Johns Hopkins Provides a National Model for Handling Difficult Airways Emergencies

The Difficult Airways Response Team, developed by otolaryngologist Nasir Bhatti, improves outcomes in tracheostomies and airway-securing outside of the operating room.

Published in Clinical Connection - Winter 2024 - 2025

After otolaryngologist Nasir Bhatti finished his fellowship training at Johns Hopkins in 2001, he was struck by three sentinel events that resulted from difficult airway emergencies outside of the operating room. Reviewing the details of these possibly preventable deaths, he realized there was no structured approach at the hospital on how to handle such situations.

Over the next few years, his analysis of airway-related adverse events — often cited as the fourth most common malpractice claim related to anesthesia — led him to help develop a standardized airway management system at The Johns Hopkins Hospital that has greatly improved outcomes.

The system incorporates standardized algorithms, a special equipment cart and a coordinated and consistent approach to improve outcomes in tracheostomies and airway-securing. The Difficult Airway Response Team, or DART — which consists of anesthesiologists, general surgeons, and otolaryngologists — carries out this work.

Implemented in 2005, the DART initiative has led to a significant reduction in unnecessary cricothyrotomies — considered a “last-ditch” surgical procedure — and improved collaboration among medical disciplines. Detailed in Anesthesia and Analgesia, this quality-improvement program has since been adopted by other hospitals in the United States.

Ongoing research by the DART team includes using AI to predict and manage difficult airways.

An associate professor in otolaryngology–head and neck surgery, Bhatti serves as director of Johns Hopkins Adult Tracheostomy Airway Services. Early on, he recognized the need to include an experienced otolaryngologist on the official difficult airway response team along with an anesthesiologist and general surgeon. Doing so usually improved outcomes, he says.

“If a certain anesthesiologist had a working relationship with an otolaryngologist and could call them up for help, the outcome would be really good,” says Bhatti. “But we were often called when it was too late, too complicated, or the situation was no longer reversible.”

“Our goal is to prevent the number of unnecessary cricothyrotomies, and that's what we were able to do.”

Nasir Bhatti
Portrait of Bhatti

Seeking to remedy that, he scheduled a weekly interdisciplinary “book group” for participants from the departments of Anesthesia and Critical Care Medicine, Emergency Medicine, General Surgery and Otolaryngology–Head and Neck Surgery. Together they studied and discussed the best practices for difficult airways.  For the first time, otolaryngologists became key members of the team.

Along with Bhatti, other trained otolaryngologists assigned to DART include Wayne Koch, Alexander Hillel and Kevin Motz.

After agreeing to follow algorithms that applied to different situations, the team members also created DART carts containing all the equipment that each member of the team might need in responding to an emergency. Located throughout the hospital, each cart is checked daily. 

“Our goal is to prevent the number of unnecessary cricothyrotomies,” says Bhatti. “And that's what we were able to do.” 

Education is another important element of DART. Whether fully trained as general surgeons, anesthesiologists or otolaryngologists, all new members are trained on the “Hopkins way of doing things.” Additionally, all trainees in these departments attend the standardized, difficult airway course.

Between July 2008 and June 2013, DART managed 360 adult difficult airway events. Twenty-three patients required emergent surgical airways while 62 patients were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART.

Now, the DART team handles 50 or 60 such calls every year, Bhatti says. Additionally, four multi-disciplinary simulation courses are held annually to ensure the quality of DART's teamwork, communication, and response times and to maintain the functionality of the difficult airway carts.

Bhatti believes that DART’s structured collaborative approach “should be the gold, or platinum standard” of taking care of airways.

“But that does not mean that any hospital in the country, or the world, has to have the exact same thing. People can have their own local version based on the expertise and resources available,” he says, adding that dozens of hospitals now use a modified model.

“We cannot prevent all bad outcomes,” he says. “The goal is to have mechanisms in place where as many of the preventable bad outcomes as possible can be prevented. And that is a good outcome for everyone.”

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