Difficult Airway Characteristics Research Articles

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.

First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility.

It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success. In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome. Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19). In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

IntroductionAirway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. MethodsThe National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. ResultsOf 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1–2.5, range 1–31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. ConclusionsEGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Individualized Treatment Effects of Bougie versus Stylet for Tracheal Intubation in Critical Illness.

Rationale: A recent randomized trial found that using a bougie did not increase the incidence of successful intubation on first attempt in critically ill adults. The average effect of treatment in a trial population, however, may differ from effects for individuals. Objective: We hypothesized that application of a machine learning model to data from a clinical trial could estimate the effect of treatment (bougie vs. stylet) for individual patients based on their baseline characteristics ("individualized treatment effects"). Methods: This was a secondary analysis of the BOUGIE (Bougie or Stylet in Patients Undergoing Intubation Emergently) trial. A causal forest algorithm was used to model differences in outcome probabilities by randomized group assignment (bougie vs. stylet) for each patient in the first half of the trial (training cohort). This model was used to predict individualized treatment effects for each patient in the second half (validation cohort). Measurements and Main Results: Of 1,102 patients in the BOUGIE trial, 558 (50.6%) were the training cohort, and 544 (49.4%) were the validation cohort. In the validation cohort, individualized treatment effects predicted by the model significantly modified the effect of trial group assignment on the primary outcome (P value for interaction = 0.02; adjusted qini coefficient, 2.46). The most important model variables were difficult airway characteristics, body mass index, and Acute Physiology and Chronic Health Evaluation II score. Conclusions: In this hypothesis-generating secondary analysis of a randomized trial with no average treatment effect and no treatment effect in any prespecified subgroups, a causal forest machine learning algorithm identified patients who appeared to benefit from the use of a bougie over a stylet and from the use of a stylet over a bougie using complex interactions between baseline patient and operator characteristics.

Risk of peri-intubation adverse events during emergency department intubation of overdose patients: a national emergency airway registry (near) analysis

Background More than 20,000 emergency department (ED) patients undergo intubation for overdose each year. While the characteristics of patients intubated for overdose and poisoning are well described, little is known about the intubation outcomes of overdose patients in the ED. Objectives We quantify the frequency of peri-intubation adverse events for patients intubated in the ED for overdose, and determine whether first attempt success without adverse events differs between patients intubated for overdose and patients intubated for other reasons. Methods We analyzed data from the National Emergency Airway Registry (NEAR), a prospective multicenter registry of ED intubations collected from an international network of 22 academic and community hospitals. We included patients 14 years and older whose first attempt was oral intubation, with data entered into NEAR between 1 January 2016 and 31 December 2018. The primary outcome was successful intubation on the first attempt. We used multivariable logistic regression to determine whether indication was independently associated with successful intubation on the first attempt after adjusting for age, gender, obesity, initial impression of difficult airway, presence of difficult airway characteristics, and use of video laryngoscopy. Secondary outcomes included successful intubation on the first attempt without adverse events, the occurrence of rescue surgical airways, and the occurrence of adverse events. Adverse events included hypoxemia, hypotension, peri-intubation cardiac arrest, bradycardia, mechanical injury to oral or airway structures, vomiting, tachydysrhythmia, esophageal intubation, laryngospasm, and pneumothorax. Results We analyzed 17,984 patients, including 1,983 (11%) intubated for overdose, and 16,001 (89%) intubated for other indications. Patients intubated for overdose were younger (median age 38 vs 55 years), were less frequently obese (26% vs 34%), and fewer had difficult airway characteristics (38% vs 53%). Overdose patients were more likely to have preoxygenation performed (45% vs 35%), more likely to have apenic oxygenation (39% vs 31%), and more likely to have bougie used (33% vs 17%). First attempt success was 90.5% in patients intubated for overdose and 87.5% in patients intubated for other reasons (absolute difference 3.0%; 95% CI: −1.3 to 7.3). First attempt success without adverse events was higher in overdose patients (85.0%) compared to other patients (78.7%) (absolute difference, 6.3%; 95% CI 1.0 to 11.7%). Overdose patients experienced significantly less hypotension (1.5% vs 4.1%), and tended to have fewer adverse events overall. Multivariable model results were consistent with the unadjusted results including no difference in first pass success (adjusted odd ratio 1.02 [95% CI 0.86–1.23]). There was a higher first pass success without complication in patients intubated for overdose (adjusted odds ratio 1.23; 95% CI 1.07 to1.43). Conclusion For patients in whom the primary indication for intubation is overdose there is an increased chance of first attempt success without adverse event.

Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study

IntroductionPrevious studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.MethodsWe conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016–December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI).ResultsOf 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9–92.3) with VL and 77.7% (95% CI 75.7–79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8–88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3–84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1–0.7) of VL attempts and 1.5% (95% CI 1.1–1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5–0.7) of VL attempts and 1.4% (95% CI 0.9–1.9) of DL attempts.ConclusionAnalysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.

Implementation of a Rapid Sequence Intubation Checklist Improves First Pass Success and Reduces Peri-Intubation Hypoxia in Critical Care Transport

<h3>Objectives</h3> We measured the impact of a rapid sequence intubation checklist (RSIC) on first pass success (FPS) during endotracheal intubation by US flight crews, taking into consideration human factors of checklist utilization. We also examined the effects of the RSIC on definitive airway sans hypoxia or hypotension on first pass among adult patients (abbreviated as DASH1a). <h3>Methods</h3> This is a before-and-after observational study within a helicopter ambulance company. The RSIC was used by the crews (Flight Paramedic and Flight Nurse) over a three-year period. Data were evaluated for 8 quarters before- and 8 quarters after- checklist implementation, spanning December 2014 to March 2019. Data included: reason for intubation, use of checklist during intubation, and correlation with the prehospital difficult airway prediction tool, HEAVEN (Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurological injury) compared with airway management prior to implementation of the checklist. The primary outcome was FPS, and this was compared among those who received RSI before the checklist, versus those who received RSI with the checklist. Also, definitive airway sans hypoxia on first pass among adult patients (DASH1a) was measured before and after RSI checklist implementation. Outcome scenarios were recorded to analyze effectiveness of the checklist. <h3>Results</h3> A total of 10,405 intubations were attempted during the study. First pass success was achieved in 90.9% of patients prior to RSIC, and 93.3% achieved FPS post-implementation (p=<0.001). In the epoch prior to the RSI checklist, there were 4015 (91.9%) of intubations that met the DASH1a metric. After RSI checklist implementation, DASH1a success improved to 94% (p<0.001). Reasons for intubation were similar between the cohorts, although there were more HEAVEN criteria, indicating more difficult airway characteristics, among the post-checklist cohort. It is also noteworthy that overall intubation success without hypoxia improved between the study timeframes, with 89.5% prior versus 93.1% of patients intubated without hypoxia after RSI checklist training, p<0.001. <h3>Conclusion</h3> Implementation of a standardized Rapid Sequence Intubation checklist is a best practice to optimize DASH1a and thereby prevent adverse events related to hypotension or hypoxia in the peri-intubation period. Data suggest that these observations held true even with more objectively difficult EMS airways, based on the higher prevalence of one or more HEAVEN criteria after the checklist implementation.

Factors Associated With Poor Long-Term Outcomes After Emergency Department Intubation.

IntroductionWhile immediate complications of ED patients undergoing endotracheal intubation (ETI) have been explored, the relationship between ED ETI and patient status at hospital discharge is unknown.MethodsWe performed a retrospective review of all intubations performed in our ED for one calendar year in adult patients (>18 years of age). We abstracted patient and ETI factors (indication, complications, etc.) to determine their impact on patient outcomes. We defined a poor outcome as either (1) death or discharge to a nursing home if admitted to the hospital from home or (2) death if admitted to the hospital from a nursing home. We examined the univariate odds ratios for poor outcomes. ResultsWe identified 122 intubations; 64 (52.5%) had a poor outcome and 58 (47.5%) did not have a poor outcome. Age in years (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07) and ETI performed for an indication of "cardiac arrest" (OR 4.49, 95% CI 1.55-13.01) were the only variables associated with a poor outcome. Other patients and intubation variables were not associated with a poor outcome including; gender, difficult airway characteristics, intubator skill level, first attempt success, airway complications, and post-intubation hypoxia or hypotension.ConclusionIn our sample from a single ED, over 50% of patients who undergo ED ETI either died in the hospital or failed to return home. While age and an ETI indication of "cardiac arrest" were associated with poor outcomes, future work is required to validate our findings in a larger cohort.

Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy

BackgroundTracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.MethodsWe conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.ResultsFPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.ConclusionAirway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study

AimTo determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. MethodsThis is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. ResultsOf 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9–1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5–8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0−4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2−2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. ConclusionsPeri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

IntroductionThe goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).MethodsWe analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014–June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE.ResultsA total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = −10.3%, 95% confidence interval (CI), −14.8% to −5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = −10.7%, 95% CI, −17.3% to −4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = −21.4%, 95% CI, −27.0% to −16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 – 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 – 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 – 0.33].ConclusionFPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.

Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study.

The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. We analyzed ED intubation data for patients aged >14years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference=8.8%, 95% confidence interval [CI]=5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI=4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference=5.9%, 95% CI=2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference=6.5%, 95% CI=3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR=1.4, 95% CI=1.2 to 1.7) and treatment for hypotension (aOR=1.8, 95% CI=1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0mg/kg versus >1.0mg/kg or patients receiving etomidate at doses ≤0.3mg/kg versus >0.3mg/kg. Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

First pass success is important in prehospital tracheal intubation to minimise the risk of physiologic deterioration

Pre-hospital tracheal intubation of the critically ill and injured can be challenging and patients are at risk of serious complications. The purpose of this study was to determine the association between the number of intubation attempts and the occurrence of physiologic deterioration. This institutional review board (IRB)-approved project was an observational study conducted in a large USA helicopter emergency medical service (HEMS) of patients undergoing rapid sequence intubation in the field by the flight crew (flight nurse/flight paramedic) over a 4 yr period from January 1, 2015 to December 31, 2018. Data were collected on patient, operator, and procedural characteristics, and included method of intubation, drugs and devices used, difficult airway characteristics, number of intubation attempts, outcome of each attempt, and complications associated with intubation. The predictor variable was first pass failure, which was defined as failure to achieve tracheal intubation on a single laryngoscope insertion. The outcome variable was physiologic deterioration, which was defined as the occurrence of any one of the following three physiologic complications: hypoxemia (SpO2 <90%), hypotension (systolic blood pressure <90 mm Hg) or cardiac arrest (loss of pulses requiring cardiopulmonary resuscitation). Patients were excluded if they were <18 or >89 yr of age, or if they were hypoxaemic, hypotensive, or in cardiac arrest before intubation was attempted. Multivariable logistic regression was performed to evaluate the relationship between first pass failure and the occurrence of physiologic deterioration. A total of 6247 patients were included in the analysis. Of these, 93.0% (n=5811) required one attempt, 5.7% (n=353) required two attempts, and 1.3% (n=83) required three or more attempts. Physiologic deterioration occurred in 5.2% of patients (n=300) who required one attempt, 26.9% of patients (n=95) who required two attempts, and 32.5% of patients (n=27) who required three or more attempts (Table 2). In the multivariable logistic regression analysis, first pass failure was associated with an increased risk of physiologic deterioration (adjusted odds ratio [aOR], 5.7; 95% confidence interval [CI], 4.4–7.4). In this study of prehospital intubations by an aeromedical service, first pass failure was associated with a marked increase in the risk of physiologic deterioration. To maximise patient safety during prehospital intubation, every effort should be made to optimise conditions for first pass success.Table 2Physiologic deterioration with first pass success vs first pass failure.Physiologic deteriorationFirst pass success% (n)First pass failure% (n)%Difference (95% CI)Hypoxaemia4.5 (262)27.1 (118)–22.6 (–26.8 to –18.4)Arterial hypotension0.7 (39)1.8 (8)–1.1 (–2.4 to 0.1)Cardiac arrest0.2 (9)1.4 (6)–1.2 (–2.3 to –0.1)Total patients*5.2 (300)28.0 (122)–22.8 (–27.1 to –18.6)*Patients may have more than one complication. Open table in a new tab *Patients may have more than one complication.

Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers.

IntroductionBag mask ventilation (BMV) and extraglottic devices (EGDs) are two common methods of providing rescue ventilation. BMV can be difficult to perform effectively, especially for inexperienced providers and in patients with difficult airway characteristics. There is some evidence that the laryngeal tube (LT) can be successfully placed by inexperienced providers to provide effective ventilation. However, it is unclear whether ventilation provided by LT is superior to that of BMV, especially in the hands of inexperienced airway providers. Therefore, we aimed to compare ventilation efficacy of inexperienced airway providers with BMV versus LT by primarily measuring tidal volumes and secondarily measuring peak pressures on a simulated model.MethodsWe performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured.ResultsTwenty participants were enrolled and 1200 breaths were measured, 600 per technique. The median ventilation volumes were 194 milliliters (mL) for BMV, and 387 mL for the laryngeal tube, with a median absolute difference of 170 mL (95% confidence interval [CI] 157–182 mL) (mean difference 148 mL [95% CI, 138–158 mL], p<0.001). The median ventilation peak pressures were 23 centimeters of water (cm H2O) for BMV, and 30 cm H2O for the laryngeal tube, with a median absolute difference of 7 cm H2O (95% CI, 6–8 cm H2O) (mean difference 8 cm H2O [95% CI, 7–9 cm H2O], p<0.001).ConclusionInexperienced airway providers were able to provide higher ventilation volumes and peak pressures with the LT when compared to BMV in a manikin model. Inexperienced providers should consider using an LT when providing rescue ventilations in obtunded or hypoventilating patients without intact airway reflexes. Further study is required to understand whether these findings are generalizable to live patients.

