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Edelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia 2019; 74:1175-1185. [PMID: 31328259 DOI: 10.1111/anae.14779] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2019] [Indexed: 12/18/2022]
Abstract
The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.
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Affiliation(s)
- D A Edelman
- Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - E J Perkins
- Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - D J Brewster
- Central Clinical School, Monash University, Melbourne, Vic., Australia
- Cabrini Hospital, Melbourne, Vic., Australia
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Green RS, Butler MB. Postintubation Hypotension in General Anesthesia: A Retrospective Analysis. J Intensive Care Med 2016; 31:667-675. [PMID: 26721639 DOI: 10.1177/0885066615597198] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department endotracheal intubations. Study objective was to determine the incidence of PIH and its impact on outcomes following tracheal intubation in a general anesthesia population. METHODS Structured chart audit of adult patients intubated for a vascular surgery procedure at a tertiary care center over a 3-year period. Outcomes included in-hospital mortality, extended intensive care unit length of stay (ICU LOS), and requirement for postoperative (postop) hemodialysis or mechanical ventilation. RESULTS Incidence of PIH was 60% (837 of 1395). Patients who developed PIH had increased mortality (8.8% PIH vs 5.2% no-PIH; P = .014), extended ICU LOS (7.9% PIH vs 2.0% no-PIH; P < .001), and postop mechanical ventilation requirement (20.7% PIH vs 3.8% no-PIH; P < .001). When controlling for confounding factors, PIH was associated with extended ICU LOS (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.01-6.62, P = .049), postop ventilation (OR 2.43, 95% CI 1.27-4.74, P = .008), and a composite end point (OR 1.72, 95% CI 1.02-2.92, P = .043). CONCLUSIONS Development of PIH occurs in 60% of patients undergoing intubation for vascular surgery and was associated with adverse outcomes including extended ICU LOS and postop ventilation requirement.
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Affiliation(s)
- Robert S Green
- 1 Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,2 Trauma Nova Scotia, Halifax, Nova Scotia, Canada.,3 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael B Butler
- 3 Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,4 Department of Mathematics and Statistics, Dalhousie University, Halifax, Nova Scotia, Canada
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Cheng Y, Xue FS, Li RP, Liao X. Comparative Performance of Glidescope Videolaryngoscope with Direct Laryngoscope for Emergency Intubation. J Emerg Med 2016; 51:187-8. [PMID: 27369858 DOI: 10.1016/j.jemermed.2013.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 01/26/2013] [Indexed: 10/21/2022]
Affiliation(s)
- Yi Cheng
- Department of Anesthesiology, Beijing An Zhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Fu-Shan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Rui-Ping Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xu Liao
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Kim TH, Hwang SO, Cha YS, Kim OH, Lee KH, Kim H, Cha KC. The utility of noninvasive nasal positive pressure ventilators for optimizing oxygenation during rapid sequence intubation. Am J Emerg Med 2016; 34:1627-30. [PMID: 27339225 DOI: 10.1016/j.ajem.2016.05.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 05/25/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The objective of the study is to investigate the feasibility of noninvasive nasal positive pressure ventilation (NINPPV) for optimizing oxygenation during the rapid sequence intubation in critically ill patients. METHODS A prospective, observational study was performed in an emergency department. Noninvasive nasal positive pressure ventilation was applied in the preoxygenation step and maintained until successful intubation. A pulse oximetry (Spo2) was continuously monitored throughout the procedure and recorded 5 times. The degree of interfering was surveyed with 10-point Likert scale. RESULTS Thirty patients were enrolled. The most of enrolled patients were diagnosed as pneumonia, acute heart failure, and traumatic brain injury. The Spo2 was increased to 100% (98%-100%) at the time of starting endotracheal intubation with NINPPV and maintained as 97% (95%-100%) until successful intubation (P< .001). Total apnea duration was 195 seconds (190-196). The degree of interfering intubation was 1 (0-1). CONCLUSIONS Noninvasive nasal positive pressure ventilation would be useful for optimizing oxygenation during rapid sequence intubation.
