Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data

Predictive Factors for First-Pass Intubation Failure in Trauma Patients

Objective

The primary objective of this study was to elucidate risk factors for multiple intubation attempts (MIA) in trauma patients requiring emergent tracheal intubation (ETI). Risk factors for mortality, intensive care unit (ICU) admission, and prolonged ventilation were assessed as secondary outcomes. The association between multiple intubation attempts and adverse outcomes has been well described in the literature. Though previous studies have identified anatomical risk factors for difficult airways, no study to date has investigated predictors for MIA in a trauma setting.

Methods

The retrospective study involved 174 adult patients who required ETI and who presented to a Level 1 Trauma Center's emergency department between January 2019 and December 2022. Comorbidities, demographic information, triage vitals, intubation characteristics, and patient outcomes were identified to ascertain predictive risk factors for MIA. Variables were assessed for statistical significance on unadjusted analysis. Significant variables were entered into multivariate logistic regression models to test for adjusted associations, with p≤.0.05 as statistically significant, and presented as adjusted odds ratios with 95% confidence intervals.

Results

Twenty-six (14.9%) of the 174 patients required multiple intubation attempts. There were no significant associations between MIA and patient gender, age, BMI, race, injury mechanism, or specific body region injuries. On univariate analysis, the MIA group had a statistically significant elevation in mean systolic blood pressure (151.71 ± 45.96 vs 133.55 ± 32.11, p = 0.019) and heart rate (106.30 ± 34.92 vs 93.35 ± 24.82, p < 0.032) compared to subjects with first-pass success. Elevation in systolic blood pressure (SBP) (151.71 ± 45.96 vs 133.55 ± 32.11, aOR 1.03 (1.01-1.06), p < 0.015) was an independent predictor of multiple intubation attempts.

Conclusion

Elevation in SBP was a significant predictor of multiple intubation attempts. Critical appraisal of patients requiring ETI with elevated SBP may mitigate risk in trauma settings.

MONTH Score in Predicting Difficult Intubations in Emergency Department; a Prognostic Accuracy Study

Introduction

MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations in the emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficult intubations in ED.

Methods

We prospectively collected data on all patients undergoing intubation in the ED of Ramathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifying the difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0.

Results

324 intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult intubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI: 61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with Intubation Difficulty Scale (IDS) score ≥ 6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The area under the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI: 0.856- 0.926).

Conclusions

It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool with high specificity and positive predictive values in identifying cases with difficult intubations in ED.

First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department

BACKGROUND

The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED.

METHODS

We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods.

RESULTS

Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events.

CONCLUSION

The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.

Videolaryngoscopy vs. flexible fibrescopy for tracheal intubation in patients with cervical spine immobilisation: a randomised controlled trial

In patients with cervical spine immobilisation, tracheal intubation devices other than a direct laryngoscope are frequently used to facilitate tracheal intubation and avoid related complications. In this randomised controlled trial, we compared videolaryngoscopic and fibrescopic tracheal intubation in patients with a cervical collar. Tracheal intubation was performed using either a videolaryngoscope with a non-channelled Macintosh blade (n = 166) or a flexible fibrescope (n = 164) in patients having elective cervical spine surgery whose neck was immobilised with a cervical collar to simulate a difficult airway. The primary outcome was the first attempt success rate of tracheal intubation. Secondary outcomes were the overall success rate of tracheal intubation; time to tracheal intubation; use of additional airway manoeuvres; and incidence and severity of tracheal intubation-related airway complications. First attempt success rate was higher in the videolaryngoscope group than in the fibrescope group (164/166 (98.8%) vs. 149/164 (90.9%), p = 0.003). Tracheal intubation was successful within three attempts in all patients. Median (IQR [range]) time to tracheal intubation was shorter (50.0 (41.0-72.0 [25.0-170.0]) s vs. 81.0 (65.0-107.0 [24.0-178.0]) s, p < 0.001) and additional airway manoeuvres were less frequent (30/166 (18.1%) vs. 91/164 (55.5%), p < 0.001) in the videolaryngoscope group compared with the fibrescope group. The incidence and severity of intubation-related airway complications were not different between the two groups. When performing tracheal intubation in patients with a cervical collar, videolaryngoscopy with a non-channelled Macintosh blade was superior to flexible fibrescopy.

Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies

Background

Airway obstruction is a relatively rare but critical condition that requires urgent intervention in the emergency department (ED). The present study aimed to investigate the association of airway obstruction with first-pass success and intubation-related adverse events in the ED.

Methods

We analyzed data from two prospective multicenter observational studies of ED airway management. We included adults (aged ≥18 years) who underwent tracheal intubation for non-trauma indications from 2012 through 2021 (113-month period). Outcome measures were first-pass success and intubation-related adverse events. We constructed a multivariable logistic regression model adjusting for age, sex, modified LEMON score (without airway obstruction), intubation methods, intubation devices, bougie use, intubator's specialty, and ED visit year with accounting for patients clustering within the ED.

Results

Of 7,349 eligible patients, 272 (4%) underwent tracheal intubation for airway obstruction. Overall, 74% of patients had first-pass success and 16% had intubation-related adverse events. The airway obstruction group had a lower first-pass success rate (63% vs. 74%; unadjusted odds ratio [OR], 0.63; 95% CI, 0.49-0.80), compared to the non-airway obstruction group. This association remained significant in the multivariable analysis (adjusted OR 0.60, 95%CI 0.46-0.80). The airway obstruction group also had a significantly higher risk of adverse events (28% vs. 16%; unadjusted OR, 1.93; 95% CI, 1.48-2.56, adjusted OR, 1.70; 95% CI, 1.27-2.29). In the sensitivity analysis using multiple imputation, the results remained consistent with the main results: the airway obstruction group had a significantly lower first-pass success rate (adjusted OR, 0.60; 95% CI, 0.48-0.76).

Conclusion

Based on these multicenter prospective data, airway obstruction was associated with a significantly lower first-pass success rate and a higher intubation-related adverse event rate in the ED.

Airway registries in primarily adult, emergent endotracheal intubation: a scoping review

BACKGROUND

Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized.

METHODS

A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review.

RESULTS

Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period.

CONCLUSIONS

Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.

Difficult Laryngoscopy Prediction Score for Intubation in Emergency Departments: A Retrospective Cohort Study

Objective

Difficult laryngoscopy is associated with difficult intubation, an increasing number of endotracheal intubation attempts, and adverse events. Clinical prediction of difficult airways in an emergency setting was limited in sensitivity and specificity. This study developed a new model for predicting difficult laryngoscopy in the emergency department.

Methods

This retrospective cohort study was conducted using an exploratory model at the Emergency Medicine of Ramathibodi Hospital. The study was conducted from June 2018 to July 2020. The eligibility criteria were an age of ≥15 years who undergo intubation in the emergency department. Difficult laryngoscopy was defined as a Cormack-Lehane grade 3 and above. The predictive model and score were developed by multivariable logistic regression analysis.

Results

A total of 617 patients met the eligibility criteria; 83 (13.45%) had difficult laryngoscopy. Five independent factors were predictive of difficult laryngoscopy. Significant factors were M: limited mouth opening, O: presence of obstructed airway, N: poor neck mobility, T: large tongue, and H: short hypo-mental distance. The difficult laryngoscopy score had an accuracy of 89%. A score of >4 increased the likelihood ratio of difficult laryngoscopy by 7.62 times.

Conclusion

The MONTH Difficult Laryngoscopy Score of >4 was associated with difficult laryngoscopy.

Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department

STUDY OBJECTIVES

Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED).

METHODS

This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation.

RESULTS

A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05).

CONCLUSIONS

In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.

Machine Learning Approaches for Predicting Difficult Airway and First-Pass Success in the Emergency Department: Multicenter Prospective Observational Study

Background

There is still room for improvement in the modified LEMON (look, evaluate, Mallampati, obstruction, neck mobility) criteria for difficult airway prediction and no prediction tool for first-pass success in the emergency department (ED).

Objective

We applied modern machine learning approaches to predict difficult airways and first-pass success.

