First-pass Intubation Research Articles

Videolaryngoscopic versus direct laryngoscopic paraglossal intubation for cleft lip/palate reconstructive surgeries: A randomised controlled trial.

Background and Aims:In the cleft lip and palate, the laryngoscope blade often tends to lodge inside midline clefts, causing reduced manoeuvrability and tissue trauma. The paraglossal technique avoids the midline and offers better Cormack Lehane (CL) grades. We aimed to assess the first-pass intubation rate in performing the left paraglossal laryngoscopy with a curved-blade videolaryngoscope (VLS) versus direct laryngoscope (DLS) in children with cleft palate and evaluate the time taken for successful endotracheal intubation (TTI) and Intubation Difficulty Score (IDS) with both devices.Methods:This randomised controlled trial included 60 patients with cleft palate, between 3 months and 6 years. Patients were randomised into group V (VLS) (n = 30) and group D (DLS) (n = 30). Left paraglossal laryngoscopy was done with VLS or DLS, and the first-pass intubation, TTI, CL grade and IDS were recorded.Results:First-pass intubation (primary outcome) was successful in all cases in group V and in 29 (96%) cases in group D (P = 0.923). Amongst the secondary outcomes, the IDS of the majority in both groups was 1–4 (slight difficulty) (P = 0.98) and the mean TTI In group D was 34.6 s (SD = 19.0) (95% CI: 27.5–41.7) versus 39.8 s (SD = 5.2) (95% CI: 37.8–41.7) in group V (P = 0.151).Conclusions:There was no significant difference in the use of a VLS over a DLS in performing the left paraglossal laryngoscopy in terms of first-pass intubation rate, CL Grade, IDS and TTI. Further studies with different VLS may be done to improve the ease of this technique.

Hemodynamic Effects of Ketamine Versus Etomidate for Prehospital Rapid Sequence Intubation

ObjectiveRapid sequence intubation (RSI) is often required in managing critically ill patients in the prehospital setting. Although etomidate is a commonly used induction agent for RSI, ketamine has gained new interest in prehospital management with reported neutral hemodynamic effects. Limited data exist to support ketamine as an alternative to etomidate, particularly in the prehospital setting. The purpose of this study was to evaluate hemodynamic changes after the administration of ketamine versus etomidate in prehospital RSI. MethodsThis retrospective study evaluated adult patients undergoing prehospital RSI over 13 months within a regional emergency transport medicine service. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) within 15 minutes of receiving ketamine or etomidate. Hemodynamic data were collected 15 minutes before and 15 minutes after administration or until additional sedative medications were given. Data were analyzed using SPSS software (Version 21; IBM Corp, Armonk, NY), with P < .05 considered significant. ResultsOne hundred thirteen patients met the inclusion criteria (ketamine, n = 33; etomidate, n = 80), with the primary reasons for intubation being respiratory failure and trauma. There was no difference between the incidence of patients who experienced a 20% decrease in SBP (16% etomidate vs. 18% ketamine, P = .79). There were no significant differences in SBP pre- to postadministration between ketamine and etomidate. ConclusionNo hemodynamic differences occurred between patients who received ketamine versus etomidate for prehospital RSI. Neither drug was associated with an increased need for additional sedatives, and neither drug was associated with an increased first-pass intubation success rate. Larger, prospective, powered studies are required to identify patients who may benefit from either ketamine or etomidate.

Evaluation of the Effect of Intubation Box use on Tracheal Intubation Difficulty with King Vision® and Truview Videolaryngoscope in Manikin in a Tertiary Care Hospital.

The procedures of introducing an airway by intubation are associated with increased risk of aerosolisation of SARS-CoV-2 virus, posing a high risk to the personnel involved. Newer and novel methods such as the intubation box have been developed to increase the safety of healthcare workers during intubation. In this study, 33 anaesthesiologist and critical care specialists intubated the trachea of the airway manikin (US Laerdal Medical AS™) 4 times using a King Vision® videolaryngoscope and TRUVIEW PCD™ videolaryngoscope (with and without an intubation box as described by Lai). Intubation time was primary outcome. Secondary outcomes were first-pass intubation success rate, percentage of glottic opening (POGO) score and peak force to maxillary incisors. Intubation time and the number of times a click was heard during tracheal intubation were considerably higher in both groups when an intubation box was used (Table 1). When comparing the two laryngoscopes, the King Vision® videolaryngoscope enabled much less time to intubate than did the TRUVIEW laryngoscope, both with and without the intubation box. (P<0.001) In both laryngoscope groups, first-pass successful intubation was higher without the intubation box, although the difference was statistically insignificant. POGO score was not affected by intubation box but a higher score was observed with King Vision® laryngoscope (Tables 1,2). This study indicates that use of an intubation box makes intubation difficult and increases the time needed to perform it. King Vision® videolaryngoscope results in lesser intubation time and better glottic view as compared to TRUVIEW laryngoscope.

Macintosh laryngoscope versus AMBU King Vision video laryngoscope for endotracheal intubation using a COVID-19 barrier box: A randomized controlled trial.

Background:Coronavirus disease 2019 (COVID-19) barrier box is being used by health-care workers for protection against aerosol-transmitted infection. Usually, a Macintosh laryngoscope (MC) or a video laryngoscope (VL) is used for endotracheal intubation (ETI). We aimed to determine the most suitable laryngoscope blade in terms of time to ETI, ease of ETI, and the first-pass success rate.Methods:American Society of Anesthesiologists Grade I and II patients undergoing surgery under general anesthesia were randomized into the MC and the King Vision VL groups in a 1:1 ratio. ETI was performed using either the MC (the MC group) or the King Vision VL (the VL group) with a COVID-19 barrier box. The first-pass intubation success rate, intubation time, and ease of ETI were analyzed.Results:The first-pass success rate was higher in the MC group (P = 0.43). The mean duration of ETI was 33 s and 47 s in the MC group and VL group, respectively. The difference was statistically significant between the groups (P = 0.002). The ease of ETI was comparable between the groups (P = 0.57), and the Cormack–Lehane grade was significantly different between the groups (P = 0.0025).Conclusion:ETI duration was shorter in the MC group than in the VL group. Hence, a MC can be used along with a COVID-19 barrier box by experienced operators for the prevention of aerosol spread.

The impact of a barrier enclosure on time to tracheal intubation: a randomized controlled trial.

PurposeNovel devices such as the barrier enclosure were developed in hopes of improving provider safety by limiting SARS-CoV-2 transmission during tracheal intubation. Nevertheless, concerns arose regarding a lack of rigorous efficacy and safety data for these devices. We conducted a randomized controlled trial to evaluate the impact of the barrier enclosure on time to tracheal intubation.MethodAfter Research Ethics Board approval, elective surgical patients with normal airway predictors were randomly allocated 1:1 to tracheal intubation with or without a barrier enclosure. The primary outcome was time to tracheal intubation. Secondary outcomes included first-pass success rate, total time of airway manipulation, anesthesiologists’ perception of intubation difficulty, likelihood of use in SARS-CoV-2-positive patients, and patients’ perception of comfort and acceptability.ResultsThere were 48 participants in the barrier enclosure group and 46 participants in the control group. The mean (standard deviation [SD]) time to tracheal intubation was 62 (29) sec with barrier closure and 53 (27) sec without barrier enclosure (mean difference, 9 sec; 95% confidence interval, − 3 to 20; P = 0.14). Anesthesiologists rated the difficulty of intubation higher with barrier enclosure (mean [SD] visual analogue scale score, 27 [26] mm vs 9 [17] mm; P < 0.001). There were no significant differences in other secondary outcomes.ConclusionIn healthy surgical patients with normal airway predictors, the use of a barrier enclosure during tracheal intubation did not significantly prolong time to intubation or decrease first-pass intubation success. Nevertheless, there was an increase in difficulty of intubation perceived by the anesthesiologists with use of a barrier enclosure.Trial registrationwww.clinicaltrials.gov (NCT04366141); registered 28 April 2020.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12630-021-02024-z.

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments.

Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs. A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed. There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p=.558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p=.037). Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.

