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Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Immunol Allergy Clin North Am 2023; 43:513-532. [PMID: 37394257 DOI: 10.1016/j.iac.2022.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/critcareguys
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2
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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3
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Jarzebowski M, Estime S, Russotto V, Karamchandani K. Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 2022; 35:109-114. [PMID: 35102045 DOI: 10.1097/aco.0000000000001100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes. RECENT FINDINGS Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure. SUMMARY Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.
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Affiliation(s)
- Mary Jarzebowski
- Department of Anesthesiology, University of Michigan Medicine, Ann Arbor, Michigan
| | - Stephen Estime
- Department of Anesthesia & Critical Care University of Chicago Medicine, Chicago, Illinois, USA
| | - Vincenzo Russotto
- Department of Anesthesia & Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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4
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Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder that usual results from a decreased level of functional C1-INH and clinically manifests with intermittent attacks of swelling of the subcutaneous tissue or submucosal layers of the respiratory or gastrointestinal tracts. Laboratory studies and radiographic imaging have limited roles in evaluation of patients with acute attacks of HAE except when the diagnosis is uncertain and other processes must be ruled out. Treatment begins with assessment of the airway to determine the need for immediate intervention. Emergency physicians should understand the pathophysiology of HAE to help guide management decisions.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Joseph J Moellman
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45267-0769, USA. https://twitter.com/edmojo
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5
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Abstract
Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.
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6
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Lee DH, Stang J, Reardon RF, Martel ML, Driver BE, Braude DA. Rapid Sequence Airway with the Intubating Laryngeal Mask in the Emergency Department. J Emerg Med 2021; 61:550-557. [PMID: 34736797 DOI: 10.1016/j.jemermed.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/23/2021] [Accepted: 09/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The administration of sedation and neuromuscular blockade to facilitate extraglottic device (EGD) placement is known as rapid sequence airway (RSA). In the emergency department (ED), EGDs are used largely as rescue devices. In select patients, there may be significant advantages to using EGDs over laryngoscopy as the primary airway device in the ED. OBJECTIVE Our study sought to describe the practice of RSA in the ED, including rates of successful oxygenation, ventilation, and complications from EGD use. METHODS We identified patients in the ED between 2007 and 2017 who underwent RSA with the LMA® Fastrach™ (hereafter termed ILMA; Teleflex Medical Europe Ltd., Athlone, Ireland) placed as the first definitive airway management device. A trained abstractor performed chart and video review of the cases to determine patient characteristics, physician use of the ILMA, indication for ILMA placement, success of oxygenation and ventilation, success of intubation, and complications related to the device. RESULTS During the study period, 94 patients underwent RSA with the ILMA. Of those, 93 (99%) were successfully oxygenated and ventilated, and when intubation was attempted, 89% were able to be intubated through the ILMA. The incidence of vomiting and aspiration was 1% and 3%, respectively. There were 30 different attending physicians who supervised RSA and the median number was 2 per physician in the 10-year study period. CONCLUSION The practice of RSA with the ILMA in the ED is associated with a high rate of successful oxygenation, ventilation, and intubation with infrequent complications, even when performed by physicians with few experiences in the approach.
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Affiliation(s)
- Daniel H Lee
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota.
| | - Jamie Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Darren A Braude
- Departments of Emergency Medicine and Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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7
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Sandefur BJ, Liu XW, Kaji AH, Campbell RL, Driver BE, Walls RM, Carlson JN, Brown CA. Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry. J Emerg Med 2021; 61:481-488. [PMID: 34479750 DOI: 10.1016/j.jemermed.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in patients with angioedema requiring intubation in the emergency department (ED). OBJECTIVE To describe airway management practices in patients intubated for angioedema in the ED. METHODS We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals. RESULTS Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%, with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope (49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension (13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed. CONCLUSIONS Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was rare, and no ED deaths were reported. © 2021 Elsevier Inc.
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Affiliation(s)
| | - Xiao-Wei Liu
- Department of Emergency Medicine, The First Affiliated Hospital of China Medical University, Liaoning, Shenyang, China
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jestin N Carlson
- Department of Emergency Medicine, Allegheny Health Network, Erie, Pennsylvania
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Krack AT, Bernstein JA, Ruddy RM. Recognition, Evaluation, and Management of Pediatric Hereditary Angioedema. Pediatr Emerg Care 2021; 37:218-223. [PMID: 33780405 DOI: 10.1097/pec.0000000000002402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
ABSTRACT Hereditary angioedema (HAE) is a rare, often underrecognized genetic disorder caused by either a C1 esterase inhibitor deficiency (type 1) or mutation (type 2). This leads to overproduction of bradykinin resulting in vasodilation, vascular leakage, and transient nonpitting angioedema occurring most frequently in the face, neck, upper airway, abdomen, and/or extremities. Involvement of the tongue and laryngopharynx has been associated with asphyxiation and death. Hereditary angioedema is an autosomal-dominant condition; therefore, there is a 50% chance an offspring will inherit this disorder. Any patient presenting with isolated angioedema should be screened with a C4 measurement, as 25% of cases have no family history of HAE. All patients with HAE will have a functional deficiency of C1 esterase inhibitor. Contributors that delay the diagnosis of HAE include recognition delay by clinicians who confuse this condition with histaminergic angioedema, the disease's varied presentations, and limitations to timely testing. Pediatric emergency clinicians should be knowledgeable about how to distinguish between bradykinin- and histamine-mediated angioedema, as there are significant differences in the diagnostic testing, treatment, and clinical response between these 2 different conditions. Evidence indicates that early diagnosis and treatment of HAE reduces morbidity and mortality. Clinician recognition of the mechanistically different problems will ensure patients are appropriately referred to an expert for outpatient management.
