Emergency Airway Research Articles

The Effect of Full-Dose Versus Half-Dose Ketamine for Induction During Rapid Sequence Intubation on Patient Outcomes.

Prehospital rapid sequence intubation (RSI), like inpatient RSI, is not without risk of adverse effects to the patient. The most notable of these adverse effects is postintubation hemodynamic instability. Air medical providers choose induction agents for critically ill patients who require emergent airway management, some of whom may already be hemodynamically unstable prior to RSI. Ketamine is often selected as the induction agent of choice for patients who are either unstable before RSI or have a high index of suspicion of becoming unstable in the postintubation period. Although widely considered to have a good safety profile for induction, ketamine administration has been correlated with episodes of postintubation hypotension. In this retrospective literature review, the effect of using half-dose ketamine for induction in patients who show pre-RSI instability (systolic blood pressure <90 mm Hg or body mass index >30) on postintubation hemodynamics is examined.

Clinical Assessment of the Ambu® Aura-i™ as an Independent Ventilatory Device and Conduit for Fiberoptic-Guided Endotracheal Intubation in Adults.

Background and aim A novel supraglottic airway device of the second generation is the Ambu® Aura-i™. It is designed to accommodate standard cuffed tracheal tubes and is phthalate-free and compatible with MRI. The primary objectives of the research were to examine the properties and efficiency of Ambu® Aura-i™ as a means of enabling fiberoptic-guided intubation, the view of the glottis during fiber optic examination, the duration of intubation in fiber optic bronchoscopy, the ease of intubation, the success rate of intubation, and the duration for device removal from the tracheal tube. Methodology A hospital-based descriptive observational study was conducted with 80 patients. An adequately sized Ambu® Aura-i™ was placed after general anesthesia was induced. Following a fiberoptic examination of the view of the glottis through the Ambu® Aura-i™, the trachea was intubated under fiberoptic guidance. The Ambu® Aura-i™ insertion time, glottic view grading, ease of intubation, and time required for fiberoptic-guided intubation were recorded. Also, the time taken to remove the Ambu® Aura-i™ was documented. Results Similar levels of ease were experienced by both groups after inserting the Ambu® Aura-i™, being easy in both group 1 (37/40) and in group 2 (38/40). In group 1, the average time taken to insert the Ambu® Aura-i™ was 13.53±1.91 seconds, while in group 2, it was 13.98±2.4 seconds. The average time required for fiberoptic-guided intubation was found to be 14.95±1.85 seconds in group 1 and 14.15±1.37 seconds in group 2, indicating a statistically negligible variation. Conclusion The low cost of Ambu® Aura-i™, size suitability and availability for almost all age groups, compatibility with MRI machines, and availability in phthalate-free versions contribute to it being a more appealing and useful ventilatory device, as well as an intubation tool for both normal and emergency airway management.

Airway risk associated with patients in halo fixation.

The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.

Current trends in emergency airway management: a clinical review.

Airway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical spaces. A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.

Emergency airway management in a patient with facial trauma: Combining clinical judgment and skill with fortuity

Airway management in maxillofacial trauma is a challenging task. Distorted anatomy leading to difficult face mask ventilation and intubation requires clinical expertise in emergency scenarios. Planning and managing such challenging airways in a timely manner requires the utmost cooperation from the patient. Here, we present a case of self-inflicted facial gunshot injury that was posted for surgical tracheostomy followed by facial wound exploration and repair. Uncooperative behavior and irritability of the patient were toppings to the difficult airway, however, timely clinical judgment and replanning according to the case requirement contributed to the successful airway management during emergency hours.

Advancing airway management for enhanced patient outcomes: a narrative review

Airway management evidence has primarily been gathered within the operating room, particularly during the induction of anesthesia. The introduction of newly developed supraglottic devices and videolaryngoscopes have significantly impacted the guidelines for managing difficult airways, prompting the need for new evaluation criteria. Moreover, airway complications such as accidental extubation may occur during surgery, while aspiration or respiratory suppression can manifest during the recovery period following extubation. In this review, I will explore the potential future standards for airway management and potential indications for its application. Additionally, I will underscore the significance of emergency airway management during both the surgical procedure and the recovery phase. It is imperative that we not only accumulate knowledge related to managing difficult airways but also focus on emergency airway management in the future. This calls for interprofessional airway management training for all members of the perioperative team. Key words: Airway Management; Videolaryngoscope; Supraglottic Device; Future Direction Abbreviations: DAM - Difficult Airway Management; DAS - Difficult Airway Society; OR - operating room; SGD - Supraglottic Device; VLS – videolaryngoscope Citation: Komasawa N. Advancing airway management for enhanced patient outcomes: a narrative review. Anaesth. pain intensive care 2024;28(1):171−176; DOI: 10.35975/apic.v28i1.2391 Received: December 12, 2023; Reviewed: December 16, 2023; Accepted: December 16, 2023

High-flow nasal oxygenation versus face mask oxygenation for preoxygenation in patients undergoing double-lumen endobronchial intubation: protocol of a randomised controlled trial

IntroductionWith the growing emphasis on swift recovery, minimally invasive thoracic surgery has advanced significantly. Video-assisted thoracoscopic surgery (VATS) has seen rapid development, and the double-lumen tube (DLT) remains the most...