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.

The effectiveness of electro-acupuncture combined with dyclonine hydrochloride in relieving the side effects of gastroscopy: a controlled trial.

The present study aimed to explore the effectiveness of electro-acupuncture (EA) in combination with a local anesthetic used in Western medicine in preventing the side effects of gastroscopy. A sample group of 150 patients were divided into three groups based on treatment methods: an EA group, a dyclonine hydrochloride mucilage group, and a combined treatment group. In the EA group, EA stimulation was given at the Hegu, Neiguan, and Zusanli acupoints; in the dyclonine hydrochloride mucilage group, patients took 10 mL of dyclonine hydrochloride mucilage orally; in the combined treatment group, prevention of side effects was attempted by administration of both acupuncture and oral local anesthetic. The incidences of nausea, emesis, salivation, cough, restlessness, and breath holding during gastroscopy were observed and recorded for the three groups. Mean arterial pressure, heart rate, and oxygen saturation were recorded before the examination, and changes in these measures were recorded as the gastroscope passed through the pylorus and after the examination. The visual analogue scale (VAS) values of nausea and emesis, the rate of successful first-pass intubation, and the time of gastroscopy were also recorded. Statistical analysis was performed using R-3.5.3 software. Incidences of side effects (e.g., nausea, emesis, salivation, restlessness, and breath holding) during the examination were lower in the combined treatment group than in the EA group and the dyclonine hydrochloride mucilage group (P<0.05 and P<0.01, respectively). Furthermore, the changes in heart rate and oxygen saturation when the gastroscope passed through the pylorus and after the examination were better in the combined treatment group than in the EA group and dyclonine hydrochloride mucilage group (P<0.01). The VAS values of nausea and emesis, the first-pass success rate, and examination duration were also better for the combined treatment group than for the other two groups (P<0.05 and P<0.01). EA combined with local anesthesia with dyclonine hydrochloride mucilage can alleviate side effects during gastroscopy, reduce patient pain, and improve the efficiency of the procedure.

Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project

IntroductionAdvanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway...

English

BACKGROUND First-pass success is the successful intubation on the first attempt. It is the desired goal of emergency intubation and failure to achieve it may increase the risk of adverse effects. With failure of first pass intubation, life-threatening complications occur, commonly in critically ill patients. The aim of this study is to determine the association between the success of first-pass intubation and frequency of adverse events during endotracheal intubation. METHODS A cross sectional analytical study was done in a tertiary care hospital between October 2016 and October 2017. 100 failed first-pass intubation cases and 100 successful first-pass intubation cases were evaluated for factors associated with failed first-pass intubation and frequency of adverse events following intubation. RESULTS The groups were matched with respect to gender, induction agent use, fentanyl use and type of laryngoscope used. Mean age in failed first-pass intubation group was 5.61 years higher than subjects in successful first-pass intubation group (P = 0.016). Proportion of subjects with difficult airway was 19 % in failed first-pass intubation group and 3 % in successful first-pass intubation (P &lt; 0.001). Failed first-pass intubation cases had higher frequency of adverse events like oesophageal intubation (9 % vs. 0 %), aspiration (7 % vs. 1 %), cuff leakage (2 % vs. 0 %) and hypotension (7 % vs. 1 %) compared to successful first-pass intubation cases. CONCLUSIONS The frequency of adverse events was high in failed first-pass intubation. Older age and presence of difficult airway were factors significantly associated with failed first-pass intubation. KEYWORDS First Pass Intubation, First-Pass Success, Adverse Events, Emergency Department, Failed First Attempt, Endotracheal Intubation

Emergency airway management in a Singapore centre: A registry study

Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.

A systematic review of meta-analyses comparing direct laryngoscopy with videolaryngoscopy.