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period.

There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED. This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age. During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]). In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study

ObjectiveVideo laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes’ (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh)...

99 A Comparison of Direct Versus Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study

Video laryngoscopy (VL) use has increased over the past few years, with 39% of emergency department (ED) intubation first attempts using VL as of 2012. Although single-center observational studies have demonstrated higher intubation success when VL is used over direct laryngoscopy (DL), randomized controlled trials, mostly from intensive care units, have failed to show superiority of VL. The primary goal of our study was to compare first-pass success rates between VL and DL in ED patients with predicted difficult airways. We hypothesized that VL would be superior to DL for first-pass intubation success in patients with difficult airways. Design - This was a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry from January 1, 2016 to December 31, 2017. Setting - Data were entered into an online data entry tool (StudyTRAX, Inc.). Variables included age, indication, methods, medications used, devices, adverse events, and outcomes. 90% recording compliance was required for data to be included in the registry. Participants - All pediatric and adult patients with an attempted intubation in the ED, defined as insertion of the device into the mouth past the alveolar ridge regardless of success, were included in the study. Observations - The primary outcome measure was the rate of first-pass success with either DL or VL for various difficult airway characteristics, including patients who were anticipated to be difficult by the intubator, greater than normal body habitus, reduced neck mobility, Mallampati score greater than 2, reduced mouth opening, thyromental distance less than 2 fingers, airway obstruction present, facial trauma, or blood or vomit in the airway. Secondary variables included patient characteristics, pre-intubation hemodynamics, oxygenation status, indications, and adverse events. A total of 12,722 intubations were included in the study. 63 intubations were missing an entry for first-pass success. The overall first-pass success rate for intubations with DL was 3485/4304 (81.0%, 95% CI 79.8-82.1%) compared to 7489/8320 (90.0%, 95% CI 89.3- 90.6%) for VL. VL also had a higher first-pass success rate for all difficult airway characteristics compared to DL. Among the 4201 patients anticipated to be difficult airways, 889/1249 (71.2%, 95% CI 68.5-73.6%) were successfully intubated on first pass with DL compared to 2456/2943 (83.5%, 95% CI 82.1-84.8%) with VL. VL was used more than twice as often as DL. We observed a higher overall first-pass success rate with VL. Furthermore, VL also had a higher first-pass success rate for patients anticipated to have difficult airways or who had specific difficult airway characteristics. Our study is limited by the observational nature of the data as well as possible reporting bias.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients with Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial: Driver BE, Prekker ME, Klein LR, et al. JAMA. 2018; 319(21):2179-2189

Intubation in the Emergency Department is a critical skill with high consequence, especially in patients with difficult airway characteristics which may lead to quick desaturation or airway failure altogether. Prior retrospective studies have shown a higher rate of success for intubation methods utilizing a bougie. This study sought to evaluate the effect of routine bougie use versus an endotracheal tube with a stylet for patients emergently intubated in the emergency department.

Emergency Tracheal Intubation in an Ankylosing Spondylitis Patient in a Sitting Position Using an Airway Scope Combined with Face-to-Face and Digital Intubation

BackgroundEmergency intubation in a patient with advanced ankylosing spondylitis (AS) who presents with severe thoracic kyphosis deformity, rigid cervical flexion deformity of the neck, and an inability to achieve the supine position is particularly challenging to emergency physicians. Case ReportThis study reports on an AS patient presenting with these difficult airway characteristics and acute respiratory failure who was successfully intubated using video laryngoscope-assisted inverse intubation (II) and blind digital intubation (BDI). By using Pentax AirwayScope-assisted inverse intubation, the tracheal tube tip was passed through the glottic opening, but an unexpected resistance occurred during tube advancement, which was overcome by subsequent BDI. By using laryngoscope-assisted II complemented by the BDI technique, the patient was successfully intubated without complications. Why Should an Emergency Physician Be Aware of This?Our case demonstrated that these two emergency airway management techniques are valuable backup methods and complement each other when applied to certain unstable airways, especially when the traditional patient position is not easily accomplished. Unexpected difficulty is not rare during airway management; emergency physicians should always be well prepared both mentally and practically.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit.

Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.