Subcutaneous Emphysema Following Laser Assisted Dilation of Subglottic Stenosis: A Case Report

Introduction: Subcutaneous emphysema is characterized by the accumulation of air beneath the dermal layers of the skin. We present a case of extensive subcutaneous emphysema of the neck, face and arms in a patient who was two days post operative from laser assisted dilation of subglottic stenosis. Materials and Methods: We present a case of subcutaneous emphysema in a patient who presented to the emergency department. As this is a case report, no additional materials or specific methods were required. Case Presentation: A 71-year-old man with history of tracheal stenosis status post laser assisted subglottic dilation presented to the emergency department two days post-operatively for progressively worsening swelling of the face, neck and arms. Physical exam was notable for crepitus of the face, neck and arms. Oropharyngeal exam showed no edema to the posterior oropharynx or tongue. Breathing was non-labored without stridor. Imaging revealed extensive subcutaneous emphysema without any obvious source. The otolaryngology (ENT) service evaluated the patient and admitted him to their service. Initially he was managed conservatively via observation and supportive care however, on day two of hospitalization his respiratory status worsened. He required intubation and tracheal stent placement. The tracheal defect was never found on exploration in the operating room, suggesting the defect was sub-centimeter in size. He was extubated on hospital day four and discharged with a plan to have the tracheal stent in place for three months. Conclusion: Subcutaneous emphysema secondary to a tracheobronchial tree defect is a known complication of laser dilatation of subglottic stenosis. Most cases resolve spontaneously and can be managed conservatively. However, patients require close airway monitoring as some may require emergent airway management. Clinicians should be aware of this complication and subsequent management.

Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU).

Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.

An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis

BackgroundOsteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications.MethodsA 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary—CUP) was admitted with a right-sided epi—/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction.ResultsDue to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient’s airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief.ConclusionsThe present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.

First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry.

In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations. We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test. Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic). Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.

Impact of airway devices and emergency airway techniques characteristics on airway adverse events in mainland China: a cross-sectional study.

Novel airway devices are becoming widely available, yet it is unclear whether the techniques or preferences of airway practitioners for airway management have been impacted. Given these facts, a cross-sectional study of the current status of airway management in mainland China was conducted and compared with previous survey findings. The national survey was conducted from November 7th to November 28th, 2022. An electronic survey was sent to the New Youth Anesthesia Forum to examine the availability of airway devices, preference for front-of-neck access (FONA) techniques, the incidence of adverse airway events, and the status of airway management training. Questionnaires were completed by 3783 respondents, with a response rate of 72.14%. So far, the availability of optical airway devices has improved dramatically, with the availability of videolaryngoscopes reaching 97.18%. When encountering "cannot intubate, cannot ventilate" (CICV) scenarios, the majority of respondents would prefer needle cricothyrotomy to establish FONA. However, less than a quarter of respondents had actually performed it. Moreover, the incidence of airway adverse events from 2016 to 2022 was 11.48%, of which 5.13% were brain damage or death. Multivariate logistic regression analysis revealed that the ability to perform FONA techniques (odds ratio [OR] 0.23, 95% CI: 0.16, 0.32; P<0.001) and the availability of difficult airway management carts or kits (OR 0.59, 95% CI 0.41, 0.85; P=0.005) were associated with a lower incidence of airway adverse events. Optical airway devices can overcome some of the challenges posed by difficult airways, yet the CICV scenario remains a major obstacle. The future focus of airway management should be training, particularly for complicated emergency airway techniques.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room.

Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

Modified cadaver technique to simulate contaminated airway scenarios to train medical providers in suction-assisted laryngoscopy and airway decontamination.

Simulation training plays a vital role in modern medical education, fostering safe skill development. Task-trainer manikin and cadaveric airway management training (CAMT) offer realistic airway management practice. Simulation allows learners the opportunity to manage high-risk, low-frequency scenarios, including difficult airways and massive airway contamination, common in emergent airway management. The suction-assisted laryngoscopy and airway decontamination (SALAD) technique was developed to address massive airway contamination. This paper describes two methods to simulate massive airway contamination utilizing cadavers. We detail our techniques for both esophageal and nasopharyngeal delivery of simulated airway contaminant. Nasopharyngeal delivery was less invasive and required less time to set up. Utilizing cadavers to simulate massive airway contamination in CAMT provides learners with tools to manage airway complications effectively, enhancing readiness for complex airway challenges while promoting patient safety in clinical practice.

