2018指南：兒童緊急氣管造口術(shù)的管理

Anaesthesia2018

doi:10.1111/anae.14307

Guidelines

Multidisciplinaryguidelinesforthemanagementofpaediatrictracheostomyemergencies

C.Doherty,1R.Neal,2C.English,3J.Cooke,?D.Atkinson,?L.Bates,?J.Moore,5

S.Monks,?M.Bowler,81.A.Bruce,9,10,13,14N.Bateman,10M.Wyatt,11J.Russell,12R.Perkins1andB.A.McGrath?,14onbehalfofthePaediatricWorkingPartyoftheNationalTracheostomySafetyProject

1Consultant,8,SpecialtyTrainee,DepartmentofPaediatricAnaesthesia,3TracheostomySpecialistNurse,

DepartmentofPaediatricENT,9Professor,10Consultant,DepartmentofPaediatricOtolaryngology,Royal

ManchesterChildren'sHospital,5Consultant,DepartmentofAnaesthesiaandIntensiveCareMedicine,Manchester

UniversityNHSFoundationTrust,Manchester,UK

2Consultant,PaediatricIntensiveCareMedicine,Paediatrics,BirminghamChildren'sHospital,Birmingham,UK4TracheostomySpecialistNurse,11Consultant,DepartmentofPaediatricOtolaryngology,GreatOrmondStreetHospital,London,UK

6Consultant,DepartmentofAnaesthesiaandIntensiveCareMedicine,RoyalBoltonHospital,Bolton,UK

7Consultant,DepartmentofAnaesthesia,EastLancashireHospitalsNHSTrust,Burnley,UK

12Consultant,DepartmentofPaediatricENT,OurLady'sChildren'sHospital,Dublin,Ireland

13ManchesterAcademicHealthScienceCentre,Manchester,UK

14DivisionofInfection,ImmunityandRespiratoryMedicine,FacultyofBiology,MedicineandHealth,UniversityofManchester,Manchester,UK

Summary

Temporaryandpermanenttracheostomiesarerequiredinchildrentomanageactualoranticipatedlong-termventilatorysupport,toaidsecretionmanagementortomanagefixedupperairwayobstruction.Tracheostomiesmayberequiredfromthefirstfewmomentsoflife,withthemajorityperformedinchildren<4yearsofage.Althoughsimilaritieswithadulttracheostomiesareapparent,therearekeydifferenceswhenmanagingtheroutineandemergencycareofchildrenwithtracheostomies.TheNationalTracheostomySafetyProjectidentifiedtheneedforstructuredguidelinestoaidmultidisciplinaryclinicaldecisionmakingduringpaediatrictracheostomyemergencies.Theseguidelinesdescribethedevelopmentofabespokeemergencymanagementalgorithmandsupportingresources.Ouraimistoreducethefrequency,natureandseverityofpaediatrictracheostomyemergenciesthroughpreparationandeducationofstaff,parents,carersandpatients.

Correspondenceto:C.Doherty

Email:catherine.doherty@mft.nhs.ukAccepted:14March2018

Keywords:airway;guideline;paediatric;tracheostomy

ThisarticleisaccompaniedbyaneditorialbyMacKinnonandVolk,Anaesthesia2018;73:

/10.1111/

anae.14378

◎2018TheAssociationofAnaesthetists1

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Anaesthesia2018Dohertyetal.

Multidisciplinaryguidelinesforthemanagementofpaediatrictracheostomyemergencies

Recommendations

1.Bedheadsignscommunicateessentialairwaydetailsandshouldbemandatedaspartofthetheatresign-outprocessfollowingtracheostomysurgery

2.Thebestavailableassistanceshouldbesummonedearlytoanemergencyandinstitutionsshouldplanforthisinadvance

3.Essentialairwayequipmentmustbeimmediatelyavailableandaccompanythepatient

4.High-andlow-fidelitysimulationhasanimportantroletoplayforhealthcarestaff,familiesandcarers,usingthealgorithmasachecklisttoguideresponders

5.Healthcareprofessionalswholookafterchildrenwithtracheostomiesshouldreceiveregulartraininginroutineandemergencytracheostomymanagement

