Reader response

Myron Yaster MD

From Lynn D Martin MD MBA

I read and enjoyed the PAAD “Rescuing failed direct laryngoscopy in children” posted on 7/15/2025 by Drs. Myron Yaster, Melissa Brooks Peterson, El Jefe, Francis Veyckemans. You may ask why? First, it describes the use of data to help increase our knowledge and awareness of current practices.^1,2 This is a good example of the effective use of a multicenter data registry (Pediatric Difficult Airway Registry); looking for, identifying, and understanding variations in clinical practice around rare events and their associated outcomes. But I truly loved the emerging refrain in the PAAD these days that we need to actually change our practices with successful implementation. Yaster et al really highlighted this with focus on both the science and SYSTEMS. Their call to action is very important and in my opinion rarely followed!

One suspects that every hospital will have a difficult airway cart and likely a process to assure it’s contents are adequately maintained. Here is where the questions start (some of which were articulated by Yaster et al.

1. Airway cart locations: Are there enough carts to meet routine and emergency needs? In easy to access locations? Rapidly available for use outside the ORs (PACUs, ICUs, ED, etc.)?

2. Airway cart contents: Are your carts contents standardized in all locations? Adequately labeled to facilitate easy use in emergency situations? Are job aids (difficult airway algorithm, etc.) immediately available for emergent situations? Are carts restocked after every use? Contents audited daily/weekly to assure they are present, functioning, and not expired? Is there a reliable process to update cart contents as the new, better products become available?

3. Airway skills: ‘Use or lose it’ is very real for all skills, but particularly complex technical skills like airway managment. Every department should have a process to train and verify proficiency in routine and select difficult airway techniques for all faculty. This training can use a combination of simulation and elective use of advanced techniques for routine care. This is also the best opportunity to retrain on difficult airway algorithms. But it is impossible for all faculty to maintain proficiency for all advanced airway techniques. This brings us to the most important recommendation: Difficult Airway Response Team (DART).

4. DART: It will be much easier to maintain advanced airway skills when a small team of selected faculty practices them more frequently. While it is impractical to have a DART member immediately available in-house, there should be enough members on the team to have 24/7/365 on-call access within 30 minutes. Known difficult airway patients on the schedule should have a pre-op DART member consultation (ideally with that individual available on the day of surgery – i.e., no handoffs). A designated DART member should be on the OR schedule every weekday for unanticipated emergent airways. Is a reliable after-event review to assure institutional learning and improvement in practice? Lastly, this team needs a designated leader AND THE NECESSARY TIME to manage this entire system.

Every institution at a minimum must address and maintain items 1 & 2 as part of common regulatory requirements. In my opinion, every institution should address item 3 and be strongly encouraged to launch a DART team (item 4). Each chief of anesthesiology should be responsible for guaranteeing that the INSTITUTION provides the needed infrastructure as outlined by Yaster et al to achieve the following:

· Standardized equipment and carts across units

· Regular multidisciplinary simulation

· Tailored training

· 24/7 team-based response protocols

· Tracking and reviewing of real-world airway outcomes. This last point is where I agree the most, but it is not currently being realized. Data registries are not real-world outcomes. They only represent process and outcomes from a limited subset of practices (participating centers). The advent of modern EMRs and software extraction tools provide the opportunity for true real-world data.

I would like to urge every pediatric anesthesia department leader to take on this righteous challenge (PALC: where are you on this?).

References

1. Stein ML, Nagle JH, Templeton TW, et al: Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry. Anaesthesia 2025; 80(6): 625–635. PMID 40113331.

2. Evans MA, Caruso TJ: Rescuing failed direct laryngoscopy in children: one size does not fit all. Anaesthesia 2025; 80(6): 621–624. PMID 40114500.