Novel Technologies and Techniques for Prehospital Airway Management: An NAEMSP Position Statement and Resource Document

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department

AIM

Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused.

MEASUREMENTS

We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success.

RESULTS

We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued.

CONCLUSIONS

It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.

New technologies in airway management: A review

The evolution of medical knowledge and technological growth have contributed to the development of different techniques and devices for airway management. These appear to play a role in optimizing the number of attempts and overall success, ultimately reducing the negative consequences of airway manipulation. In this literature review, we highlight the recent evidence regarding new technologies applied to airway management. Before intubation, every patient should have an individualized structured airway management plan. Technology can help with both airway evaluation and tracheal intubation. Point-of-care cervical ultrasound and artificial intelligence models with automated facial analysis have been used to predict difficult airways. Various devices can be used in airway management. This includes a robotic video endoscope that guides intubation based on real image recognition, a laryngeal mask with a non-inflatable cuff that tries to reduce local complications, video laryngeal masks that are able to confirm the correct position and facilitate intubation, Viescope™, a videolaryngoscope developed for combat medicine with a unique circular blade, a system that uses cervical transillumination for glottis identification in difficult airways and Vivasight SL™ tracheal tube, which has a high-resolution camera at its tip guaranteeing visual assurance of tube position as well as guiding bronchial blocker position. To conclude, we detailed the challenges in airway management outside the operating room as well as described suction-assisted laryngoscopy and airway decontamination technique for contaminated airways. Further research in the clinical setting is recommended to better support the use of these technologies.