Introduction

Theindicationsfortracheostomyinchildrenhaveevolvedovertheyears,whichhaveinfluencedtheincidenceofpaediatrictracheostomyinourhospitalsandcommunitiesandthebaselinecharacteristicsandcomor-biditiesofthesechildren.Vaccinationprogramsandimprovementsinanaestheticskillsandequipmenthavesignificantlyreducedtheneedforemergencytracheostomyduetoairwayobstruction,especiallyasaconsequenceofupperairwayinfection[1].Thecommon-estindicationsfortracheostomyinachildinclude:actualoranticipatedlong-termventilatorysupport;requirementforbroncho-pulmonarysecretionmanagement;orthepresenceofafixedupperairwayobstruction,typicallysubglotticstenosis,bilateralvocalcordparalysis,tumoursandcongenitalairwaymalformationsandassociatedsyn-dromes[2-6].Respiratorypapillomatosis,causticalkaliingestionandcraniofacialsyndromeshaveincreasedthefrequencyofpaediatrictracheostomyoverthepastdecade,althoughevolvingsurgicaltechniquessuchasmicrodebridementmayavoidtracheostomyinsomecircumstances.

Tracheostomiesmayberequiredfromtheveryfirstdaysoflife,includingperi-deliveryexitproceduresforknownfetalairwayabnormalities[7].Approximately1200surgicaltracheostomieswereperformedinchildrenaged16yearsorlessduring2014-2015inEngland[8].One-thirdoftheprocedureswereperformedinchildrenundertheageofoneyearandtwo-thirdsinchildrenundertheageoffouryears,aconsistentfindingsincethe1970s[9,10].AnestimatefromtheUSAin1997suggestednearly5000paediatrictracheostomieswereperformed[11].Mostcaseseriesreportahigherincidenceofmalechil-drenrequiringtracheostomy,probablybecausetheyare

moresusceptibletogeneticdiseases[12].Tracheos-tomiesmaybetemporary,althoughtheyremaininsitusig-nificantlylongerthantemporarytracheostomiesinadultpractice,especiallyifthechildhasadegreeofneurologicalimpairment[13].Similarly,tracheostomiesaremuchmorelikelytoberequiredpermanentlyinchildren,withsignifi-cantlifestylechangesforthechildandtheirparentsorcarers[14-16].Childrenwithreversible,treatableoracquiredpathologies,suchasvocalcordpalsiesorsubglotticstenoses,aremorelikelytogetdecannulatedandthenumberofassociatedcomorbiditiesislinkedtothelikeli-hoodofeventualdecannulation[17].Treatmentcantakemonthstoyears,sometimeswaitingforchildrentogrowortoundergostagedmaxillofacialorheadandneckrecon-structiveorcorrectivesurgery.

Performingatracheostomyandchangingatracheo-stomytubecanbedifficultinpaediatricpatients,duetoanatomicalandtechnicalfactors.Thetracheaissmallandpliableandcanbedifficulttopalpate,withthetechnicalchallengesmagnifiedbytheshortneck,headandneckvesselsandthepleuraextendingintotheneck.Thesizeofthetracheadictatesthatacartilagewindowshouldnotbeusedinchildren,toavoidcreatingastenoticsegmentatthesiteofthetracheostomy.Instead,averticaltracheotomyisused,whichmayhinderreplacementofblocked,ordis-lodged,tubeuntilstomamaturationiscomplete.'Maturationsutures'areusedtoacceleratethisprocess,and'staysutures'aresitedoneithersideoftheverticaltracheostomytoaidopeningofthelumeninanemergency,beforetheplannedfirsttubechange[18].

Tracheostomiesinchildrenaretypicallyopensurgicalprocedures,althoughpercutaneousandhybridtechniqueshavebeendescribed[19,20].Incontrast,adulttracheostomiesarepredominantlyperformedper-cutaneouslywiththecommonestindicationbeingtoaidweaningfrommechanicalventilationintheacutelycriti-callyill[21].Tracheostomyforchildrenisusuallyaplannedprocedure,oftenfollowingrelativelylongstaysontheintensivecareunitwhencomparedwithadultpractice[22]

Duetothesmalltrachealdiameter,paediatrictra-cheostomytubesaregenerallyuncuffedanddonothaveaninnertube,toavoidreducingtheinternaldiameterofthetracheostomytubelumenfurther[4].Neonataltra-cheostomytubesareshorterinlengththanthepaediatrictubes.Cuffedtubesareoccasionallyrequiredifhighven-tilationpressuresareneededorifthereisahighriskofaspiration[23].

