First-attempt intubation success and complications in patients with COVID-19 undergoing emergency intubation

The use of vasopressors to reduce post-intubation hypotension in critically ill adult patients undergoing emergent endotracheal intubation: a scoping review

INTRODUCTION

Patients requiring emergent endotracheal intubation are at higher risk of post-intubation hypotension due to altered physiology in critical illness. Post-intubation hypotension increases mortality and hospital length of stay, however, the impact of vasopressors on its incidence and outcomes is not known. This scoping review identified studies reporting hemodynamic data in patients undergoing emergent intubation to provide a literature overview on post-intubation hypotension in cohorts that did and did not receive vasopressors.

METHODS

A systematic search of CINAHL, Cochrane, EMBASE and PubMed-Medline was performed from database inception until September 28, 2023. Two independent reviewers completed the title and abstract screen, full text review and data extraction per PRISMA guidelines. Studies including patients < 18 years or intubations during cardiac arrest were excluded. Primary outcome was the presence of hypotension within 30 min of emergent intubation. Secondary outcomes included mortality at 1 h and in-hospital.

RESULTS

The systematic search yielded 13,126 articles, with 61 selected for final inclusion. There were 24,547 patients with a mean age of 57.2 years and a slight male predominance (63.8%). Respiratory failure was the most common intubation indication. Across 18 studies reporting on vasopressor use prior to intubation, 1171/7085 patients received vasopressors pre-intubation. Post-intubation hypotension occurred in 22.2% of patients across all studies, and in 34.3% of patients in studies where vasopressor administration pre-intubation was specifically reported. One-hour mortality of patients across all studies and within the vasopressor use studies was 1.2% and 1.6%, respectively. In-hospital mortality across studies was 21.5%, and 13.1% in studies which reported on vasopressor use pre-intubation.

CONCLUSION

Patients requiring emergent intubation have a high rate of post-intubation hypotension and in-hospital mortality. While there is an intuitive rationale for the use of vasopressors during emergent intubation, current evidence is limited to support a definitive change in clinical practice at this time.

Facilitated Intubation: Time to Re-examine an Old Technique With Its Associated Risks Mitigated by New Technology

BACKGROUND

Facilitated intubation (FI) refers to intubation performed using a sedative or anesthetic drug as an induction agent, without the use of a paralytic (neuromuscular blocking agent). In comparison, rapid sequence intubation (RSI) employs both an induction agent and a paralytic drug. RSI has been seen to outperform FI in terms of first-pass success when performing direct laryngoscopy and was quickly adopted as the gold standard in all situations. Recently, ketamine-only intubation has been used in situations where there is distorted anatomy or apnea intolerance (physically and physiologically difficult airways) resulting in an increased risk of a can't intubate/can't oxygenate scenario or significant hypoxemia. Frequent and recurring national ketamine shortages have resulted in renewed interest in whether or not other forms of FI are feasible in an era where other factors that mitigate complictions in achieving first-pass success (video laryngoscopy, bougie use, semi-Fowler positioning) are commonly used. We present a case series with outcomes for profoundly hypoxic patients with coronavirus disease 2019 (COVID-19) (physiologically difficult airways) undergoing FI during a time of national ketamine shortage, using modern techniques and technology to maximize first-pass success and minimize peri-intubation complication.

METHODS

We included patients with COVID-19 pneumonia with pre-intubation oxygen saturations of less than 80% (significant hypoxemia) requiring intubation who presented to a tertiary care center in southern United States between August 25, 2021, and October 22, 2021. In this specific cohort, patients underwent endotracheal intubation with midazolam for induction without the use of paralytic agents. We used video-assisted laryngoscopy to increase the success of the first-pass attempt as well as placing the patients in a semi-Fowler position (head of bed elevation 30-45°) and bilevel positive pressure pre-oxygenation to minimize peri-intubation complications.

RESULTS

Our case series included 29 consecutive patients that met the inclusion criteria. The mean ± standard deviation (SD) age of the patients was 49.5±15.0 years. The mean±SD pre-intubation oxygenation of our cohort was 73.1±5.9%. All 29 intubations were successful on the first-pass attempt. Only one patient (3.4%) required a rescue paralytic to facilitate oral opening. Of note, 27/29 (93%) of the patients did not receive any immunizations (including partial) for COVID-19. There were no incidents of peri-intubation arrest (cardiac arrest within 30 minutes of induction) or aspiration.