PurposeIn the preceding 20 years, many randomized-controlled trials and meta-analyses have compared direct Macintosh laryngoscopy with videolaryngoscopy. The videolaryngoscope blades have included both traditional Macintosh blades and hyperangulated blades. Macintosh and hyperangulated blades differ in their geometry and technique for tracheal intubation; certain patient populations may benefit from one blade type over another. The primary objective of this systematic review was to assess whether published meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy have accounted for the videolaryngoscope blade type. Secondary objectives evaluated heterogeneity among practitioner experience and specialty, clinical context, patient population, and original primary study outcomes.SourceA search was performed across Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar, and ANZCA discovery. A systematic review identified meta-analyses which compared direct Macintosh laryngoscopy to videolaryngoscopy. There were no patient age or clinical specialty restrictions. Exclusion criteria included non-English language, studies comparing non-Macintosh blade to videolaryngoscopy, and studies in awake patients.Principal findingsTwenty-one meta-analyses were identified that were published between 1 January 2000 and 7 May 2020. Macintosh and hyperangulated videolaryngoscope blades were combined in most studies (16/21; 76%). Heterogeneity was also present among practitioner experience (20/21; 95%), clinician specialty (15/21; 71%), and clinical locations (10/21; 48%). Adult and pediatric patients were combined or not defined in 5/21 studies (24%). The primary outcomes of the meta-analyses varied, with the most common (7/21; 33%) being first-pass tracheal intubation success.ConclusionsHeterogeneity across important clinical variables is common in meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy. To better inform patient care, future videolaryngoscopy research should differentiate blade type, clinical context, and patient-related primary outcomes.

Video laryngoscopy is associated with improved first-pass intubation success compared with direct laryngoscopy in emergency department trauma patients.

ObjectiveWe aimed to assess differences in (1) first‐pass intubation success, (2) frequency of a hypoxic event, and (3) time from decision to intubate to successful intubation among direct laryngoscopy (DL) versus video laryngoscopy (VL) intubations in emergency department (ED) patients with traumatic injuries.MethodsThis retrospective cohort study was performed at a Level I trauma center ED where trauma activations are video recorded. All patients requiring a Level I trauma activation and intubation from 2016 through 2019 were included. Multivariable logistic regression was used to assess the association between initial method of intubation and first‐pass success. Differences in frequency of a hypoxic event and time to successful intubation were assessed using bivariate tests.ResultsOf 164 patients, 68 (41.5%) were initially intubated via DL and 96 (58.5%) were initially intubated via VL. First‐pass success for DL and VL were 63.2% and 79.2%, respectively. In multivariable regression analysis, VL was associated with higher odds of first‐pass intubation success compared with DL (odds ratio: 2.28; 95% confidence interval: 1.04, 4.98), independent of mechanism of injury, presence of airway hemorrhage or obstruction, and experience of intubator. Frequency of a hypoxic event during intubation was not significantly different (13.2% for DL and 7.3% VL; P = 0.1720). Median time from decision to intubate to successful intubation was 7 minutes for both methods.ConclusionsVideo laryngoscopy, compared with direct laryngoscopy, was associated with higher odds of first‐pass intubation success among a sample of ED trauma patients. Frequency of a hypoxic event during intubation and time to successful intubation was not significantly different between the 2 intubation methods.

Improving Intubation Success in Pediatric and Neonatal Transport Using Simulation.

Pediatric and neonatal first-pass intubation rates are higher in adult trained retrieval services than in neonatal or pediatric trained services. Some authors have attributed this to more frequent opportunities to practice the skill in the adult population. The aim of this study was to increase the first-pass intubation rate without adverse events by introducing daily intubation simulation at our mixed neonatal and pediatric retrieval service. This prospective cohort study performed from July to December 2018 in our mixed neonatal and pediatric retrieval service involved 16 medical staff performing simulated intubation at commencement of their retrieval shift with a retrieval nurse. Checklists for neonatal and pediatric intubation were introduced to the retrieval service for the intervention cohort. Participants were asked to complete questionnaires about intubation performed on retrieval to gather data not routinely collected by the service. Seven hundred and sixty-eight patients were retrieved by the service and 70 patients required intubation by the retrieval team during the intervention period. First-pass intubation rates were higher during the intervention period compared with a historical cohort, despite less intubations being performed overall. First-pass intubation rates improved from 59% to 78% in neonatal patients (P = 0.032), 58% to 65% in pediatric patients (P = 0.68) and from 58% to 74% overall (P = 0.043). There were no severe adverse events detected during the intervention period. Minor adverse events were associated with multiple attempts at intubation (P < 0.001). Overall compliance with simulation protocol was 43.5%, and on average, each doctor completed simulation once per month. Simulation is a useful adjunct to support neonatal and pediatric intubation training in the current environment of reducing intubation frequency.