Around20%ofadultswhoundergotracheostomyintheUKandUSAdonotsurvivetohospital

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discharge[24-27].Comparablefiguresforpaediatricpatientsundergoingtracheostomycomefromsmallercaseseries,butaretypicallyreportedatbetween2%and10%withsignificantgeographicalvariation[3,9,28-34].Inbothagegroups,mortalityislargelyduetothesignificantunderlyingcomorbiditiesthatcontributetotherequirementfortracheostomy[35].However,morbidityandmortalitythatisdirectlyduetothetracheostomyitselfdoesoccurintheperi-operative,hospitalandcommunitysettings,contributingtoasignificanthealthcareresourceburden[36].

Tracheostomycomplicationsoccursurprisinglyfre-quentlyandinfluenceoutcomes[37,38].OnerecentNorthAmericanpaediatrictertiarycentrestudyreportedearlycomplicationsin11%andlatecomplicationsin68.8%ofalltracheostomiesinserted[39],whichisconsis-tentwithotherreportedinstitutionalcaseseries[2,30,32,33,38,40-43].Theearlypostoperativecomplicationrateinpreterminfantsmaybedoublethatoffull-terminfants[44],andtherequirementfortracheostomyinthepretermperiodisalsoassociatedwithpoordevelopmen-taloutcomes[45].Thecommonestreportedincidentsdescribetubedisplacement,blockageoratubebeingpulledout[46].Childrenwhoareventilatordependanthaveworseoutcomesfollowinganincidentthanthosebreathingunaided[47].Complicationssuchassubglotticstenosesorgranulomaformationassumegreaterimpor-tanceinthechildduetothesmallcalibreoftheairway,althoughaccidentaldecannulationmayalsobecomemoreprevalentasmanualdexteritydevelopsinolderchildren.Thevastmajorityofsignificanteventsoccurmorethanoneweekafterthetracheostomyinsertionincludingcatastrophiceventsoccurringathome[28].

Medicolegalreportsreinforcethepotentialforsevereandpermanentdamagewhentracheostomycomplicationsoccur,mostcommonlyforperi-operativenegligence,dislodgedtubesandmucousplugs.AwardamountswerehighatamedianofUSD$2,000,000inoneUSstudywithotolaryngologistsandnursesthemostcommonlynameddefendants[48].Thisdemonstratestheimportanceofpropertrainingofallmembersofamulti-disciplinaryteam,whichisoftenfoundlacking[49].

Complicationsandincidentsrelatingtotracheo-stomiesandlaryngectomiesinadultshavebeenwelldocumentedinaseriesofnationalreportsandanalysesofdataregistries[24,26,50-52].Whenincidentsoccur,somemeasureableharmisreportedin57to82%,withthelevelofharmdependantonlocation[50,51,53,54].Recurrentthemesthatemergedfromincidentanalyses

haveledtocommonrecommendationstoimprovecare,includingthefollowing:

●Trainingfortracheostomyemergenciesincludingrecognitionandmanagementofblockedanddisplacedtubes

Hospital-wideprotocolsandstandardisedtrainingintracheostomycare

●Bed-sideinformationincludingdetailsoftheairwayandtracheostomytube

●Bed-sidetracheostomyboxescontainingessentialequipmentforeachpatient

Understandingthepotentialproblemswithtra-cheostomycareledtothedevelopmentofnationallyrecognisedguidelinesforthemanagementofadulttra-cheostomyandlaryngectomyemergencies,ledbyclini-ciansattheNationalTracheostomySafetyProject(NTSP)[55].Emergencyguidelinesweresupportedbymultidisci-plinarystakeholderRoyalCollegesandprofessionalandpatientgroupsandacomprehensivepackageofeduca-tionalresources(.uk).Implementa-tionoftheseguidelineshashadanimpactonthequalityandsafetyofcare[53].Theseguidelinesare,however,notimmediatelyapplicabletochildren.

Althoughtherearecleardifferencesbetweenadultandpaediatrictracheostomycareandpractice,therecur-rentthemeswehaveidentifiedarelikelysimilarataninstitutionalandorganisationallevel[56].Manyoftheseadverseeventsareavoidable[57],andarealsoamenabletoprospectivequalityimprovementstrategies[58].Therefore,thePaediatricWorkingGroupoftheNTSPwasestablishedwiththeaimofdevelopingpaediatrictracheostomyemergencyguidelines,usingasimilarmethodologytothepreviouslypublishedNTSPadulttra-cheostomyemergencyguidelines[55].

