2019 HSC Section 2 - Practice Management

International Journal of Pediatric Otorhinolaryngology 114 (2018) 120–123

N. Murray et al.

Fig. 1. CARE 1 Airway. The larynx and trachea of a normal newborn airway is shown. A standard age-appropriate endotracheal tube can be easily placed.

Fig. 2. CARE 2 Airway. The larynx and trachea of a one-year-old with grade 2 subglottic stenosis is shown. No larger than a 3.0 endotracheal tube can be placed.

Table 2 Results.

Group (n = 66):

Accuracy: Number Correct (out of 30)

Fleiss' kappa Interrater Reliability:

All Otolaryngologists (15)

27.7 ± 2.9 26.6 ± 3.5

0.780 0.700

Attending Otolaryngologists (9) Resident Otolaryngologists (6)

29.3 ± 1.2

0.926

Resident Pediatricians (51)

26.6 ± 2.9 p = 0.23 a

0.658

a Otolaryngology versus pediatrics.

resources to be immediately requested to avoid wasting time with futile attempts at standard intubation. Our aim with this project has been to create a mechanism for any caregiver to quickly, easily, and correctly identify those trach patients who will require special maneuvers for intubation- and thus ensure that fi rst responders to an emergency know immediately not to waste va- luable time on maneuvers that will not be successful. Currently, without a widely used classi fi cation system, the transfer of this critical in- formation takes time, and, further, it may get lost in the midst of other critical information regarding the complex patient. We have shown previously that, among a small group of pediatric otolaryngologists, the CARE system is a reproducible, easy to teach, and reliably applied system for classifying a patient's airway above their tracheotomy tube. However, in the reality of a pediatric tertiary care hospital, the fi rst responder to an airway emergency on a tracheoto- mized patient is unlikely to be a pediatric otolaryngologist attending or even an otolaryngology resident. The fi rst physician responder is likely to be a pediatric resident. With this second study, we have shown that the CARE system can be taught to pediatric residents and applied with no statistical di ff erence when compared with otolaryngology attendings

Fig. 3. CARE 3 Airway. The larynx of a four-year-old with complete glottis stenosis is shown. The trachea cannot be seen at all from the larynx. This child is un-intubatable.

to tracheotomy tube failure. Prompt management of the patient's airway is crucial during an instance of tube failure due to accidental decannulation or plugging. Knowledge of the patient's airway above the tracheotomy tube will guide the fi rst responder to the most successful method of reestablishing the patient's airway. A patient with a normal airway above the tracheotomy (CARE class 1) can be intubated orally. However, a patient who requires special equipment or skills to re- establish an airway, such as a patient with 70% subglottic stenosis who is paralyzed and on a ventilator (CARE class 2v) will require those

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