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Affiliation(s)
- Tae Hoon Kim
- Department of Emergency Medicine, Busan Baik Hospital, Inje University, Republic of Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Republic of Korea.
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Acute emergency care and airway management of caustic ingestion in adults: single center observational study. Scand J Trauma Resusc Emerg Med 2016; 24:45. [PMID: 27068119 PMCID: PMC4827211 DOI: 10.1186/s13049-016-0240-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 04/06/2016] [Indexed: 12/11/2022] Open
Abstract
Background Caustic ingestions are rare but potentially life-threatening events requiring multidisciplinary emergency approaches. Although particularly respiratory functions may be impaired after caustic ingestions, studies involving acute emergency care are scarce. The goal of this study was to explore acute emergency care with respect to airway management and emergency department (ED) infrastructures. Methods We retrospectively evaluated adult patients after caustic ingestions admitted to our university hospital over a 10-year period (2005–2014). Prognostic analysis included age, morbidity, ingested agent, airway management, interventions (endoscopy findings, computed tomography (CT), surgical procedures), intensive care unit (ICU) admission, length of stay in hospital and hospital mortality. Results Twenty-eight patients with caustic ingestions were included in the analysis of which 18 (64 %) had suicidal intentions. Ingested agents were caustic alkalis (n = 22; 79 %) and acids (n = 6; 21 %). ICU admission was required in 20 patients (71 %). Fourteen patients (50 %) underwent tracheal intubation and mechanical ventilation, of which 3 (21 %) presented with difficult airways. Seven patients (25 %) underwent tracheotomy including one requiring awake tracheotomy due to progressive upper airway obstruction. Esophagogastroduodenoscopy (EGD) was performed in 21 patients (75 %) and 11 (39 %) underwent CT examination. Five patients (18 %) required emergency surgery with a mortality of 60 %. Overall hospital mortality was 18 % whereas the need for tracheal intubation (P = 0.012), CT-diagnostic (P = 0.001), higher EGD score (P = 0.006), tracheotomy (P = 0.048), and surgical interventions (P = 0.005) were significantly associated with mortality. Conclusions Caustic ingestions in adult patients require an ED infrastructure providing 24/7-availability of expertise in establishing emergent airway safety, endoscopic examination (EGD and bronchoscopy), and CT diagnostic, intensive care and emergency esophageal surgery. We recommend that - even in patients with apparently stable clinical conditions - careful monitoring of respiratory functions should be considered as long as diagnostic work-up is completed.
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Green R, Hutton B, Lorette J, Bleskie D, McIntyre L, Fergusson D. Incidence of postintubation hemodynamic instability associated with emergent intubations performed outside the operating room: a systematic review. CAN J EMERG MED 2015; 16:69-79. [PMID: 24424005 DOI: 10.2310/8000.2013.131004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Hemodynamic instability following emergent endotracheal intubation (EETI) is a potentially life-threatening adverse event. The objectives of this systematic literature review were to document the incidence of postintubation hemodynamic instability (PIHI), to determine the definitions for PIHI used in the available literature, and to examine factors associated with PIHI in adult patients who require EETI. DATA SOURCE Articles published in Medline (1966-August 2012). STUDY SELECTION This systematic review included adult, in-hospital studies of EETIs. Studies with nonemergent or pediatric patient populations were excluded. DATA EXTRACTION Two authors independently performed data abstraction. Disagreements were resolved by a third party. The methodological quality of included studies was assessed with the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. DATA SYNTHESIS We estimated the pooled prevalence of PIHI across studies using a random effects meta-analysis. Subgroups analyzed included study design, intubation setting, geographic location of the study, physician experience, medications used for sedation, neuromuscular blockade, and definition of PIHI. Eighteen studies were analyzed, with sample sizes from 84 to 2,833 patients. The incidence of PIHI ranged from 5 to 440 cases per 1,000 intubations, with a pooled estimate of 110 cases per 1,000 intubations (95% CI 65-167). CONCLUSIONS PIHI was found to occur in 110 cases per 1,000 in-hospital, emergent intubations. However, heterogeneity among the included studies limits the reliability of this summary estimate. Further investigation is warranted.
