Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review

BACKGROUND: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. OBJECTIVES: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. SEARCH STRATEGY AND METHODOLOGY: Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.     

The Easytube for airway management in prehospital emergency medicine

Background

Securing the airway in emergency is among the key requirements of appropriate prehospital therapy. The Easytube (Ezt) is a relatively new device, which combines the advantages of both an infraglottic and supraglottic airway.

Aims

Our goal was to evaluate the effectiveness and the safety of use of Ezt by emergency physicians in case of difficult airway management in a prehospital setting with minimal training.

Methods

We performed a prospective multi-centre observational study of patients requiring airway management conducted in prehospital emergency medicine in France by 3 French mobile intensive care units from October 2007 to October 2008.

Results

Data were available for 239 patients who needed airway management. Two groups were individualized: the “easy airway management” group (225 patients; 94%) and the “difficult airway management” group (14 patients; 6%). All patients had a successful airway management. The Ezt was used in eight men and six women; mean age was 64 years. It was used for ventilation for a maximum of 150 min and the mean time was 65 min. It was positioned successfully at first attempt, except for two patients, one needed an adjustment because of an air leak, and in the other patient the Ezt was replaced due to complete obstruction of the Ezt during bronchial suction.

Conclusion

The present study shows that emergency physicians in cases of difficult airway management can use the EzT safely and effectively with minimal training. Because of its very high success rate in ventilation, the possibility of blind intubation, the low failure rate after a short training period. It could be introduced in new guidelines to manage difficult airway in prehospital emergency.     

Adoption of video laryngoscopy in Massachusetts emergency departments

Background

Previous research suggests that video laryngoscopy may be superior to direct laryngoscopy.

Objectives

We sought to determine the proportion of Massachusetts emergency departments (EDs) that have adopted video laryngoscopy, the characteristics of user and non-user EDs, the reasons why non-users do not use video laryngoscopy, and how the adoption of video laryngoscopy compares to typical technology adoption life cycles.

Methods

Surveys were mailed to directors of all non-federal EDs in Massachusetts (n = 74) in early 2009. Non-responders received repeat mailings and were then contacted via telephone or e-mail.

Results

Sixty-three of 74 (85%) EDs responded and 43% had adopted video laryngoscopy. EDs with video laryngoscopy had a higher median annual visit volume than EDs without video laryngoscopy (48,000 vs. 36,500, p = 0.04), but had similar mean intubations per week (4.5 vs. 4.4, p = 0.97) and mean surgical airways per year (0.7 vs. 1.1, p = 0.19). Half of the EDs affiliated with emergency medicine residency programs had video laryngoscopy available. Among EDs with video laryngoscopy, the technology had been available for > 5 years in 4% (1/27), 1–5 years in 44% (12/27), and < 1 year in 52% (14/27). Although EDs not using video laryngoscopy did not do so primarily because it was too expensive (69% [25/36]), video laryngoscopy adoption has still progressed more rapidly than predicted by the typical technology adoption timeline.

Conclusion

Video laryngoscopy has been adopted by 43% of Massachusetts EDs; results were similar in academic institutions. Cost is the primary barrier to adoption for non-user EDs, but adoption is progressing more rapidly than expected for a new technology.     