The application of extracorporeal membrane oxygenation in emergent airway management - a single-center retrospective study

BackgroundEmergent airway occurrences pose a significant threat to patient life. Extracorporeal membrane oxygenation (ECMO) has been proven to be an effective method for managing emergent airways.MethodsA retrospective analysis was conducted on all patients receiving ECMO as an adjunct for emergent airway management from January 2018 to December 2022 at the People’s Hospital of Zhongshan City. We collected the basic information of the patients, their blood gas data before and after ECMO, the related parameters of ECMO, and the outcome and then analyzed and summarized these data.ResultsSix patients, with an average age of 51.0(28–66) years, received veno-venous (VV)- ECMO as an adjunct due to emergent airway issues. The average ECMO support duration was 30.5(11–48) hours. All six patients were successfully weaned off ECMO support, with five (83.3%) being successfully discharged after a hospital stay of 15.5(7–55) days. All six patients underwent VV-ECMO through femoral-internal jugular vein cannulation. Among these, five patients, whose airway obstruction was due to hemorrhage, underwent a non-anticoagulant ECMO strategy with no recorded thrombotic events.ConclusionsThe rapid establishment of ECMO support is aided by the establishment of a standardized ECMO initiation protocol and the formation of a multidisciplinary rapid-response ECMO team, which is particularly crucial for emergent airway management. When airway obstruction results from hemorrhagic factors, the early adoption of a non-anticoagulant ECMO strategy can be considered when implementing VV-ECMO.

Management of Paediatric Airway Emergencies: A Systematic Review of Current Practice Guidelines and Clinical Outcomes

Introduction: Paediatric airway emergencies are a significant cause of morbidity and mortality in children. The purpose of this systematic review is to summarize current practice guidelines and clinical outcomes in managing paediatric airway emergencies. Methods: A comprehensive search of electronic databases was conducted to identify relevant studies. Inclusion criteria were studies that reported on the management of paediatric airway emergencies. Data extraction and analysis were conducted based on pre-defined criteria. Results: An overview of current practice guidelines from various organizations was provided, highlighting key recommendations for paediatric airway emergencies. A review of studies reporting clinical outcomes of paediatric airway emergencies showed variations in mortality rates and causes of death, as well as complication rates and types of complications such as respiratory failure, hypoxia, pneumothorax, aspiration, bradycardia, hypotension, and esophageal perforation. Discussion: Comparison of guidelines and reported outcomes revealed areas of agreement such as the importance of early recognition and intervention in paediatric airway emergencies and disagreement with regard to the use of progressive airway management techniques such as intubation and surgical airway management. Potential explanations for discrepancies were discussed. Limitations of the review were also acknowledged, including potential publication bias and heterogeneity of study designs. Future research directions were suggested, such as the need for standardized data collection and reporting in clinical trials. Conclusion: This systematic review provides a comprehensive overview of current practice guidelines and clinical outcomes in managing paediatric airway emergencies. The findings highlight the importance of early recognition and prompt management of these emergencies, as well as the need for further research to improve clinical outcomes.

Predictors of Per-Intubation Cardiac Arrest in Pediatrics Patients Presenting to the Emergency Department

INTRODUCTION: Airway management is one of the vital resuscitative procedures undertaken in many critically ill pediatric patients presenting for emergency care. Around (2–33/10,000) of all pediatric patients presenting to the emergency department (ED) require airway protection for various conditions, such as respiratory failure, airway protection, and cardiac arrest 1-3. In children, airway management demands great caution because of their age-related differences in anatomical and physiological characteristics and limited physiological reserves. Rapid sequence intubation (RSI) has become the standard technique to facilitate pediatric emergency airway management. AIM OF STUDY: To determine the risk factors associated with peri-intubation cardiac arrest in pediatric patients presenting to the emergency department. RESULTS: Total 125 patients were recruited with case to control ratio of 1:4. Data was analyzed for demographic, examination, level of training, drug and outcome variables. The median age group was 18months. Among patients who underwent PICA 40% achieved the ROSC. The most common cardiacrhythm was bradycardia. The patients who underwent PICA had raised heart rate and low blood pressure. The hypoxia was found to be significant contributor to PICA. ROC curve applied to values with significant result after regression analysis. CONCLUSION: The major contributor to peri-intubation cardiac arrest is hypoxia OR 8.96 [2.52 -31.88]. Level of training had no significant relation to PICA. SI and MSI were strongly associated with PICA with OR of 3.78 [1.06 -13.52] &amp; 4.93 [1.09 -22.24] respectively.

Clinical Application of Bilateral Nasopharyngeal Airway in Painless Colonoscopy for Obese Patients.

