Real-Time Emergency Airway Consultation via Telemedicine: Instituting the Pediatric Airway Response Team Board!

Abstract

It is time to bring real-time pediatric airway expertise to every child experiencing an acute difficult airway condition. Technological advancements have coalesced to make real-time emergency airway consultation with experts an achievable reality. With the availability of high-definition video glasses and portable cameras, the rise of telemedicine, the availability of video laryngoscopy, and the introduction of 5th generation broadband cellular network (5G technology), airway experts can see and discuss difficult airways with the frontline clinicians in prehospital settings and nonpediatric centers. Thus, pediatric airway experts can guide these intubators through difficult airway scenarios just as we do every day in the operating room when we instruct residents, fellows, and student nurse anesthetists during elective and difficult intubations in a tertiary pediatric hospital. Respiratory failure is the most common cause of cardiopulmonary arrest in children and often requires advanced airway placement. Placing an endotracheal tube (ETT) can be difficult for clinicians who do not routinely manage airways in children, including those in prehospital settings, emergency departments (ED), and intensive care units (ICUs). In Europe, ambulances are often staffed by physicians with specialized expertise such as critical care–trained anesthesiologists for medical emergencies and obstetricians for obstetrical emergencies. In many other parts of the world, including the United States, anesthesiologists are in short supply. We do not have the luxury of having anesthesiologists, especially pediatric anesthesiologists, in all settings and institutions where children need care. However, technology is coalescing to allow us to solve this problem. The proliferation of video laryngoscopes, acceptance of telemedicine, and introduction of 5G networks can be harnessed to bring real-time emergency pediatric airway expertise to patients anywhere a difficult airway is found—in the field or at the bedside. THE NEED FOR EMERGENT AIRWAY CONSULTATION Pediatric airway management both within large tertiary care centers and outside the operating room is plagued with high complication and failure rates that lead to high morbidity and mortality. In the prehospital setting, Gausche et al1 showed that intubations of children were successful only 57% of the time and were associated with complications that included an incorrect ETT size (24%), unrecognized mainstem intubation (18%), and ETT dislodgement (14%), and additional studies have further substantiated these findings.2–4 These high failure rates are, at least in part, due to caregivers’ lack of airway management experience for pediatric patients.5 Successful ETT placement in children within the hospital is also problematic. In pediatric and neonatal ICUs (NICUs), practitioners may be losing some of their intubation skills because more children and infants are treated with noninvasive modalities, such as bilevel positive airway pressure, rather than invasive ETT placement. Recently, a multicenter study by Foglia et al6 showed that first-attempt intubation success rates were 49% and 46% in the NICU and delivery room, respectively. Adverse events from intubation were 18%, and severe oxygen desaturation occurred in 48% of attempts. Residents performed only 15% of intubations in the NICU and 2% in the delivery room, suggesting that these complications were not related to the level of training by the neonatologist. In the pediatric ICU (PICU), the success rate for intubation on first attempt is higher at 60%, but the second attempt success rate is only 24%. These rates are similar to those reported in the ED.7 Many have suggested that anesthesiologists should manage all intubations in the adult population. In 2009, Stephens et al8 performed a retrospective analysis of adult trauma patients cared for over 10 years, wherein each patient’s airway was managed by an anesthesiologist following a specific rapid sequence protocol. Their reported success rate for securing the airway was 99.7%, and they suggested that all emergency airways should be supervised by an experienced anesthesiologist. Studies performed outside the United States where ambulances are staffed by critical care anesthesiologists showed higher first-attempt success, and that a pediatric airway refresher course increased first-pass intubation success rates in children to as high as 95.3%.9 Based on these data, should pediatric anesthesiologists or critical care anesthesiologists who have taken routine refresher courses in pediatric airway management be the only ones to perform advanced airway management in children? In 2013, the United States was estimated to have 980 NICUs with nearly 22,000 beds. One 2004 study estimated that there were approximately 4000 PICU beds, and an analysis of the Virtual Pediatric Intensive Care Unit Performance System database of 54 participating PICUs showed that an estimated 67,000 