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Anand VG, Girinivasan, Leelakrishna, Thavamani. Evaluation of the new supraglottic airway S.A.L.T to aid blind orotracheal intubation: A pilot study. Int J Crit Illn Inj Sci 2014; 3:241-5. [PMID: 24459620 PMCID: PMC3891189 DOI: 10.4103/2229-5151.124112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Objective: Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T) is a new airway gadget conceived as an effective device to facilitate blind oro-tracheal intubation. Literature review showed no available clinical study on human subjects. The aim of our study was to evaluate S.A.L.T as an adjunct to blind oro-tracheal intubation. Methods: Study design: Single centre, Single group, Open label, Prospective, Interventional pilot study. Study Group: 30 adult patients of either sex belonging to ASA I and II, scheduled for elective surgery under General anaesthesia. Patients were pre-medicated with inj. Glycopyrrolate 0.2 mg and inj. Midazolam 2 mg and induced with Inj. Propofol 2 mg/kg IV. After inj. Suxamethonium 1.5 mg/kg IV, S.A.L.T was inserted and a size 7.0 ID cuffed ETT was inserted through it immediately. The time period, from insertion of the S.A.L.T to the insertion of the ETT was noted. A successful intubation was defined as to insert SALT and intubate through it within 2 minutes irrespective of the number of attempts. Airway trauma, if any was recorded. Results: Only 40% of the patients were successfully intubated [(20.4% to 59.6% with 95% confidence interval (CI)]. The mean number of attempts required for intubation was 1.4 ± 0.67 (CI - 0.99 to 1.8) and the mean time for intubation was 26.3 ± 19.0 seconds (CI - 14.3 to 38.4 sec). Mallampati class I had more success rate than class III (P < 0.05). No airway trauma was recorded. Conclusion: S.A.L.T shows limited usefulness as an adjunct for aided blind oro-tracheal intubation.
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Affiliation(s)
- Vijay G Anand
- Department of Anaesthesiology and Critical Care, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India
| | - Girinivasan
- Department of Anaesthesiology and Critical Care, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India
| | - Leelakrishna
- Department of Anaesthesiology and Critical Care, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India
| | - Thavamani
- Department of Anaesthesiology and Critical Care, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India
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Borràs R, Periñan R, Fernández C, Plaza A, Andreu E, Schmucker E, Añez C, Valero R. [Airway management algorithm in the obstetrics patient]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:436-443. [PMID: 22947195 DOI: 10.1016/j.redar.2012.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 05/05/2012] [Indexed: 06/01/2023]
Affiliation(s)
- R Borràs
- Departamento de Anestesiología y Reanimación, Institut Universitari Dexeus, Barcelona, España.
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Nicolaisen N, Ahmed A, Hancock T, Ogren R. Field airway management of a construction worker with an impaling rebar injury to the neck and brain. PREHOSP EMERG CARE 2012; 16:548-52. [PMID: 22823946 DOI: 10.3109/10903127.2012.695438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article discusses a case of airway management by air ambulance emergency medical services (EMS) providers in a 22-year-old man impaled through the neck into the brain with 0.5-inch rebar. Penetrating neck injuries (PNIs) with impalement are extraordinarily rare. It is important for EMS providers and emergency medicine physicians to have an understanding of the initial management of an impaled patient with PNI, including having an organized approach to establishing a definitive airway and recognizing the airway complications that PNI may cause. This article discusses out-of-hospital management of impaled patients.
