42 Clinical Characteristics of Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry

Abstract

Angioedema is common and life-threatening airway obstruction may occur. When intubation is required, it is often difficult to complete when swelling is extensive. First-attempt success is crucial since multiple intubation attempts are associated with increased peri-intubation complications. With more widespread availability of flexible and rigid video equipment, it is important to characterize current airway management practices, success rates and rescue techniques in these patients. We analyzed data from the National Emergency Airway Registry (NEAR), a multicenter prospective observational registry of 25 community and academic EDs. Patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2017 were included. We report univariate descriptive data as proportions with 95% confidence intervals (CIs). Of 12,044 discrete patient encounters, 71 (0.6%) patients underwent an intubation attempt for angioedema. The median patient age was 59 years (IQR 42 to 64 years), and 17 (23.9%) were female. Emergency physicians were the primary operators during the first-attempt in 92% of cases. Flexible endoscopic devices were the most common initial device (51%) followed by the C-MAC video laryngoscope (21%) and Glidescope video laryngoscope (13%). A direct laryngoscope was used in only 6 cases (8%). Oral and nasal intubation routes were used in 56% and 44%, respectively. A sedative agent was used during first intubation attempt in 82% of encounters and a paralytic was used in 61% of patients. Etomidate and succinylcholine were the most common sedative and paralytic agents administered, respectively. The first-attempt success rate among all angioedema patients was 82% (95% CI [71% to 90%]). Ultimate success was 99%. Nasal routes had a higher first-attempt success rate compared to oral routes (97%, 95% CI [83.3-99.2] vs. 69%, 95% CI [52.4-83.0], respectively). Flexible endoscopes were successful on first-attempt in 33/36 (92%, 95% CI [78%-98%]) patients. Rigid video laryngoscopes and direct laryngoscopes were successful in 24/29 (83%, 95% CI [64%-94%]) and 2/6 (33%, 95% CI [4%-78%]), respectively. The first-attempt success rate among patients in whom a sedative agent was used was 79% (95% CI, [67%-89%]) vs 92% (95% CI, [64%-99%]) among patients in whom no sedative agent was administered. First-attempt success rates were similar between paralyzed and non-paralyzed patients (81% vs. 82%, respectively). No patients underwent a primary cricothyrotomy on first attempt; one patient required a rescue surgical airway. Intubation for angioedema in this multicenter ED cohort was rare. In the hands of emergency physicians, first-attempt success rate was 82% with an ultimate success rate of 99%. The highest first attempt success was observed in patients undergoing nasal flexible endoscopic intubations. Rescue cricothyrotomy was performed once. Further study is needed to determine optimal emergent airway management in this population of patients.