Supraglottic airway devices (SAD) could be lifesaving as rescue ventilation devices. If it is not feasible or fails, direct surgical access should be considered without any delay[ 1 4 ] Plan for oxygenation: In AE, we must adopt all the measures to maintain oxygenation like preoxygenation with 100%, nasal high flow oxygen, application of positive end expiratory pressure (PEEP), maintaining haemodynamic stability and appropriate ventilatory settings. [ 5 6 ] Additional methods like supraglottic jet ventilation, special tracheal tube and transtracheal jet ventilation have also been tried to improve oxygenation.…”

“…Preparation: A dedicated trained difficult airway response team or DART (multidisciplinary team of anaesthesiologists and ENT surgeons) should be available round the clock for prompt action in case of an airway emergency. [ 4 ] All the emergency intubations are difficult, and a difficult airway cart should be ready[ 3 ]…”

Assessing anesthesiology residents’ out-of-the-operating-room (OOOR) emergent airway management

“…[1–5] Complications include hemodynamic instability, oxygen desaturation, aspiration, esophageal intubation, multiple laryngoscopy attempts, cricothyroidotomy, and death. [2, 6–8] Mortality rates following emergent intubation have been observed to be as high as 46%.…”