children were admitted in 2008 alone.10 Most of these patients require airway management, either invasively via an ETT or noninvasively through ventilatory support. One could argue that pediatric anesthesiologists should supervise all invasive pediatric airway management, but is it feasible? Muffly et al11 recently published a study reporting that 4048 pediatric anesthesiologists were practicing in the United States, approximately 9% of the total anesthesiology workforce, and were primarily located in urban areas along each coast, identifying a huge workforce issue and regions in need. In addition, critical care–trained anesthesiologists are not staffed in all locations and hospitals where children are treated. Halpern et al12 showed that only 48% of the 2814 acute care hospitals studied actually had critical care–trained intensivists on staff. In summary, emergency airway management for children is relatively infrequent but is associated with high morbidity and mortality. The shortage of pediatric airway experts such as pediatric anesthesiologists or adult critical care anesthesiologists with supplemental pediatric training makes it nearly impossible for them to be physically present at all pediatric airway emergencies. A TECHNOLOGICAL SOLUTION Telemedicine, or the use of video and audio devices to provide medical advice and perform visual examinations of patients, has become a rapidly advancing specialty. Utilization of secured Internet networks and video cameras has allowed specialists in distant geographic locations to take full medical histories and perform thorough clinical evaluations and physical examinations. Telemedicine by anesthesiologists and emergency room physicians has recently been suggested as a way to provide perioperative management and controlled consultation to paramedics during trauma. The time has come to utilize some of these same principles, while adapting and improving others, so that telemedicine can be used for an online pediatric difficult airway response team (pDART). pDART AIRWAY EMERGENCY PROGRAM: EXTENDING TELEMEDICINE TO REAL-TIME AIRWAY EMERGENCIES Sakles et al13 were the first to report using telemedicine for airway management in the prehospital setting. The group described the use of a video laryngoscope (GlideScope, Bothell, WA) screen that can be viewed not only by the intubating paramedic but also by a consulting ED physician. While the use of video laryngoscopy has allowed multiple clinicians to view the glottis at the same time, the consulting telemedicine expert cannot view the extraoral environment that also plays a significant role in successful airway management, including patient position, chest wall movement, and monitors showing vital signs. With the rise of 5G, reliable video and audio communication can now enable telemedicine consultation with pediatric airway experts in the field or at the bedside without the delay of satellite connections or expensive Internet equipment. By using available video laryngoscopic devices, existing glasses-with-camera technology, and 2-way audio communication with a privacy-protected, Health Insurance Portability and Accountability Act (HIPAA)-compliant application on a handheld device or tablet, we can bring the expertise of the pDART to all children with difficult airway scenarios. Doing so requires coupling the application to a network of pediatric airway experts trained to deliver verbal instruction during airway emergencies. This program can be instituted both within a large hospital where experts currently are employed as well as at institutions and prehospital settings with fewer resources. We believe that we can significantly improve first-pass success at ETT placement, decrease morbidity and mortality, and improve patient care for pediatric patients. Further, this approach can ultimately be expanded to adult difficult airway scenarios. Devices and Equipment Current technology is available that can be used to create the real-time pDART telemedicine platform. Though smartphone and tablet cameras do not possess the hands-free capability needed for this platform, they can provide the central processing unit and telecommunication backbone for the system. Linking technology similar to that implemented in devices like Google Glass (Google Inc, Mountain View, CA) or Davideo Rikor Glasses (Davideo Camera Company, Framingham, MA), either physically or via Bluetooth to the smartphone or tablet, allows the intubator as well as the consultant an unobstructed view of the airway and of the entire patient (Supplemental Digital Content, Video 1, https://links.lww.com/AA/D3). Ideally, having a second image of the video laryngoscope’s image could improve the view for the consultant and thus optimize the ability to guide the intubator. Reliable 2-way audio must be incorporated to enable the consultant to provide instruction to the intubator. Two-way communication can easily be accomplished with an earpiece attached to the smartphone or tablet or by using devices that already have this feature (Davideo Rikor glasses, for instance). In addition, the technology must be high quality with no delays in video or audio transmission, and the camera must always be in the line of sight of the wearer. Thus, in the ideal system, a HIPAA-protected application would form the basis of the hardware, which would provide 1-way video of the intubator’s view to the consultant via camera-based glasses, a view of the video laryngoscope screen, and 2-way audio. The addition of real-time vital signs monitoring for the consultant would be helpful but not necessary in the initial iteration of the system, as the vital signs could be viewed through the wearable camera. The pDART Communication Platform: the “pDART Board” Many existing telemedicine videoconferencing technologies are optimized to ensure HIPAA rules for maintaining patient anonymity and are already on the market. These technologies can be adapted for use with smartphones and tablets, allowing mobility for both the provider and the consultant to remote areas and regions where pediatric airway management expertise is limited.Figure.: A diagram of the pDART Telemedicine Program components including the clinician performing pediatric airway management, his encountering difficulty and connecting to a nationwide network of pediatric airway experts, an expert receiving the request for assistance, and providing real-time assistance and feedback to the clinician to assist in securing the patient’s airway. pDART indicates pediatric difficult airway response team; POV, point-of-view.Although the technological platform is important, the critical element is the link to pediatric airway experts who can provide consultation 24 hours per day, 7 days per week. Existing platforms, such as MDLIVE, Doctor on Demand, Lemonaid, etc, could be used but require adaptation to incorporate all the necessary components. One option is to create a computer system wherein experts at children’s hospitals near the emergency would be contacted first, expanding out to other centers if the local center is not available. Experts will be on call for the program throughout the day and night. Eventually, experts from around the world would supervise and respond during their normal waking hours to limit poor decision-making that often accompanies fatigue. The ultimate goal will be to expand pediatric airway services internationally and to remote areas where medical care is almost nonexistent (Figure). pDART Board Member Training Pediatric airway experts will need to be evaluated and trained before they provide their services to the pDART Board Telemedicine Airway Emergency Program. A supervisory committee will be instituted with pediatric airway experts across the world to discuss and implement criteria for individuals to participate in the program. Criteria for participation will include, but not be limited to, training and board certification in anesthesiology and/or pediatric anesthesiology and a minimum number of pediatric intubations performed monthly. Pediatric emergency physicians and pediatric critical care physicians with focused expertise in airway management may be considered in certain situations. In addition, practice scenarios will be implemented and competency evaluated before a physician can become a consulting expert. The platform can also be acquired for “in-house” use within the emergency medical and hospital systems. For institutions where resources are available and experts are already employed, purchasing a license for platform use and utilizing their experts would be an option. The institution would therefore be responsible for training and evaluating their in-house experts as well as performing regular quality and safety studies to determine efficacy and areas for improvement. IMPLEMENTATION BARRIERS As mentioned in previous telemedicine publications,13–15 maintaining HIPAA compliance is important, necessary, and potentially difficult to execute. Our pDART Telemedicine Airway Program will only increase the resources allotted to clinicians caring for pediatric airways during an emergency; however, there are several barriers that need to be addressed. Table. - Benefits and Barriers to Implementing a Real-Time Telemedicine Program for Difficult Airway Management Benefits Barriers Real-time consultation for rare, high-risk procedures HIPAA-compliant communication platform Out-of-network access to experts Equipment and compliance cost and adaptation Hands-free telemedicine system allows entire scene visualization, not just streamed monitors Training consultant physicians on optimal techniques for providing feedback and instruction Relatively inexpensive compared to deploying experts into the field Image and video storage Mobile platform for out-of-hospital consultation Poor wireless connectivity in rural areas within the United States or globally Some anticipated implementation barriers or limitations might include HIPAA compliance, equipment and platform development, cost, and reliability, as well as medicolegal issues surrounding indirect, potentially out-of-state consultation, and physician reimbursement (Table). HIPAA compliance: Utilizing password-protected applications on a handheld or tablet device can address confidentiality and conform to HIPAA standards. Currently, there are many secure electronic medical record applications allowing clinicians to access patient data via their mobile devices, and implementation of the pDART Board can be easily executed following these standards. Consent is not an issue when 2 medical personnel are communicating about the same patient during an emergency and therefore should not be required. Equipment and platform: Development of the application will be the initial barrier to implementation. By using an application that can be downloaded onto a handheld device or tablet, software dissemination can be easy. Video imaging eyewear is currently available from several companies (listed previously) and their prices range between $100 and $300, but lower latency equipment might cost more than $1000, though these will often have heads up display technology, allowing for a degree of augmented reality. For prehospital services and smaller institutions without pediatric anesthesia or critical care physicians on staff, this added cost will have to be implemented within each budget. This cost is fairly low and will likely not impede the implementation of this program. Videolaryngoscopes are becoming more and more prevalent and costs have been declining, whereby many can be purchased for just more than $1000. Thus, cost is unlikely to represent a major barrier, but linking the images directly to the application as well as storing the images might be challenging. Equipment malfunction, such as loss of video imaging or audio, could require backup solutions to be in place. Expert personnel and medicolegal issues: Recruiting and maintaining certification of pediatric airway experts will require programmatic oversight and effort. Experts within the field are often willing to help and are invested in optimizing care for our children; however, they will likely need monetary or academic compensation before they can devote dedicated time away from their regular practice to assist this program. For those utilizing experts outside their institution, consultants will need to undergo specialized licensing to ensure reciprocity for practicing medicine in other states. Currently, some malpractice insurance will cover physicians across state borders; however, programs that support telemedicine programs will have to address this concern. Reimbursement: Currently, Medicare will reimburse for telemedicine consultation, and in the United States, Congress is evaluating 2 bills modernizing telehealth reimbursement.16 Telemedicine reimbursement plans may have to be updated to address emergency consultation for high-risk procedures, such as intubation, for the program to be sustainable. In 2017, a bipartisan Congressional Telehealth Caucus was created to address the medicolegal aspects of telemedicine. In spring of 2020, Centers for Medicare and Medicaid Services (CMS) is set to launch a 5-year trial of the Emergency Triage, Treat, and Transport Model that will reimburse emergency medical systems and qualified health care providers for consultation and treatment in the field, transport to the ED, or transport to facilities other than the ED such as a primary care office or an urgent care facility.17 Network connectivity: Utilizing only the telephone may provide a reasonable secondary plan; however, loss of wireless service would still be a possibility. The use of newer 5G networks will likely decrease this risk significantly. In the prehospital setting, using the ambulance as a WiFi hotspot may solve connectivity problems within the United States, but rural areas may not have this luxury. CONCLUSIONS Video and audio technology advancements have begun to lay the groundwork that will enable patients with limited access to expert medical care to receive expert consultation and participation in their care. Pediatric airway management is a medical procedure wrought with complications and high failure rates when performed by nonairway experts; but with the assistance of telemedicine, expert consultation can be accessed immediately and patient outcomes improved. Patient privacy, equipment availability, and reliable telecommunications are potential limitations that require formal evaluation. Pediatric airway experts are eager and willing to provide assistance by working with other pediatric clinicians to improve the airway outcomes of our children. DISCLOSURES Name: Nicholas M. Dalesio, MD, MPH. Contribution: This author helped create the concept and idea and write the manuscript. Name: Laeben C. Lester, MD. Contribution: This author helped write the manuscript. Name: Ben Barone, BS. Contribution: This author helped analyze the data and write the manuscript. Name: J. Kate Deanehan, MD. Contribution: This author helped write the manuscript. Name: James C. Fackler, MD. Contribution: This author helped write the manuscript. This manuscript was handled by: James A. DiNardo, MD, FAAP.

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