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Affiliation(s)
- Andrew T Krack
- From the Clinical Fellow, Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, and University of Cincinnati Department of Pediatrics
| | - Jonathan A Bernstein
- Professor of Medicine, Department of Internal Medicine, Division of Immunology/Allergy, University of Cincinnati Medical Center
| | - Richard M Ruddy
- Professor of Pediatrics, Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, and University of Cincinnati Department of Pediatrics, Cincinnati, OH
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9
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Use of the intubating laryngeal mask airway in the emergency department: A ten-year retrospective review. Am J Emerg Med 2020; 38:1367-1372. [DOI: 10.1016/j.ajem.2019.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022] Open
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10
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Affiliation(s)
- Antoine Eskander
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
| | - John R de Almeida
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
| | - Jonathan C Irish
- From the Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology (A.E., J.R.A., J.C.I.) and the Institute for Health Policy Management and Evaluation (A.E., J.R.A.), University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital (A.E.), the Institute for Clinical Evaluative Sciences (A.E.), and Princess Margaret Cancer Centre (J.R.A., J.C.I.) - all in Toronto
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11
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Abstract
Airway emergencies are life-threatening events that face providers of many different backgrounds. In cannot-intubate-cannot-ventilate situations, emergent access to the airway can be obtained through the cricothyroid membrane by cricothyroidotomy. The 3 main techniques are open, percutaneous, and needle cricothyroidotomy. To date, there is no compelling evidence demonstrating superiority of a particular approach. Ultimately, the method used for cricothyroidotomy should be based on the comfort and experience of the provider performing the procedure.
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Affiliation(s)
- Alejandro Bribriesco
- Department of Thoracic & Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195, USA.
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, 660 South Euclid, Campus Box 8234, St Louis, MO 63110, USA
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Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. 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. JAMA 2018; 319:2179-2189. [PMID: 29800096 PMCID: PMC6134434 DOI: 10.1001/jama.2018.6496] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. OBJECTIVE To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. DESIGN, SETTING, AND PATIENTS The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. INTERVENTIONS Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). MAIN OUTCOMES AND MEASURES The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. RESULTS Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. CONCLUSIONS AND RELEVANCE In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02902146.
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Affiliation(s)
- Brian E. Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Lauren R. Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Robert F. Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - James R. Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Erik T. Fagerstrom
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | | | - John W. McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jon B. Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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13
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Joshua J, Scholten E, Schaerer D, Mafee MF, Alexander TH, Crotty Alexander LE. Otolaryngology in Critical Care. Ann Am Thorac Soc 2018; 15:643-654. [PMID: 29565639 PMCID: PMC6207134 DOI: 10.1513/annalsats.201708-695fr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/22/2018] [Indexed: 01/02/2023] Open
Abstract
Diseases affecting the ear, nose, and throat are prevalent in intensive care settings and often require combined medical and surgical management. Upper airway occlusion can occur as a result of malignant tumor growth, allergic reactions, and bleeding events and may require close monitoring and interventions by intensivists, sometimes necessitating surgical management. With the increased prevalence of immunocompromised patients, aggressive infections of the head and neck likewise require prompt recognition and treatment. In addition, procedure-specific complications of major otolaryngologic procedures can be highly morbid, necessitating vigilant postoperative monitoring. For optimal outcomes, intensivists need a broad understanding of the pathophysiology and management of life-threatening otolaryngologic disease.
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Affiliation(s)
- Jisha Joshua
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | - Eric Scholten
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
| | | | - Mahmood F. Mafee
- Division of Neuroradiology, Department of Radiology, University of California–San Diego, San Diego, California
| | | | - Laura E. Crotty Alexander
- Pulmonary and Critical Care Section, Department of Medicine, Veterans Affairs San Diego Healthcare System, San Diego, California; and
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine
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14
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Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017; 70:473-478.e1. [PMID: 28601269 DOI: 10.1016/j.annemergmed.2017.04.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/14/2017] [Accepted: 04/19/2017] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success. METHODS We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation. RESULTS Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]). CONCLUSION Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.
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Affiliation(s)
- Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - Kenneth Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ryan Buckley
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
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