COVID-19 aerosol box as protection from droplet and aerosol contaminations in healthcare workers performing airway intubation: a randomised cross-over simulation study

BackgroundConcerns over high transmission risk of SARS-CoV-2 have led to innovation and usage of an aerosol box to protect healthcare workers during airway intubation in patients with COVID-19. Its efficacy...

Abstract 201: Bougie-Assisted Endotracheal Intubation in the Pragmatic Airway Resuscitation Trial

Objective: Paramedics often perform endotracheal intubation (ETI) in the management of out-of-hospital cardiac arrest (OHCA). While ETI assisted by use of the gum elastic Bougie has been associated with improved first-pass intubation success in the emergency department, its influence upon out-of-hospital cardiac arrest (OHCA) ETI is unknown. We compared success rates and outcomes between Bougie-assisted and standard ETI in the Pragmatic Airway Resuscitation Trial (PART). Methods: We conducted a secondary analysis of PART, a clinical trial comparing initial-ETI vs. initial-laryngeal tube airway management strategies in adult OHCA. We included only patients receiving initial ETI attempts. The primary exposure was Bougie-assisted vs. standard ETI. The primary outcome was first-pass ETI success. Secondary outcomes included overall ETI success, time to successful ETI, 72-hour survival, hospital survival and hospital survival with favorable neurologic status. We assessed the associations between Bougie-assistance and ETI outcomes using Generalized Estimating Equations and Cox Regression, adjusting for for age, sex, race, witnessed arrest, bystander CPR and initial rhythm. Results: Of the 3,004 patients enrolled in PART, 1,227 received initial ETI, including 440 Bougie-assisted and 787 standard ETI. First-pass ETI success did not differ between Bougie-assisted and standard ETI (53.1% vs. 42.8%; adjusted OR 1.12, 95% CI: 0.97 to 1.39). Overall ETI success was slightly higher for Bougie-assisted ETI (56.2% vs. 49.1%; adjusted OR 1.19, 95% CI: 1.01 to 1.32). Time to ETI was longer for Bougie-assisted than standard ETI (median 13 vs. 11 min; adjusted HR 0.63, 95% CI: 0.45 to 0.90). While survival to hospital discharge was lower for Bougie-assisted than standard ETI (3.6% vs. 7.5%; adjusted OR 0.94, 95% CI: 0.92 to 0.96), there were no differences in 72-hour survival or hospital survival with favorable neurologic status. Conclusion: In the PART trial, Bougie assistance resulted in slightly higher overall ETI success but with longer airway placement time. Bougie assistance was not associated with first-pass ETI success. The association between Bougie-assisted ETI and OHCA survival was unclear. The role of Bougie-assisted ETI in OHCA is uncertain.

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department.

The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH<7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI]= 1.0 to 18.1, p=0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI= 4.1 to 25.3, p=0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI= 11.0 to 38.9, p<0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI= 2.5 to 21.8, p=0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI= -35.5 to -1.5, p=0.038), respectively. We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.

Beyond Tools: Continuous High-Fidelity Training at the Center of Successful First-Pass Intubation in Ground Emergency Medical Services

ObjectiveIncreased emphasis on the use of video laryngoscopy in emergency medical services has potentially caused providers to forfeit the skills required to perform direct laryngoscopy. The purpose of this study was to determine if the introduction of a continuous high-fidelity training program improves first-pass intubation success in a non–rapid sequence induction ground-based emergency medical services agency with an established video laryngoscopy program. MethodsThis is a retrospective analysis of quality improvement data of advanced airway management performed by an ambulance service between 2012 and 2019. A mandatory biannual high-fidelity simulation training curriculum was introduced at the beginning of 2017. ResultsA total of 459 patients underwent intubation attempts during the 7-year study period. First-pass intubation success improved from 57.6% to 81.4%, an improvement of 23.8% (95% confidence interval [CI], 15.4-31.5; P < .001), and overall intubation success improved from 77% to 91%, an improvement of 14.1% (95% CI, 7.3-20.3; P < .001). The average number of intubation attempts per patient decreased by 0.19 (95% CI, 0.09-0.29; P < .0003). The mean time of arrival to intubation time increased by 2.21 minutes (95% CI, 0.84-3.58; P = .0016). ConclusionImplementation of a high-fidelity airway training program is associated with improvements in overall endotracheal intubation and first-pass endotracheal intubation success rates in all adult patient categories.

Analysis of the airway registry from an academic emergency department in South Africa.

Airway management is an essential skill for doctors working in the emergency department (ED). Safety and efficacy are crucial to its success. Analysis of an airway registry can provide feedback that can be used for quality improvement purposes. To examine the first airway registry from an ED in South Africa (SA), a low- to middle-income country (LMIC), and compare the findings with international data. A retrospective analysis of 13 months' data from the airway registry of an academic ED with an annual census of 60 000 patients. Data analysed included demographics, indications for intubation, intubator training level, type of intubation device, number of attempts, adverse events, pre-oxygenation methods, and drug and intravenous fluid use. A total of 321 intubations were included. The majority of the patients (71.6%) had non-traumatic indications for intubation. The overall first-pass intubation success (FPS) rate for doctors was 81.8%. Although this rate is lower than the mean rate suggested in an international meta-analysis (84.1%), it is within the 95% confidence interval (80.1 - 87.4%). Overall FPS rates showed no difference between video laryngoscopy (81.7%) compared with direct laryngoscopy (73.3%) (p-value 0.079), although better glottic views were obtained with video laryngoscopy (80.5% were Cormack-Lehane grade 1). Analysis of pre-oxygenation methods found that although sicker patients had received more aggressive pre-oxygenation, e.g. with non-invasive or bag-mask ventilation techniques, they still desaturated more often (35.8% and 62.5%, respectively) than less sick patients who received simple non-rebreather facemask pre-oxygenation (4.5%). This analysis of the first airway registry from an SA ED highlights that airway management in an LMIC can be performed on par with accepted international standards. It serves as a good baseline for further research into airway management in other LMICs and provides useful feedback for quality improvement purposes.

Robotic‐assisted cardiac surgery without lung isolation utilizing single‐lumen endotracheal tube intubation

This study assessed the feasibility and outcomes of performing robotic cardiac surgery without lung isolation using single-lumen (SL) endotracheal tube intubation. Between 2013 and 2017, 132 patients underwent robotically-assisted atrial septal defect closure. A retrospective analysis was performed of 23 patients (11 males, mean age 30.9 ± 5 years) who underwent robotic surgery with double-lumen (DL) endotracheal tube intubation (group 1) compared with 109 patients (57 males, mean age 32.4 ± 7.5 years) undergoing the same procedure with SL endotracheal intubation (group 2). The patient groups were compared in terms of demographic characteristics, operative data, and complications. The technical feasibility of the robotic procedure without lung isolation was evaluated. There were no mortality, intraoperative complication, and conversion. Mean total anesthesia time was significantly decreased in the SL intubation group (238.3 ± 22.4 vs 227.2 ± 21.2 minutes; P = .025). First-pass intubation success was significantly higher in the SL intubation group (17 [73.9%] vs 98 [89.9%] patients; P = .032). Mean ventilation time (10.9 ± 5.3 hours), intensive care unit stay (16.8 ± 10.1 hours), and the length of hospital stay (3.8 ± 1.2 days) was significantly decreased in patients with SL tube (P < .05). Unilateral reexpansion pulmonary edema was observed in five (21.7%) patients with DL tube, whereas no patient with SL tube had this complication. SL endotracheal tube intubation without lung isolation is a feasible and safe airway alternative in robotic cardiac procedures. This approach resulted in shorter anesthesia time, ventilation time and the length of hospital stay. Port placement and robotic set-up can be uneventfully performed without lung isolation.