CONCLUSIONS

In 29 physiologically difficult patients with acute respiratory failure, in whom the physician determined that RSI posed a higher than normal risk, FI assisted by VL, semi-Fowler positioning, and bilevel positive pressure pre-oxygenation resulted in excellent successful first-pass intubation rates without any incidences of peri-intubation arrest or aspiration. While this cohort was small, our study reveals that FI with midazolam does not likely pose a higher risk than ketamine-only intubation and warrants further study.

Endotracheal Intubation of Difficult Airways in Emergency Settings: A Guide for Innovators

Over 400,000 Americans are intubated in emergency settings annually, with indications ranging from respiratory failure to airway obstructions to anaphylaxis. About 12.7% of emergency intubations are unsuccessful on the first attempt. Failure to intubate on the first attempt is associated with a higher likelihood of adverse events, including oxygen desaturation, aspiration, trauma to soft tissue, dysrhythmia, hypotension, and cardiac arrest. Difficult airways, as classified on an established clinical scale, are found in up to 30% of emergency department (ED) patients and are a significant contributor to failure to intubate. Difficult intubations have been associated with longer lengths of stay and significantly greater costs than standard intubations. There exists a wide range of airway management devices, both invasive and noninvasive, which are available in the emergency setting to accommodate difficult airways. Yet, first-pass success rates remain variable and leave room for improvement. In this article, we review the disease states most correlated with intubation, the current landscape of emergency airway management technologies, and the market potential for innovation. The aim of this review is to inspire new technologies to assist difficult airway management, given the substantial opportunity for translation due to two key-value signposts of medical innovation: the potential to decrease cost and the potential to improve clinical outcomes.

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis

BACKGROUND

Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway.

METHODS

We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale.

RESULTS

We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse.

CONCLUSIONS

Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Introduction of Infection Prevention Tracheal Intubation Protocol during the COVID-19 Pandemic Is Not Associated with First-Pass Success Rates of Endotracheal Intubation in the Emergency Department: A Before-and-After Comparative Study

Aerosols and droplets have put healthcare workers performing airway management at high risk of contracting coronavirus disease 2019 (COVID-19). Experts have developed endotracheal intubation (ETI) guidelines and protocols to protect intubators from infection. We aimed to determine whether changes in the emergency department (ED) intubation protocol to prevent COVID-19 infection were associated with first-pass success (FPS) rates in ETI. We used data from the airway management registries in two academic EDs. The study was divided into pre-pandemic (January 2018 to January 2020) and pandemic (February 2020 to February 2022) periods. We selected 2476 intubation cases, including 1151 and 1325 cases recorded before and during the pandemic, respectively. During the pandemic, the FPS rate was 92.2%, which did not change significantly, and major complications increased slightly but not significantly compared with the pre-pandemic period. The OR for the FPS of applying infection prevention intubation protocols was 0.72 (p = 0.069) in a subgroup analysis, junior emergency physicians (PGY1 residents) had an FPS of less than 80% regardless of pandemic protocol implementation. The FPS rate of senior emergency physicians in physiologically difficult airways decreased significantly during the pandemic (98.0% to 88.5%). In conclusion, the FPS rate and complications for adult ETI performed by emergency physicians using COVID-19 infection prevention intubation protocols were similar to pre-pandemic conditions.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

OBJECTIVE

Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative.

METHODS

We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs.

RESULTS

Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status.

CONCLUSIONS

During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020. With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly. We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU). We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020 and June 2020 to determine if they met the inclusion criteria. These subjects were required to be spontaneously ventilating upon admission and eventually required intubation. Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospective ICU admission analysis. We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects. Our primary outcome of interest was intubation-related mortality. We defined intubation mortality as unexpected death (within 48 hours of intubation). Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress. COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects. COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed the rates of intubation survival were no different between the COVID and non-COVID groups. We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

Trends in endotracheal intubation for patients with COVID-19 by emergency physicians

Emergency physicians perform endotracheal intubations for patients with COVID-19. However, the trends in the intubation for COVID-19 patients in terms of success rate, complications, personal protective equipment (PPE) information, barrier enclosure use, and its transition have not been established. We conducted a retrospective study of COVID-19 cases that required tracheal intubation at four hospitals in the Tokyo metropolitan area between January 2020 and August 2021. The overall intubation success rate, operator experience, and infection control methods were investigated. We then compared the early and late phases of the pandemic for a period of 8 months each. A total of 211 cases met the inclusion criteria, and 133 were eligible for analysis. The intubation success rate increased from 85% to 94% from early to late phase, although the percentage of intubations performed by emergency medicine residents increased significantly in the late phase (p = 0.03). The percentage of light PPE use significantly increased from 65% to 91% from early to late phase (p < 0.01), whereas the percentage of barrier enclosure use significantly decreased from 26% to 0% (p < 0.01). Furthermore, the infection prevention methods during intubation became more simplified from early to late phase.