This study aims to evaluate the safety and efficacy of using bilateral nasopharyngeal airways (NPA) during colonoscopic polypectomy performed under sedation anesthesia in obese patients. Ninety obese patients undergoing colonoscopic polypectomy under elective sedation anesthesia at Shanghai Shuguang Hospital were randomly allocated to two groups. Patients in group B had a nasopharyngeal airway inserted bilaterally after induction of anesthesia, whereas patients in group U had a nasopharyngeal airway inserted in only one nostril. Spontaneous breathing was maintained in both groups. The primary observation parameter was the incidence of oxygen saturation (SpO2) ≤ 92% during anesthesia, while secondary observation parameters included preoperative, intraoperative, and post-operative SpO2 levels, mean arterial pressure (MAP), heart rate (HR), dosage of propofol, duration of the operation, time to anesthesia recovery, need for emergency airway intervention, and occurrence of other adverse events. Hypoxia occurred in 5 out of 45 patients (11.1%) in group B, whereas it was observed in 14 out of 45 patients (31.1%) in group U (P < 0.05). Patients in group B exhibited higher SpO2 levels during and after surgery compared to those in group U (P<0.05). Furthermore, the decrease in intraoperative and post-operative SpO2 levels from baseline was significantly lower in group B compared to group U (P < 0.05). The number of emergency airway interventions, operation time, propofol dosage, and anesthesia recovery time were significantly lower in group B compared to group U (P<0.05). However, there were no significant differences in MAP, HR, or the incidence of adverse events between the two groups (P>0.05). The utilization of bilateral nasopharyngeal airway placement proves to be an effective strategy in decreasing the occurrence of hypoxia among obese patients undergoing colonoscopy under sedation anesthesia, thereby improving procedural safety.

Factors associated with first pass success rate during intubation in the emergency department: a systematic review

Many emergency departments are now evaluating the quality of airway management, with the first-pass success rate being a widely used indicator of competence that has been linked to adverse event rates. The present study aimed to quantify adverse events related to endotracheal intubation in emergency departments, focusing on the first-pass success rate.We conducted a thorough search of MEDLINE, EMBASE, and PubMed using keywords such as \&amp;quot;multiple intubation attempts,\&amp;quot; \&amp;quot;intubation,\&amp;quot; \&amp;quot;first-pass success,\&amp;quot; and \&amp;quot;learning curve\&amp;quot; to identify relevant research. Our search was further expanded to include references from the identified articles. We collected and assessed citations spanning a twenty-year period from 2000 to 2020, involving emergency airway management by both prehospital and in-hospital clinicians.Eight articles were included in the final review. Among them, three trials evaluated the impact of the number of intubation attempts on the complication rate, yielding odds ratios of 6.7 (n = 2284), 4.7 (n = 1903), and 4.5 (n = 2616). Multiple intubation attempts were found to increase the risk of complications, a finding supported by a 2004 analysis of 2833 airway management incidents. In this analysis, more than one intubation attempt was associated with a fivefold increase in the overall complication rate.First-pass success rates varied between 71% and 87.5% for prehospital physicians and between 60% and 97% for in-hospital physicians. Achieving first-pass success was shown to reduce problems and increase the likelihood of sufficient oxygenation. Conversely, multiple intubation attempts were correlated with a higher rate of unfavorable outcomes.

Can't intubate, can't oxygenate? What is the preferred surgical strategy? A retrospective analysis.

Cricothyrotomy (CTM) is currently recommended as the preferred method due to its ease, speed, and safety in life-threatening airway emergencies where standard tracheal intubation and mask ventilation fail. This retrospective study analyzed 33 cases of "can't intubate, can't oxygenate or ventilate" (CICOV): 12 of percutaneous dilatational tracheostomy (PDT) and 21 of CTM. The CTM group was younger (median age 44) and mainly consisted of trauma patients. The PDT group was more diverse and procedures were performed by anesthesia and critical care consultants. Initial success rates were 100% for PDT (12/12) and 86% for CTM (18/21), with one conversion from CTM to PDT. No perioperative complications occurred in the PDT group, while the CTM group experienced two cases of false tracts requiring re-do and three cases of bleeding. Immediate mortality within 24 hours was reported in 5/19 CTM patients and none in the PDT group. Successful liberation from mechanical ventilation at hospital discharge was achieved in 6/12 PDT patients and 11/21 CTM patients. Among the 21 CTM cases, all 16 survivors underwent subsequent tracheostomy. Tracheal decannulation occurred in 4/12 PDT patients and 10/21 CTM patients. Favorable immediate neurological outcomes (GCS ≥ 11T) were observed in 8/12 PDT patients and 8/21 CTM patients, while 3 PDT patients remained anesthetized until death and 7 CTM patients died within the first 72 hours without recovery attempts. In experienced hands, PDT could be a legitimate clinical option for the surgical airway in cases of CICOV. CTM may be more suitable for practitioners who encounter CICOV infrequently.