Ourobjectivewastodevelopsimple,clearandauthoritativeguidelinesthatwerespecificforchildrenwithtracheostomies,followingwideconsultationwithkeynationalstakeholdersandbodiesinvolvedinpaediatrictracheostomycare.Ourfocuswasmanagementofpost-placementincidentsandtheimmediatemanagementofpotentiallylife-threateningcomplications.Aswiththeadultguidelines,weaimedtoproduceresourcesthatwereapplicabletoallmultidisciplinarystaff,regardlessofbackground,thatcouldbetaughtconsistentlyandeasilyaspartofstandardeducationpackages.Theseguidelineswerealsotobeapplicableforcarersandparents.Chil-drenwithatracheostomyoftenhaveothercomorbiditiesthatrequirecareatdifferenthealthcaresitesandhence

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theimportanceofhavingastandardisedguidelineforalltouse.Thepurposeofthisarticleistopresentthesepaediatricguidelinesandtheirrationale.

Methods

APaediatricNTSPNationalWorkingPartywasformedin2013comprisingamultidisciplinaryteamofpaediatricear,noseandthroat(ENT)surgeons,paediatricintensivecareunit(PICU)consultants,paediatricanaesthetistsandspecialistpaediatrictracheostomycarenurses(bothhospitalandcommunitybased)frompaediatrichospitalsacrosstheUKandIreland.

AliteraturereviewwasundertakeninNovember2015andupdatedinFebruary2017,whichsearcheddatabases(Embase,PubMed,Medline),searchengines(GoogleandGoogleScholar)andNHSEvidencebases(www.evidence.nhs.uk).ScientificpapersandexistingnationalorinstitutionalguidelineswithEnglishlanguageabstractswereretrievedandreviewed,alongwithanyresourcesknowntotheWorkingPartymembers.Appro-priateconsiderationwasgiventoUK'andUS'spellingsofkeywords.Twoauthors(BMandCD)filteredpublications,resources,websites,expertopinionandcommunications,withfurtherarticlesretrievedfromrelevantreferences.Themajorityofpublishedliteratureregardingpaediatrictra-cheostomiesconsistsofsingle-centreretrospectivereviewsofpractice,detailingindicationsandsurgicaltechniqueswithfewreportingemergencymanagementprocedures[59,60].

ldentifiedconsensusstatementsandbest-practiceguidelinessuggestedthathealthcareprofessionalswholookafterchildrenwithtracheostomiesshouldreceiveregulartraininginroutineandemergencyairwayman-agement[61-63].OnenationalsurveyofUSotolaryngol-ogistsreportedthat98%ofrespondentswereinstructingfamiliesandcarersoftracheostomisedchildrenintherecognitionofrespiratorydistress,emergencymanage-mentandtubereplacement[64].However,compre-hensive,universalguidancewasnotdescribedinthepublishedliterature.Wealsoreviewedlocalguidelinesandpoliciesforthemanagementofpaediatrictra-cheostomyemergenciesthatwereknowntotheauthorsorretrievedthroughoursearchstrategies.Mostdetailedtracheostomycarebundlesanddailycare,withlittlereferencetoemergencymanagement.

Thisguidelinerecognisesthelackofaconsensusformanagingapaediatrictracheostomyemergencyorpaedi-atricfront-of-neckairway(FONA)andthelimitedevidenceforanychosentechnique.Wemakerecommendationstoguidethemultidisciplinaryresponder,carerorteamin

managingthecommonesttracheostomyproblemsthatoccurinchildren,usingsimpleandfamiliartechniquesthatarelikelytobeofbenefit,beforeimplementingmoreadvancedorinvasiveinterventions.Aswithotherdifficultairwaymanagementguidelines,regardlessofthechosentechniques,priorfamiliarityandpreparednesswillmaximisethechancesofsuccess[65,66].

ThePaediatricWorkingGrouphaddevelopedaninitialdraftguidelinein2013comprisingemergencyalgorithmandpairedbedheadsign.Thedesignofthealgorithmwasbasedonthepublishedguidelinesforman-agementofadulttracheostomyandlaryngectomyemer-gencies[55],withmodificationswheretherewerefelttobesignificantdifferencesinpaediatricmanagement.EarlyversionswerediscussedamongtheWorkingPartyandourmultidisciplinarycolleagues,andweretestedusinghigh-fidelitymedicalsimulationatlocalbespokemeetingsusingfacultyandvolunteers.Keystepsweredesignedtoaddresscontributingfactorstopoorlymanagedemergen-cies,whichincludelackofaccesstoinformationoremer-gencyalgorithms,lossofsituationalawarenessandpoorcommunication[50,51].Werecognisedtherolethatsimu-lationcouldplayinfurtherrefiningthealgorithmkeystepsandhavepreviouslydescribedtestingversionsofthealgorithminover450volunteerhealthcareprofessionalencountersatnationalandinternationalmeetings,wherethealgorithmwasalsoformallypresented[59].Wewereabletodemonstratesignificantimprovementsinperfor-mancemetricswhenmultidisciplinaryrespondersfollowedthealgorithminsimilarscenarios.Scenarioswerecom-pletedmorequickly,thesimulatedchildrenwerelesshypoxicandmorecandidatescalledforhelp[59].

ThenearfinalversionofthealgorithmwasagreedbytheWorkingPartyandmadefreelyavailableontheNTSPwebsite()inMay2015.Thealgorithmpageswereaccessed99,096timesuptotheendofJanuary2017,withthepaediatricalgorithmviewed4,250times.Emailcommentswereinvitedbutnonewerereceived.Duringthisperiod,thealgorithmwasalsoassessedinsixtracheostomyemergencycourseshostedbytheAdvancedLifeSupportGroup(www.)withdetailedfeedbackfrominstructorsandparticipants.

TheWorkingPartyinvitedformalreviewsofthealgo-rithmfromseveralorganisationswithastatedinterestinpatientsafety,airwaymanagementandprofessionalguidelinesinchildren.TheseincludedtheAdvancedLifeSupportGroup,theAssociationofPaediatricAnaes-thetists,theBritishAssociationofPaediatricOtolaryn-gologists,theGlobalTracheostomyCollaborative,the

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PaediatricIntensiveCareSociety,theResuscitationCouncil(UK)andtheRoyalCollegeofPaediatricsand

ChildHealth.

TheWorkingPartyagreedthefinalversionsofthealgorithmandpairedbedheadsignsinJanuary2017afterreviewingfeedback.Theprojecthasnotbeendirectlyfunded,althoughtheNTSPhassupportedsomemeetingcosts.

Results

Paediatricpatientswhorequireatracheostomyaremorelikelythanadultstohaveadifficultorimpossibletomanagenativeupperairway,andairwaymanagementismademoredifficultbyintercurrentcriticalillnessanddependenceoninvasiveventilatorysupport[67,68].Aswiththeadultguidelines,severalbasicprinciplesunderpinthepaediatricguidance.

First,bedheadsignswereadaptedtoprovideessen-tialinitialinformationtoemergencyrespondersthatwasspecifictothechildandtotheirparticulartracheostomy,consistentwiththeviewsoftheIntensiveCareSociety,DifficultAirwaySociety,NationalPatientSafetyAgencyandtheadultNTSPwork[52,55,69-71].Awiderangeoftracheostomytubesandassociateddevicesareavailable,includingsomecustom-madedevices[72,73].Eachhasspecificfeatures,whichareimportantinanemergencywhensuctionoratubechangemaybeurgentlyrequired,andregularcarers,parentsorthemedicalrecordsarenotimmediatelyavailable.Asdifferentmanufacturers'tubescomeinsubtlydifferentsizesandlengths,bedheadinfor-mationsuchastheinternaldiameterofthetracheostomytube,thecalibreofsuctioncatheterstobeused,andthedepththatasuctioncathetershouldinsertedtoshouldbekeptwiththechildatalltimes[72].

Thebedheadsignsalsoincorporatedetailsofthechild'supperairwaypatency,andeaseofmanagement.Werecommendthatmultidisciplinaryteamscompletethesefieldsbasedonhistoricalairwaymanagement(fromanaestheticchartsoroperationnotes)orfollowingairwaymanagementprocedures(oftenintheatre).Itmaybeclearthatitismucheasiertoreplaceatubeintothetra-cheostomystomaorthenativeupperairway(s)shouldtracheostomyblockageordisplacementoccurandthisinformationmustbeclearlycommunicated.Werecom-mendthatcompletionofthebedheadsignbemandatedaspartofthetheatresignoutprocedurefollowinganewtracheostomyprocedure,orairwaymanagementintheatre.

Therearetwoversionsofthisbedheadsign;the'NEWtracheostomy'sign(Fig.1a)isuseduptofirsttube

changeandthe'Tracheostomy'signisusedthereafter(Fig.1b).Newstomasarelikelytohavetheadditionalsafetyfeaturesof'staysutures'(Figs.2aandb)and'mat-urationsutures'(Fig.3)whichsecuretheedgeofthetrachealwalltotheanteriorneckskin[39,63].Thelocationandpurposeofthesesuturesaredocumentedonthebedheadsignandthestaysuturesaretypicallyremovedatthefirsttubechange.Thisoftencoincideswithdischargefromacriticalcareenvironmenttowardlevelcare.The(established)tracheostomybedheadsignisthencompleted.

Althoughmuchlesscommoninchildrenthananopensurgicalprocedure,ifthetracheostomyhasbeenpercutaneouslyinserted,thisshouldbeclearlyrecordedonthebedheadsign[19].Itislikelythatthedilatedtissuesofapercutaneouslyformedstomawillrecoilintheeventoftubedisplacement,makingre-insertionpotentiallymoredifficult,especiallyinthefirst7-10daysfollowinginsertion[74].Thisknowledgemaydirectresponderstomanagetheupperairwayasapriority.Asurgically-formedstomacanreasonablybeexpectedtobematuredenoughtoallowsafetubeexchangeafterthreedays,dependantonpatientfactorsorlocalpractices[63].

ThepairedpaediatricbedheadsignsareprovidedontheNTSPwebsiteinMicrosoftPowerPointformattoallowforlocaladaptations,anddouble-sidedversionsensurethattheemergencymanagementalgorithmisalsoimmediatelyavailable.

ThesecondprinciplethattheWorkingPartyadoptedfromtheadultguidelineswasthatthealgorithmandbed-headshouldbeabletobeusedbymultidisciplinarystaffwhomightcareforachildinthecommunity,secondaryortertiarylocations.Informationshouldalsobeunderstand-ablebyparentsandcarersandthealgorithmshouldbeabletoguidenon-medicallytrainedprimaryrespondersintheinitialmanagementoftracheostomyemergencies.Theseprimaryrespondersmaynotonlyincludeparents,carersandcommunityorschoolnursesbutalsohospitalstaffwithlimitedtrainingandinfrequentcontactwithtracheostomypatients[75].Suchresponderswillbemanag-ingchildrenwithestablishedstomasandareguidedinbasicresponsestotracheostomyemergencies.Respon-derswithmoreadvancedairwayandtracheostomyskillswillmanagechildrenwithnewtracheostomiesandprovidesecondarysupporttothemanagementofestablishedtracheostomyproblems.Thealgorithmalsoguidessecondaryrespondersthroughbasicmanagementbutcontinuestoprimaryandsecondaryoxygenationtechniques.Twodouble-sidedpairedbedheadsignsandalgorithmsarethereforeprovided:

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(a)

Thispaediatricpatienthasa

Newtracheostomy

PatientID:

PotientLabel/Detais

Tracheostomy:

Addtubespecification

indudingcufforinnertube

mmID,mmdistallength

Suction:

Indicateonthisdiagram

FGCathetertoDepthcmanysuturesinplace

Upperairwayabnormality:Yes/No

umentlaryngoscopygradeandnotesonupperairwaymanagementorpatientspecificresuscitationplans

Due1sttracheostomychange:/(byENTonly)

InanEmergency:Call2222andrequesttheResuscitationTeamandENTsurgeon

FollowtheEmergencyPaediatricTracheostomyManagementAlgorithmonreverse

(b)

Thispaedjatricpatienthasa

Tracheostomy

Patientlabet/Detoils

Addtubespecificationindudingcufforinnertube

mmID,mmdistallength

Suction:

FGCathetertoDepthcm

Upperairwayabnormality:Yes/No

umentlaryngosC0pygradeandnotesonupperairwa