(1255) Malpositioned Airway Masquerading as a Pulmonary Hypertensive Crisis: Anchoring Bias in the PICU

Introduction: Pediatric critical care providers are taking care of a growing number of patients with complex medical histories who need a tracheostomy and have co-morbidities such as chronic lung disease (CLD) and pulmonary hypertension (PH). A PH crisis is a life-threatening event that can be easily missed and quickly lead to cardiorespiratory arrest. Recognition requires a high index of suspicion; however, cognitive errors can also mislead providers to overlook more common etiologies of deterioration in a child with an advanced airway.

Description: A 4-year-old child with trisomy 21, CLD of prematurity, ventilator and tracheostomy dependence, surgically corrected atrioventricular canal, and mild PH presented with an episode of accidental tracheostomy decannulation that led to persistent hypoxia. In the months preceding, she had multiple episodes of hypoxia leading to cardiac arrest presumed to be due to PH crisis. During the index event, she similarly had desaturations, poor chest rise, wheezing, prolonged expiratory phase and hemodynamic instability. Her tracheostomy tube was quickly replaced at bedside, but she did not improve. She was treated with bronchodilators, inhaled nitric oxide, volume administration, sedation and paralysis. Due to continued failure of improvement, her tracheostomy tube was reassessed and it was found to be malposed with its inferior tip obliquely projected to the left aspect of the trachea. The cuff was found to be overinflated and deflation lead to immediate improvement with resolution of the acute episode.

Discussion: Our case highlights the possibility of cognitive errors during fast paced situations. PH crisis is known to cause airway obstruction due to compression of airways from hypertensive arterioles. CLD exacerbations can also present similarly with bronchospasm. In this case, providers were misled due to anchoring and availability bias. The basic principles of artificial airway troubleshooting such as employing the “DOPE” mnemonic (displacement, obstruction, pneumothorax, equipment failure) were overlooked in the face of a high index of suspicion for more complex pathophysiology and recent information. Overall, awareness of cognitive biases affecting clinical decision making can help mitigate diagnostic errors during high acuity situations.