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Affiliation(s)
- Nicola Nicolaisen
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA
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Airway management practices in adult intensive care units in Israel: a national survey. J Clin Monit Comput 2012; 26:415-21. [PMID: 22614337 DOI: 10.1007/s10877-012-9368-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 04/26/2012] [Indexed: 12/19/2022]
Abstract
Timely and adequate management of normal and compromised airway is a crucial task facing medical teams taking care of patients in intensive care units. We investigated the airway management practices in the Israeli intensive care units (ICUs). A postal survey was sent to the 20 main ICUs in Israel. We investigated which medical specialty (ICU, anesthesiology or ENT) is involved with airway management in the ICUs and summarized the availability of airway equipment and medication necessary for endotracheal intubation, the use of dedicated airway management algorithms, the approaches to specific airway scenarios and education in airway management. The response rate was 70 % (14 out of the 20 units). Intubation with normal airway is performed mainly by ICU doctors (86 %). A difficult airway is most frequently cared for by anesthesiologists (79 %), while impossible intubation/mask ventilation is mainly managed by anesthesiologists and ENT surgeons (50-79 %). Airways in C-spine injury are mainly managed by anesthesiologists (70 %). Surgical airway is mainly performed by ENT surgeons (79 %). The ASA difficult airway algorithm is used in 71 % of the units. Fiberoptic intubation is used significantly more often than other methods in two scenarios: 78 % of the difficult airways and 64 % of the C-spine injuries (p < 0.0001). Only 43 % of the units reported holding quality assurance meetings. 69 % of the units' heads are satisfied with their airway management policies. Equipment and medications necessary for airway management are available in most of the units. Difficult airways in ICUs are mainly managed by anesthesiologists and ENT surgeons. Few ICUs have quality assurance meetings.
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The use of i-gel extraglottic airway in a trauma patient. Am J Emerg Med 2012; 30:829-30. [PMID: 22463968 DOI: 10.1016/j.ajem.2012.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 01/23/2012] [Indexed: 11/23/2022] Open
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The Easytube for airway management in prehospital emergency medicine. Resuscitation 2011; 81:1516-20. [PMID: 20621409 DOI: 10.1016/j.resuscitation.2010.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 04/19/2010] [Accepted: 06/02/2010] [Indexed: 11/20/2022]
Abstract
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.
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Initial ventilation through laryngeal tube instead of face mask in out-of-hospital cardiopulmonary arrest is effective and safe. Eur J Emerg Med 2010; 17:10-5. [PMID: 20201123 DOI: 10.1097/mej.0b013e32832d852a] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Bag-valve-mask ventilation is recommended as the initial airway management option for paramedics during cardiopulmonary resuscitation, although this technique requires considerable skill and is associated with the risk of stomach insufflation, regurgitation, and aspiration. The present two-phase study investigated the efficacy and safety of the laryngeal tube (LT-D) used by paramedics as the sole technique for ventilation in out-of-hospital cardiac arrest. METHODS Paramedics staffing the emergency services' ambulances were selected for the study and trained in the use of the LT-D (phase I). They were then requested to use the device in patients requiring out-of-hospital cardiopulmonary resuscitation without prior bag-valve-mask ventilation. Patients were evaluated with regard to successful placement and effective ventilation using the airway. On arrival at the scene, the emergency physician replaced the LT-D with an endotracheal tube and assessed the incidence of regurgitation and injuries to the airways (phase II). RESULTS Forty patients were enrolled into this study. One was excluded from analysis because of protocol violation. Insertion of the LT-D was successful and ventilation was effective in 33 patients (85%). Ventilation was not possible in six patients (15%) because of cuff rupture (n = 3) or massive regurgitation and aspiration before LT-D insertion (n = 3). No patient regurgitated after tube placement. No airway injuries were observed. The participants rated ventilation using the LT-D as effective. CONCLUSION The LT-D is feasible and effective for airway management and ventilation when used by paramedics in out-of-hospital cardiopulmonary resuscitation and can be recommended as the sole technique in such situations.
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Evaluación de la vía aérea en el paciente crítico. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)61006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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White W, Chandra A, Emmett DC. The impact of provider and environmental factors on the outcomes of urgent tracheal intubation at a large teaching hospital. Hosp Top 2007; 85:29-35. [PMID: 17711812 DOI: 10.3200/htps.85.3.29-35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- William White
- The Charleston Area Medical Center School of Nurse Anesthesia, Charleston, WV, USA
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