Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Ventilator-assisted preoxygenation in an aeromedical retrieval setting

OBJECTIVE

Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting.

METHODS

Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2).

RESULTS

VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events.

CONCLUSION

VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.

Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit

BACKGROUND

There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly.

AIMS

The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes.

METHODS

We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes.

RESULTS

We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia.

CONCLUSION

Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE

To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED.

METHODS

A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

RESULTS

Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8).

CONCLUSIONS

Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

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.

Emergency airway management in a tertiary trauma centre (AIRMAN): a one-year prospective longitudinal study

PURPOSE

Emergency airway management can be associated with a range of complications including long-term neurologic injury and death. We studied the first-pass success rate with emergency airway management in a tertiary care trauma centre. Secondary outcomes were to identify factors associated with first-pass success and factors associated with adverse events peri-intubation.

METHODS

We performed a single-centre, prospective, observational study of patients ≥ 17 yr old who were intubated in the emergency department (ED), surgical intensive care unit (SICU), medical intensive care unit (MICU), and inpatient wards at our institution. Ethics approval was obtained from the local research ethics board.

RESULTS

In a seven-month period, there were 416 emergency intubations and a first-pass success rate of 73.1%. The first-pass success rates were 57.5% on the ward, 66.1% in the intensive care units (ICUs) and 84.3% in the ED. Equipment also varied by location; videolaryngoscopy use was 65.1% in the ED and only 10.6% on wards. A multivariate regression model using the least absolute shrinkage and selection algorithm (LASSO) showed that the odds ratios for factors associated with two or more intubation attempts were location (wards, 1.23; MICU, 1.24; SICU, 1.19; reference group, ED), physiologic instability (1.19), an anatomically difficult airway (1.05), hypoxemia (1.98), lack of neuromuscular blocker use (2.28), and intubator inexperience (1.41).

CONCLUSIONS

First-pass success rates varied widely between locations within the hospital and were less than those published from similar institutions, except for the ED. We are revamping ICU protocols to improve the first-pass success rate.

Evaluation of endotracheal intubations in the emergency department of a tertiary care facility

OBJECTIVE

In this study, we aimed to evaluate the performance of emergency department intubations for 1 year.

METHODS

This was a retrospective analysis of prospectively collected data. The collected variables were patient demographics, indication for intubation, preintubation hemodynamics, preoxygenation methods, medications used for premedication, induction and paralysis, type of laryngoscope used, Cormack-Lehane (C-L) grades, number of intubation attempts, and peri-intubation adverse events.

RESULTS

A total of 194 patients were included. The median age of the population was 66.5 years (53.75-79); 61.9% of the patients were male. The majority of the patients were intubated due to medical conditions. The main indication for endotracheal intubation was respiratory failure in 38.6% of the patients. Preoxygenation before intubation was performed in 87.2% of the patients. Fifty-eight percent of the population were hemodynamically stable before the intubation. Fentanyl was the agent used for premedication, induction agents of choice were ketamine and midazolam, and rocuronium was the neuromuscular blocking agent. The C-L grades 1 and 2 were detected in 87.6% of the patients. The first-pass success rate was 72.8%. The peri-intubation adverse events were mainly hypotension and desaturation observed in 82 (42%) patients. The patients with higher C-L grades needed more intubation attempts (P < 0.001). Peri-intubation adverse events were associated with the increased number of intubation attempts (P < 0.001).

CONCLUSION

This and similar studies or an airway registry on a national level may help improve the quality of service given and delineate the deficiencies of the airway-related procedures in the emergency department.

A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic

OBJECTIVE

Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes?

METHODS

A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days.

RESULTS

Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172).

CONCLUSION

A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.

Multidisciplinary Difficult Airway Team Characteristics, Airway Securement Success, and Clinical Outcomes: A Systematic Review

Objective:

To investigate whether implementation of a multidisciplinary airway team was associated with improvement in (1) rate of successful airway securement at first attempt; (2) time to secure airway; and (3) overall complication rate in patients with a difficult airway, as compared with usual care.

Data Sources:

Ovid Medline, Embase, Scopus, Cochrane Central, and CINAHL databases.

Review Methods:

Systematic review of literature on inpatient multidisciplinary team management of difficult airways, including all studies performed in inpatient settings, excluding studies of ventilator weaning, flight/military medicine, EXIT procedures, and simulation or educational studies. DistillerSR was used for article screening and risk of a bias assessment to evaluate article quality. Data was extracted on study design, airway team composition, patient characteristics, and clinical outcomes including airway securement, complications, and mortality.

Results:

From 5323 studies screened, 19 studies met inclusion criteria with 4675 patients. Study designs included 12 quality improvement projects, 6 cohort studies, and 1 randomized controlled trial. Four studies evaluated effect of multidisciplinary difficult airway teams on airway securement; all reported higher first attempt success rate with team approach. Three studies reported time to secure the difficult airways, all reporting swifter airway securement with team approach. The most common difficult airway complications were hypoxia, esophageal intubation, hemodynamic instability, and aspiration. Team composition varied, including otolaryngologists, anesthesiologists, intensivists, nurses, and respiratory care practitioners.

Conclusion:

Multidisciplinary difficult airway teams are associated with improved clinical outcomes compared to unstructured emergency airway management; however, studies have significant heterogeneity in team composition, algorithms for airway securement, and outcomes reported. Further evidence is necessary to define the clinical efficacy, cost-effectiveness, and best practices relating to implementing difficult airway teams in inpatient settings.

Safety of rapid sequence intubation in an emergency training network

OBJECTIVE

Rapid sequence intubation (RSI) is a core critical care skill. Emergency medicine trainees are exposed to relatively low numbers of RSIs. We aimed to improve patient outcomes by implementing an RSI checklist, electronic learning and audit, in line with current best evidence.

METHODS

Prospective observational study of RSIs performed in the EDs of two Queensland hospitals between January 2014 and December 2016. Data collected included: first-pass success (FPS), predicted difficulty, indication for intubation, drugs used, positioning, number of attempts, checklist use and complications. Descriptive statistics and multivariable modelling were used to describe differences in FPS, and complications.

RESULTS

Six hundred and fifty-five patients underwent RSI with FPS of 86.6%. Complications were reported in 15.9%, mainly hypotension (10.9%) and desaturation (4.0%). FPS improved with bougie use (88.9% vs 73.0% without bougie, P < 0.001) and video-laryngoscopy (88.2% vs 72.9% using standard laryngoscopy, P < 0.001). New desaturation was reduced with apnoeic oxygenation (2.0% vs 22.2%, P < 0.001), bougie use (2.8% vs 8.9%, P < 0.001), checklist use (2.3% vs 22.7%, P < 0.001) and achieving FPS (2.1% vs 16.3%, P < 0.001). Complications were reduced with checklist use (13.3% vs 43.2%, P < 0.001) and apnoeic oxygenation use (3.9% vs 31.1%, P < 0.001). Logistic regression found checklist use was associated with reduced desaturation (OR 0.1, 95% CI 0.04-0.27) and the composite variable of any complication (OR 0.39, 95% CI 0.17-0.89).

CONCLUSIONS

Implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of RSI. In our setting, checklist use was associated with fewer complications.

The knowledge of Cormack-Lehane intubation grade and intensive care unit outcome

Background

For patients on invasive mechanical ventilation (MV), it is unclear if knowledge of intubation grade influences intensive care unit (ICU) outcome. We aimed to determine if there was an independent relationship between knowledge of intubation grade during ICU admission and in-hospital mortality.

Methods

We performed a retrospective cohort study of all patients receiving invasive MV at the Alfred ICU between December 2011 and February 2015. Demographics, details of admission, the severity of illness, chronic health status, airway detail (unknown or known Cormack-Lehane (CL) grade), MV duration and in-hospital mortality data were collected. Univariable and multivariable analyses were conducted to assess the relationship. The primary outcome was in-hospital mortality, and the secondary outcome was the duration of MV.