Factors associated with first-pass success of emergency endotracheal intubation

Study objectiveEndotracheal intubation is frequently performed in emergency departments (EDs). First-pass success is important because repeated attempts are associated with poor outcomes. We sought to identify factors associated with first-pass success in emergency endotracheal intubation.MethodsWe analyzed emergency orotracheal intubations on adult patients in an ED located in South Korea from Jan. 2013 to Dec. 2016. Various operator-, procedure- and patient-related factors were screened with univariable logistic regression. Using variables with P-values less than 0.2, a multiple logistic regression model was constructed to identify independent predictors.ResultsThere were 1154 eligible cases. First-pass success was achieved in 974 (84.4%) cases. Among operator-related factors, clinical experience (OR: 2.93, 5.26, 3.80 and 5.71; 95% CI: 1.62–5.26, 2.80–9.84, 1.81–8.13 and 2.07–18.67 for PGY 3, 4 and 5 residents and EM specialists, respectively, relative to PGY 2 residents) and physician based outside the ED (OR: 0.10; 95% CI: 0.04–0.25) were independently associated with first-pass success. There was no statistically or clinically significant difference for first-pass success rate as determined by operator's gender (83.6% for female vs. 84.8% for male; 95% CI for difference: −3.1% to 5.8%). Among patient-related factors, restricted mouth opening (OR: 0.47; 95% CI: 0.31–0.72), restricted neck extension (OR: 0.57; 95% CI: 0.39–0.85) and swollen tongue (OR: 0.46; 95% CI: 0.28–0.77) were independent predictors of first-pass success.ConclusionsOperator characteristics, including clinical experience and working department, and patient characteristics, including restricted mouth opening, restricted neck extension and swollen tongue, were independent predictors of first-pass success in emergency endotracheal intubation.     

Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study

Objective

Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations.

Methods

Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling.

Results

A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS.

Conclusion

Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.     

昏迷病人舌后坠两种院前急救处理方法的疗效观察

目的探讨昏迷病人舌后坠两种院前急救处理方法的疗效。方法总结1998年1月-2004年12月我院在急诊进行院前抢救行气道通气病人情况。随机抽取120例使用口咽通气管的昏迷病人作为A组,并对应地抽取120例使用传统通气方法的昏迷病人作为B组。结果两组病人置管成功率、管道脱出率和气道密闭性良好情况比较,经统计学分析,均P<0．01,差异有统计学意义。结论昏迷病人采用口咽通气管的置入方法,可改善昏迷病人舌后坠而引起的气道梗阻呼吸困难,且易置入及固定,省时省力。     

Success of the gum elastic bougie as a rescue airway in the emergency department

Background: The gum elastic bougie (GEB) is a rescue airway device commonly found in the emergency department (ED). However, data documenting its efficacy are lacking in the emergency medicine literature. Study Objectives: To determine the success rate of endotracheal intubation using a GEB and the reliability of “palpable clicks” and “hold-up” in the ED setting. Methods: The GEB was introduced at our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000. Physicians were trained in the use of the GEB before initiation of the study. Over the course of 1 year, we conducted a prospective, observational study of GEB practices in the ED. The study population included all adult patients on whom intubation was attempted with a GEB. All emergency physicians attempting intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), and presence of “palpable clicks” and “hold-up.” Indications for GEB use in our ED include a difficult or rescue airway and for training purposes. Data were analyzed using standard statistical methods and 95% confidence intervals. Results: In our study period, there were 26 patients on whom intubation was attempted with a GEB. The overall success rate was 20/26 (76.9%; 95% confidence interval [CI] 60.7–93.1%). Among cases where the GEB was used for training purposes (all grade 1 or 2a laryngeal view), six of seven (85.7%) intubations were successful. When the GEB was used for clinically indicated purposes, 14 of 19 (73.7%; 95% CI 53.9–93.5%) intubations were successful. Palpable clicks were appreciated in 11/20 successful intubations (sensitivity 55.0%; 95% CI 33.2–76.8%); there was one false positive (specificity 80%; 95% CI 40.9–98.2%). Of 20 successful intubations, hold-up was deferred in five cases; of 15 remaining cases, hold-up was appreciated in 5/15 (sensitivity 33.3%; 95% CI 9.5–57.2%); there were no false positives (specificity 100%; 95% CI 60.7–100%). Conclusions: In our ED setting, the GEB had a success rate of 73.7% when utilized as a rescue airway after failed attempts. The characteristics of “palpable clicks” and “hold-up” were unreliable.     

Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy

Background

Videolaryngoscopy has become a popular method of intubation in the Emergency Department (ED), however, little research has compared this technique with direct laryngoscopy (DL).

Objective

To compare the success rates of GlideScope (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) and DL in emergent airways with known difficult airway predictors (DAPs).

Methods

We evaluated 772 consecutive ED intubations over a 23-month period. After each intubation, the physician completed a data collection form that included: demographics, DAPs, Cormack-Lehane view, optical clarity, lens contamination, and complications. DAPs included: cervical immobility, obesity, small mandible, large tongue, short neck, blood or vomit in the airway, tracheal edema, secretions, and facial or neck trauma. Primary outcome was first-attempt success rates. Multivariate logistic regression was performed to evaluate the odds of failure for DL compared to GVL.

Results

First-attempt success rate with DL was 68%, GVL 78% (Fisher’s exact test, p = 0.001). Adjusted odds of success of GVL compared to DL on first attempt equals 2.20 (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.51–3.19). After statistically controlling for DAPs, GVL was more likely to succeed on first attempt than DL (OR 3.07, 95% CI 2.19–4.30). Logistic regression of DAPs showed that the presence of blood, small mandible, obesity, and a large tongue were statistically significant risk factors for decreasing the odds of success with DL and increasing the odds of success of GVL.

Conclusion

For difficult airways with the presence of blood or small mandible, or a large tongue or obesity, GVL had a higher success rate at first attempt than DL.     

喉罩在抢救急性危重哮喘患者中的应用

目的 探讨喉罩在抢救急性危重哮喘患者中的应用价值.方法 对我院2002年至2009年应用喉罩和口鼻罩无创通气治疗的32例急性危重哮喘患者进行回顾性对比分析,其中应用喉罩(观察组)17例,应用口鼻罩(对照组)15例.分析2组血氧饱和度上升时间、呼吸机脱机时间、疾病好转时间等.结果 观察组中血氧饱和度上升时间、呼吸机脱机时间、疾病转归时间[分别为(389.63±32.82)s、(19.31±2.26)h、(16.22±3.85)h]与对照组[(467.36±41.15)s、(25.18±3.73)h、(23.66±2.38)h]比较差异均有统计学意义(P均<0.01);无创正压通气后观察组在3、12 h时动脉血二氧化碳分压(PaCO_2)下降、动脉血氧分压(PaO_2)升高、pH值上升,与治疗前比较差异均有统计学意义(P<0.05或P<0.01);而对照组治疗后3 hPaCO_2、pH值则与治疗前比较差异无统计学意义(P>0.05),但PaO_2差异有统计学意义(P<0.05),在12 h时PaCO_2、PaO_2、pH值的变化与治疗前差异均有统计学意义(P均<0.05).结论 在急性危重哮喘患者中选喉罩通气,更能提高通气效率,加快临床表现的缓解.     

Incidence of difficult airway situations during prehospital airway management by emergency physicians—A retrospective analysis of 692 consecutive patients

IntroductionIn the prehospital setting, advanced airway management is challenging as it is frequently affected by facial trauma, pharyngeal obstruction or limited access to the patient and/or the patient's airway. Therefore, incidence of prehospital difficult airway management is likely to be higher compared to the in-hospital setting and success rates of advanced airway management range between 80 and 99%.Methods3961 patients treated by an emergency physician in Zurich, Switzerland were included in this retrospective analysis in order to determine the incidence of a difficult airway along with potential circumstantial risk factors like gender, necessity of CPR, NACA score, GCS, use and type of muscle relaxant and use of hypnotic drugs.Results692 patients underwent advanced prehospital airway management. Seven patients were excluded due to incomplete or incongruent documentation, resulting in 685 patients included in the statistical analysis. Difficult intubation was recorded in 22 patients, representing an incidence of a difficult airway of 3.2%. Of these 22 patients, 15 patients were intubated successfully, whereas seven patients (1%) had to be ventilated with a bag valve mask during the whole procedure.ConclusionIn this physician-led service one out of five prehospital patients requires airway management. Incidence of advanced prehospital difficult airway management is 3.2% and eventual success rate is 99%, if performed by trained emergency physicians. A total of 1% of all prehospital intubation attempts failed and alternative airway device was necessary.     

Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians

STUDY OBJECTIVE: To determine the characteristics of prehospital tracheal intubation and the incidence of difficult-to-manage airways in out-of-hospital patients managed by emergency medicine physicians with anaesthesia training. METHODS: In a prospective study, conducted over a 4-year period, we evaluated all airway interventions performed by anaesthesia-trained emergency physicians. RESULTS: One thousand, one hundred and six out of 16,559 patients (6.8%) required tracheal intubation. Orotracheal intubation was attempted in 982, laryngoscopic aided nasotracheal intubation in 64 and blind nasotracheal intubation in 90 of the cases. Two techniques were used in 30 patients. Failure rates were 2.4, 8.1 and 25.6%, respectively. A Combitube or LMA was used in 2.0%. In one case of failed Combitube insertion successful needle cricothyrotomy was performed. In patients undergoing direct laryngoscopy, Cormack-Lehane laryngeal grade views I-IV were seen in 52.0, 28.8, 12.6 and 6.6% of cases, respectively. A difficult to manage airway (DMA) was reported in 14.8%, multiple intubation attempts in 4.3% and failed intubation in 2.0% of all cases. Grouping patients based on clinical presentation revealed a significantly higher incidence of DMA in trauma patients (18.6%) and during cardiopulmonary resuscitation (16.7%) than in the remaining patient group (9.8%). Intubation failed significantly more often in trauma (3.9%) than in the remaining patient group (1.1%). CONCLUSION: When compared to studies on laryngoscopy performed in the operating room, this study demonstrated a higher incidence of difficult and failed laryngoscopy, DAM, and high laryngeal grade views when patients were managed in a prehospital setting by anaesthesia trained physicians.     

Non-invasive mechanical ventilation in Australian emergency departments: A prospective observational cohort study

Objectives

Data describing use of non-invasive ventilation (NIV) in the emergency department (ED) setting consist primarily of physician surveys. Our objective was to conduct a prospective study to document the characteristics of patients receiving NIV, interfaces, mode, and parameters used as well as NIV duration and decision-making responsibility.

Methods

We conducted a 2-month prospective observational study of adult patients who received NIV in 24 EDs. Patient characteristics, delivery methods, and decision-making responsibility were documented for each ED presentation.

Results

Data were recorded on 245 patients; 185 patients received non-invasive positive pressure ventilation (NIPPV) and 60 received continuous positive airway pressure (CPAP). Acute cardiogenic pulmonary oedema (ACPO) (80/245, 33%) and exacerbation of chronic obstructive pulmonary disease (COPD) (75/245, 31%) were the two most frequent indications for NIV. Compared to patients with respiratory failure from other aetiologies, those with ACPO were more likely to receive CPAP (28/80 [35%] versus 32/165 [19%] P = 0.008). Initial NIV settings were selected by ED nurses for 118/245 (48%) patients, by ED physicians for 118/245 (48%) patients, and by ICU staff for 3/245 (1.5%) patients (not reported for 6 [2.5%] patients). The role of ED nurses in the selection of initial NIV settings was not influenced by ED location, patient type or triage category.

Conclusions

Acute exacerbations of CPO and COPD were the most common indications for NIV. Clinicians demonstrated a preference for NIPPV for all patient aetiologies except ACPO. Responsibility for NIV management was shared by ED nurses and physicians.     

A BRILL idea? The benefits,risks, insights,learning and limitations of an emergency airway registry in pre‐hospital and retrieval medicine

Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre‐hospital emergency anaesthesia is key to the safety and evolution of this common but high‐risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre‐hospital and retrieval medicine, for both research and quality improvement purposes.