Difficult/Critical Airway Clinical Pathway — All Settings

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Related Pathways

Relative Contraindication Neuromuscular Blockage

Anterior mediastinal masses
Obstructing airway mass
Infiltrative storage diseases (glycogen storage diseases and others)

Sugammadex can be used to reverse the paralytic effects of rocuronium and vecuronium

Child Requiring Intubation

KOPH Difficult/Critical Airway

Child Requiring Urgent/Emergent Intubation on Inpatient Units
Outside ED, PICU, N/IICU, CICU, OR
Call 4-CODE
Code Team will activate Airway Response Team as necessary

Assess Airway

Review Patient Information in Epic

L.E.M.O.N. Method

Critical Airway Known

Difficult Airway
Known/Anticipated

No Airway Issues Identified

While Awaiting Airway Response Team
Monitor, Continue O₂
Consider the following based on airway characteristics:
- Bag Mask Ventilation
- Nasal/Oral Airways
- Laryngeal Mask (LMA)

Perform Bag Mask Ventilation
Use nasal/oral/laryngeal airways as necessary

Routine Airway Management
by Clinical Team

Inadequate

Adequate

Failed BVM or laryngoscopy

Consider laryngoscopy
- Most experienced practitioner

Laryngoscopy
- Limit to 2 attempts

Failure

To Activate the Airway Response Team

Call Medical Emergency Line, 4-CODE (4-2633)
or
Click 4CODE on your smartphone
then
State Airway Emergency and give location

Activate Airway Response Team

Consider Laryngeal Mask Airway

Airway Response Team Arrives

Airway Team Provides Expert Support to Local Team
- Laryngeal Mask
- Indirect Laryngoscopy
- Considerations for Sedation, Neuromuscular Blockade
- Fiberoptic Laryngoscopy
- Fiberoptic Laryngoscopy through LMA
- Invasive Airway

Posted: January 2014
Revised: July 2024

Authors:
- A. Nishisaki, MD;
- R. Giordano, RRT-NPS;
- J. Lavelle, MD;
- A. Ades, MD;
- J. Lioy, MD;
- L. Javia, MD;
- K-Y. Tay, MD;
- A. Costarino, MD;
- B. Bruins, MD

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Clinical Pathway for Children with Difficult/Critical Airway

Evidence