Standard Rapid Sequence Intubation Research Articles

Failed airway in the emergency department; what’s next?

A failed airway is defined as an unsuccessful intubation. It is a rare occurrence in the emergency department (ED) and always poses a challenge to emergency physicians. The ‘can’t intubate, can ventilate’ situation is one of the two ways a failed airway can occur in ED. Here, we present a case of failed emergency endotracheal intubation due to unanticipated subglottic stenosis. An elderly presented to a district hospital (without specialist) with acute bronchospasm, in which he was treated as severe exacerbation of chronic obstructive pulmonary disease (COPD). Despite maximal medical therapy, symptoms worsen, requiring intubation for airway protection. Standard rapid sequence intubation (RSI) was performed, with a good view of glottic opening; however endotracheal tube (ETT) size 7.5 could not be passed beyond the larynx. Several attempts using smaller-size ETTs still failed. A laryngeal mask airway (LMA) was inserted as a rescue device for ventilation. The patient was then sent to our centre for further evaluation and treatment. Initial examination in our ED revealed an elderly that was sedated and ventilated through LMA. Ventilation and oxygenation via the LMA were adequate. Diagnostic endoscopy was performed through LMA using flexible intubating scope which showed subglottic stenosis around 2cm below the vocal cord. The patient was referred to the Ear, Nose and Throat (ENT) team, where emergency tracheostomy was then performed in operating theatre. He was discharged well after 14 days of admission and given follow-up for his COPD and tracheostomy care.

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine.

Endotracheal intubation (ETI) is a high-risk procedure commonly performed in emergency medicine, critical care, and the prehospital setting. Traditional rapid sequence intubation (RSI), the simultaneous administration of an induction agent and muscle relaxant, is more likely to harm patients who do not allow appropriate preparation and preoxygenation, have concerning airway anatomy, or severe hypoxia, acidemia, or hypotension. Ketamine, a dissociative anesthetic, can be used to facilitate two alternatives to RSI to augment airway safety in these scenarios: delayed sequence intubation – the use of ketamine to allow airway preparation and preoxygenation in the agitated patient; and ketamine-only breathing intubation, in which ketamine is used without a paralytic to facilitate ETI as the patient continues to breathe spontaneously. Ketamine may also provide hemodynamic benefits during standard RSI and is a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine’s unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety.

Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia

Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation. We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt. The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO2, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO2 values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]). In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.

Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study

ObjectiveThis study sought to determine the effectiveness of apneic oxygenation in preventing hypoxemia during prehospital rapid sequence intubation (RSI). MethodsWe performed a case-cohort study using a pre-existing database looking at intubation management by a single helicopter emergency medical service between July 2013 and June 2015. Apneic oxygenation using high-flow nasal cannula (15 L/min) was introduced to the standard RSI protocol in July 2014. Severe hypoxemia was defined as an incidence of oxygen saturation less than 90%. We compared patients who received apneic oxygenation during RSI with patients who did not using the Fisher exact test. ResultsNinety-three patients were identified from the database; 29 (31.2%) received apneic oxygenation. Nineteen patients had an incidence of severe hypoxemia during RSI (20.43%; 95% confidence interval, 12.77%-30.05%). There was no statistically significant difference between the rate of severe hypoxemia between patients in the apneic oxygenation group versus the control group (17.2% vs. 21.9%, P = .78). ConclusionIn this study, patients who received apneic oxygenation did not show a statistically significant difference in severe hypoxemia during RSI.

Use of modified rapid sequence tracheal intubation in pediatric patients.

Background:Rapid sequence intubation (RSI) has been an established practice, but is not without risks to patient. In different situations, a modification of the standard RSI technique may be more appropriate. The definition of a modified rapid sequence intubation (MRSI) is not well-documented. The purpose of this survey was to determine the working definition of MRSI as well as the modality of its use.Materials and Methods:This descriptive study consisted of a survey of pediatric anesthesiologists and included basic questions related to the anesthesiologist's experience, practice setting and use of MRSI. Responses were compiled and analyzed to identify the working definition, technique, perceived indications/complications as well as hands-on performance of tracheal intubation during use of MRSI in children.Results:The mean ± SD years in practice of the 228 respondents were 14.9 ± 8.16 years, with pediatric patients comprising 77 ± 33% of their practice. 76.8% completed a fellowship in pediatric anesthesia. 60% of the respondents’ practice setting was at a Children's Hospital. Different respondents agreed with different techniques of MRSI with the majority (65%) defining a MRSI as equivalent to a RSI, but with mask ventilation. The major indication of use of a MRSI was a concern about apnea time tolerance with traditional RSI (74%).Conclusion:Technique of a MRSI varies among pediatric care providers.

Providing Safe Passage

Rapid sequence intubation (RSI) is a lifesaving technique performed by advanced practice nurses when patients require endotracheal intubation but are at risk for gastric aspiration. In the acute care setting, the procedure often is indicated when critically ill or injured patients exhibit difficulty maintaining a patent airway and/or are displaying inadequate oxygenation and ventilation. The goal of this article is to provide advanced practice nurses with information that promotes safe and effective clinical decision making during RSI on the basis of the current state of the science. Standard RSI practices in stable patients are reviewed, and the need for individualized modifications of this “ideal” practice in unstable, critically ill patients is addressed. Factors predisposing a patient to difficult airway management, proper equipment, and patient preparation are highlighted, along with the relevant pharmacology. Finally, prevention of potential complications during RSI in the acute care setting is discussed.

Providing Safe Passage

Rapid sequence intubation (RSI) is a lifesaving technique performed by advanced practice nurses when patients require endotracheal intubation but are at risk for gastric aspiration. In the acute care setting, the procedure often is indicated when critically ill or injured patients exhibit difficulty maintaining a patent airway and/or are displaying inadequate oxygenation and ventilation. The goal of this article is to provide advanced practice nurses with information that promotes safe and effective clinical decision making during RSI on the basis of the current state of the science. Standard RSI practices in stable patients are reviewed, and the need for individualized modifications of this "ideal" practice in unstable, critically ill patients is addressed. Factors predisposing a patient to difficult airway management, proper equipment, and patient preparation are highlighted, along with the relevant pharmacology. Finally, prevention of potential complications during RSI in the acute care setting is discussed.

Video analysis of Emergency Medicine residents performing rapid-sequence intubations

The purpose of this study was to evaluate Emergency Medicine resident physicians’ compliance with our institution’s rapid sequence intubation (RSI) protocol by the use of videotape analysis. We conducted a prospective, observational study of Emergency Medicine resident physicians (EM 1,2,3) as they were videotaped performing RSI on medical and trauma patients. The videotapes were reviewed by the study investigators to assess the rates of deviation from our standard RSI protocol. Forty-four RSIs performed by 33 residents were studied. The most common deviations from our standard RSI protocol concerned proper use of the Sellick maneuver (45%) and use of the end-tidal CO 2 detector (34%). Videotape analysis provides an objective measure of Emergency Medicine resident performance of RSI.