Results

Amongst 3556 patients studied, 611 (17.2%) had an unknown CL grade. Unadjusted mortality was higher in patients with unknown CL grade compared to known CL grade patients (21.6% vs. 9.9%). After adjusting for age, sex, severity of illness, type of ICU admission, cardiac arrest, limitations to treatment and diagnosis, having an unknown CL grade during invasive MV was independently associated with an increase in mortality (adjusted OR 1.5, 95% CI 1.14-1.98, p < 0.01).

Conclusion

Amongst ICU patients receiving MV, not knowing CL grade appears to be independently associated with increased mortality. This information should be communicated and documented in all patients receiving MV in ICU.

État de choc après intubation : facteurs de risque et moyens de prévention en réanimation

La survenue d’un état de choc postintubation d’un patient de réanimation est fréquente. L’identification de facteurs de risque liés au patient (sujet âgé, pathologie respiratoire grave septique avec retentissement marqué, antécédents cardiorespiratoires) et à la procédure (hypnotiques, ventilation mécanique) est importante. Elle doit permettre d’anticiper des moyens de traitement de l’état de choc postintubation dans le cadre d’un bundle : présence de deux opérateurs, préoxygénation optimisée, expansion volémique, vasopresseurs, agents pour une induction en séquence rapide, préparation et initiation de la sédation d’entretien, capnographie, ventilation protectrice.

Emergency airway management in Australian and New Zealand emergency departments: A multicentre descriptive study of 3710 emergency intubations

OBJECTIVE

The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs.

METHODS

We established a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry [ANZEDAR]) prospectively capturing intubations from 43 Australian and New Zealand EDs over 24 months using the ANZEDAR form. Information recorded included patient demographics, intubation indications, predicted difficulty, rapid sequence induction and endotracheal intubation preparation technique, induction drugs, airway adjuncts and complications. Factors associated with first attempt success were explored.

RESULTS

Of the 3710 intubations captured, 3533 were in adults (95.2%), 2835 (76.4%) for medical and 810 (21.8%) for trauma indications. Overall, 3127 (84.3%) patients were successfully intubated at the first attempt; the majority by ED doctors (2654 [72.1%]). A total of 10 surgical airways were performed, all of which were successful cricothyroidotomies. Propofol, thiopentone or ketamine were used with similar frequency for induction, and suxamethonium was the most often used muscle relaxant. Adverse events were reported in 964 (26%), the majority involving desaturation or hypotension.

CONCLUSION

Australasian ED doctors, predominantly specialist emergency physicians or trainees, perform the majority of ED intubations using rapid sequence induction as their preferred technique mainly for medical indications. First attempt success rate was not different between different types of EDs, and is comparable published international data. Complications are not infrequent, and are comparable to other published series. Monitoring and reporting of ED intubation practice will enable continued improvements in the safety of this high-risk procedure.

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients

OBJECTIVES

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.

METHODS

A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice.

RESULTS

The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).

CONCLUSIONS

Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction

Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

Methods

A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients.

Results

In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001).

Conclusion

Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

The MACOCHA score is feasible to predict intubation failure of nonanesthesiologist intensive care unit trainees

PURPOSE

Endotracheal intubation (ET) in intensive care unit (ICU) patients is regarded as more challenging than elective intubations in the operating room. Despite challenging conditions in ICU, trainees are often the initial operators performing ET. Because nonanesthesiologist intensivists with limited experience in ET run most of the nonsurgical ICUs, it is of exceptional importance to identify patients with predictable difficult ET in advance to prepare for a difficult airway scenario and thus avoid severe complications.

METHODS

In this prospective, observational, single-center study, we used a truncated MACOCHA score to evaluate intubation performance of nonanesthesiologist ICU trainees in an interdisciplinary medical ICU.

RESULTS

We show that (a) ET could be performed safely and without fatal complications in all cases; (b) the MACOCHA score is feasible on a nonanesthesiologist ICU; (c) a truncated MACOCHA score of at least 8 predicts failure of ICU trainees; and (d) availability of an ear, nose, and throat physician and an anesthesiologist is required to warrant successful management of difficult airways.

CONCLUSION

Our findings are a further step to implement the MACOCHA score into the standard admission procedure of an ICU to identify early those patients in whom additional support is needed in case of ET and to improve patient safety.