Timing to Intubation COVID-19 Patients: Can We Put It Off until Tomorrow?

Background: The decision to intubate COVID-19 patients receiving non-invasive respiratory support is challenging, requiring a fine balance between early intubation and risks of invasive mechanical ventilation versus the adverse effects of delaying intubation. This present study analyzes the association between intubation day and mortality in COVID-19 patients. Methods: We performed a unicentric retrospective cohort study considering all COVID-19 patients consecutively admitted between March 2020 and August 2020 requiring invasive mechanical ventilation. The primary outcome was all-cause mortality within 28 days after intubation, and a Cox model was used to evaluate the effect of time from onset of symptoms to intubation in mortality. Results: A total of 592 (20%) patients of 3020 admitted with COVID-19 were intubated during study period, and 310 patients who were intubated deceased 28 days after intubation. Each additional day between the onset of symptoms and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.018; 95% CI, 1.005–1.03). Conclusion: Among patients infected with SARS-CoV-2 who were intubated and mechanically ventilated, delaying intubation in the course of symptoms may be associated with higher mortality. Trial registration: The study protocol was approved by the local Ethics Committee (opinion number 3.990.817; CAAE: 30417520.0.0000.0068).

Comparison of tracheal intubation between sitting position and standing position in COVID-19 patients: A manikin study

It is recommended to use visual laryngoscope for tracheal intubation in a Corona Virus Disease 2019 patient to keep the operator farther from the patient. How the position of the operator affects the distance in this setting is not ascertained. This manikin study compares the distances between the operator and the model and the intubation conditions when the operator is in sitting position and standing position, respectively.Thirty one anesthesiologists with minimum 3-years' work experiences participated in the study. The participant's posture was photographed when he performed tracheal intubation using UE visual laryngoscope in standing and sitting position, respectively. The shortest distance between the model's upper central incisor and operator's face screen (UF), the horizontal distance between the model's upper central incisor and the operator's face screen, the angle between the UF line and the vertical line of the model's upper central incisor were measured. The success rate of intubation, the duration of intubation procedure, the first-attempt success rate, the Cormack-Lehane grade, and operator comfort score were also recorded.When the operator performed the procedure in sitting position, the horizontal distance between the model's upper central incisor and the operator's face screen distance was significantly longer (9.5 [0.0-17.2] vs 24.3 [10.3-33.0], P ≤ .001) and the angle between the UF line and the vertical line of the model's upper central incisor angle was significantly larger (45.2 [16.3-75.5] vs 17.7 [0.0-38.9], P ≤ .001). There was no significant difference in UF distance when the operator changed the position. Cormack-Lehane grade was significantly improved when it was assessed using visual laryngoscope. Cormack-Lehane grade was not significantly different when the operator assessed it in sitting and standing position, respectively. No significant differences were found in the success rate, duration for intubation, first-attempt success rate, and operator comfort score.The operator is kept farther from the patient when he performs intubation procedure in sitting position. Meanwhile, it does not make the procedure more difficult or uncomfortable for the operator, though all the participants prefer to standing position.

First-attempt intubation success and complications in patients with COVID-19 undergoing emergency intubation

Objectives

To evaluate the first-attempt success rates and complications of endotracheal intubation of coronavirus disease 2019 (COVID-19) patients by emergency physicians.

Methods

This prospective observational study was conducted from March 24, 2020 through May 28, 2020 at the emergency department (ED) of an urban, academic trauma center. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID-19 submitted to endotracheal intubation. No patients were excluded. The primary outcome was first-attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation.

Results

A total of 112 patients with confirmed or suspected COVID-19 were enrolled. Median age was 61 years and 61 patients (54%) were men. The primary outcome, first-attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. Forty-eight (42%) patients were hypotensive and required norepinephrine immediately post-intubation. Fifty-eight (52%) experienced peri-intubation hypoxemia, and 2 patients (2%) had cardiac arrest. There were no cases of failed intubation resulting in death up to 24 hours after the procedure.

Conclusion

Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting.