Date of this Version

2024

Document Type

DNP Project

Rights

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Abstract

Background: Traditionally, demographic-based formulas have been utilized to determine the appropriate endotracheal tube (ETT) size in pediatric patients. However, formulas, such as Cole’s age-based formula, vary widely in accuracy, resulting in an overestimated or underestimated ETT size. Implications of an inappropriately sized ETT include subglottic stenosis, ischemia, infection, and irreversible loss of connective tissue around the cartilage. Proper ETT sizing is pivotal for optimal general anesthesia. Ultrasonographic assessment of the subglottic diameter provides a real-time measurement for accurate ETT sizing in pediatric patients. This project aims to assess anesthesia provider knowledge and attitude toward ultrasonographic measurement of the subglottic diameter versus traditional age-based formulas for ETT sizing in pediatric patients.

Methods: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed search engines were accessed via the Florida International University (FIU) library database. A comprehensive search was conducted for full-text, peer-reviewed research studies published within the last 10 years, which assessed using ultrasonographic measurement of the subglottic diameter to appropriately size ETTs in pediatric surgical patients. An online module will be implemented to anesthesia providers regarding ultrasonographic measurement of the subglottic diameter to approximate ETT size in pediatric surgical patients. A Qualtrics pre- and post-test will be used to assess anesthesia provider knowledge and attitude.

Results: Knowledge improved on characteristic anatomical differences observed in the pediatric patient compared to the adult patient. All the participants (100.00%) agreed that ninety percent of subglottic stenosis results from tracheal intubation. Congenital heart disease was correctly selected by all participants (100.00%) as the special pediatric population that may require a larger ETT size than the calculated age-based size. Knowledge improved on initial placement of the high-resolution linear probe used for subglottic measurement of the pediatric airway. Attitude toward the accuracy of age-based formulas for calculating ETT size in pediatric patients declined in support. Improvement in attitude toward using point of care ultrasound (POCUS) to measure the subglottic diameter of a pediatric airway was observed. An increase in attitude was noted in agreement that ultrasound is a reliable tool to approximate ETT size in pediatric patients.

Discussion: An increase in provider knowledge and attitude was observed regarding the utilization of ultrasound as a tool to approximate ETT size in pediatric surgical patients. Current evidence-based research emphasizes the influence anesthesia providers have on the direction of pediatric airway management. Specifics regarding special airway considerations of congenital disease populations showed improvement in the post-test. Participants identified understanding a need for special management of the pediatric airway. Providers' attitudes changed following participation in the educational module. A small sample size contributed to limitations in drawing conclusions. The topic of pediatric anesthesia may have contributed to a niche/self limiting response. Potential implications exist for decreased responsiveness related to email bombardment. Future consideration for staggered project release dates. Implementing a QI project raises awareness of the topic and ignites the process of change.

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