Methods

In a multicenter prospective study that enrolled consecutive patients who underwent tracheal intubation in 13 EDs, we developed 7 machine learning models (eg, random forest model) using routinely collected data (eg, demographics, initial airway assessment). The outcomes were difficult airway and first-pass success. Model performance was evaluated using c-statistics, calibration slopes, and association measures (eg, sensitivity) in the test set (randomly selected 20% of the data). Their performance was compared with the modified LEMON criteria for difficult airway success and a logistic regression model for first-pass success.

Results

Of 10,741 patients who underwent intubation, 543 patients (5.1%) had a difficult airway, and 7690 patients (71.6%) had first-pass success. In predicting a difficult airway, machine learning models—except for k-point nearest neighbor and multilayer perceptron—had higher discrimination ability than the modified LEMON criteria (all, P≤.001). For example, the ensemble method had the highest c-statistic (0.74 vs 0.62 with the modified LEMON criteria; P<.001). Machine learning models—except k-point nearest neighbor and random forest models—had higher discrimination ability for first-pass success. In particular, the ensemble model had the highest c-statistic (0.81 vs 0.76 with the reference regression; P<.001).

Conclusions

Machine learning models demonstrated greater ability for predicting difficult airway and first-pass success in the ED.

Rapid Intubation Sequence: 4-Year Experience in an Emergency Department

Background

The rapid intubation sequence is advanced airway management that effectively ensures an adequate supply of oxygen in critically ill patients. The medical personnel in the emergency department performed this procedure.

Objective

To describe the main characteristics of the rapid intubation sequence in an emergency department of a high complexity hospital.

Methods

This is a descriptive, cross-sectional, retrospective study. We included all older patients with a rapid intubation sequence requirement in the emergency department from 2014 to 2017. We used central tendency measures for numerical variables and proportions for categorical variables.

Results

A total of 401 patients were eligible for this analysis. The main indication for intubation was the Glasgow Coma Scale = <8 in 170 patients (42.4%), followed by hypoxemia in 142 patients (35.4%). In 36 patients, at least one complication occurred. RSI was performed in 54.4% by emergency physician. RSI was successful on the first attempt in 90.5%. Only 36 patients (9%) presented complications.

Conclusion

In this study, we found that the rapid intubation sequence was not related to a high proportion of complications. Perhaps, this is attributed to the degree of medical training and the use of emergency department protocols in our hospital.

Effects of prior exposure to a visual airway cognitive aid on decision-making in a simulated airway emergency: A randomised controlled study

BACKGROUND

Decision-making deficits in airway emergencies have led to adverse patient outcomes. A cognitive aid would assist clinicians through critical decision-making steps, preventing key action omission.

OBJECTIVE

We aimed to investigate the effects of a visual airway cognitive aid on decision-making in a simulated airway emergency scenario.

DESIGN

Randomised controlled study.

SETTING

Single-institution, tertiary-level hospital in Toronto, Canada from September 2017 to March 2019.

PARTICIPANTS

Teams consisting of a participant anaesthesia resident, nurse and respiratory therapist were randomised to intervention (N = 20 teams) and control groups (N = 20 teams).

INTERVENTION

Participants in both groups received a 15-min didactic session on crisis resource management which included teamwork communication and the concepts of cognitive aids for the management of nonairway and airway critical events. Only participants in the intervention group were familiarised, oriented and instructed on a visual airway cognitive aid that was developed for this study. Within 1 to 4 weeks after the teaching session, teams were video-recorded managing a simulated 'cannot intubate-cannot oxygenate' scenario with the aid displayed in the simulation centre.

MAIN OUTCOME MEASURES

Decision-making time to perform a front-of-neck access (FONA), airway checklist actions, teamwork performances and a postscenario questionnaire.

RESULTS

Both groups performed similar key airway actions; however, the intervention group took a shorter decision-making time than the control group to perform a FONA after a last action [mean ± SD, 80.9 ± 54.5 vs. 122.2 ± 55.7 s; difference (95% CI) -41.2 (-76.5 to -6.0) s, P = 0.023]. Furthermore, the intervention group used the aid more than the control group (63.0 vs. 28.1%, P < 0.001). Total time of scenario completion, action checklist and teamwork performances scores were similar between groups.

CONCLUSIONS

Prior exposure and teaching of a visual airway cognitive aid improved decision-making time to perform a FONA during a simulated airway emergency.

Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry

BACKGROUND

An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand.

OBJECTIVE

To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR).

METHODS

A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs.

RESULTS

An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%).

CONCLUSIONS

Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.

Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department

Introduction

Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group.

Methods

A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each.

Results

This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation.

Conclusion

Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.

Incidence and Associated Factors of Laryngospasm among Pediatric Patients Who Underwent Surgery under General Anesthesia, in University of Gondar Compressive Specialized Hospital, Northwest Ethiopia, 2019: A Cross-Sectional Study

Introduction

Laryngospasm is a glottis closure due to reflex constriction of the laryngeal muscles. It can occur at any phase of the anesthetic. Different studies have been done previously with various results and indicative values which initiated us to do this research. This study aimed to assess the incidence and associated factors of laryngospasm among pediatric patients who underwent surgery under general anesthesia (GA).

Methods

Institution-based, cross-sectional study was conducted on pediatric patients from February to August, 2019, in University of Gondar Comprehensive Specialized Hospital (UOGCSH). Data were entered and analyzed with SPSS version 20. Variables with P value less than <0.2 in bivariate analysis were fitted into the multivariable logistic regression analysis to identify factors associated with laryngospasm. Both crude and adjusted odds ratio with 95% CI were calculated to show strength of association. In multivariable analysis, P value of <0.05 was considered as statistically significant.

Results

The incidence of laryngospasm among pediatric patients who underwent surgery under GA was 57 (18.4%). Of this, 34 (59.6%), 12 (21.1%), and 11 (19.3%) happened during emergence, maintenance, and induction phases of GA, respectively. In multivariable analysis, airway anomalies (AOR: 14.64, 95% CI: 1.71, 125.04), secretion (AOR: 2.45, 95% CI: 1.19, 5.06), attempts of airway devices (AOR: 2.47, 95% CI: 1.16, 5.22), upper respiratory tract infection (AOR: 2.91, 95% CI: 1.008, 8.41), and inadequate depth of anesthesia (AOR: 7.92, 95% CI: 2.7, 23.22) were significantly associated with incidence of laryngospasm.

Conclusions

Laryngospasm can occur at any phase of the anesthetic. At UOGCSH, the overall rate of laryngospasm was 18.4%, with the vast majority of episodes occurring on emergence. Inadequate depth of anesthesia, URTI, airway anomalies, multiple attempts of airway devices, and oropharyngeal secretion were predictors of laryngospasm. So, added vigilance is needed in patients with URTI, airway anomalies, or those who require multiple attempts at airway device insertion. Prompt clearing of airway secretions and adequate depth of anesthesia may help to prevent laryngospasm. Since the majority of our patients received an IV induction, endotracheal intubation, and maintenance with halothane, caution must be taken in extrapolating these results to other patient populations.

Is Video Laryngoscopy the Optimal Tool for Successful Intubation in a Neonatal Simulation Setting? A Single-Center Experience

Background  Endotracheal intubation is a skill required for resuscitation. Due to various reasons, intubation opportunities are decreasing for health care providers. Objective  To compare the success rate of video laryngoscopy (VL) and direct laryngoscopy (DL) for interprofessional neonatal intubation skills in a simulated setting. Methods  This was a prospective nonrandomized simulation crossover trial. Twenty-six participants were divided into three groups based on their frequency of intubation. Group 1 included pediatric residents; group 2 respiratory therapists and transport nurses; and group 3 neonatal nurse practitioners and physicians working in neonatology. We compared intubation success rate, intubation time, and laryngoscope preference. Results  Success rates were 100% for both DL and VL in groups 1 and 2, and 88.9% for DL and 100% for VL in group 3. Median intubation times for DL and VL were 22 seconds (interquartile range [IQR] 14.3-22.8 seconds) and 12.5 seconds (IQR 10.3-38.8 seconds) in group 1 ( p  = 0.779); 17 seconds (IQR 8-21 seconds) and 12 seconds (IQR 9-16.5 seconds) in group 2 ( p  = 0.476); and 11 seconds (IQR 7.5-15.5 seconds) and 15 seconds (IQR 11.5-36 seconds) in group 3 ( p  = 0.024). Conclusion  We conclude that novice providers tend to perform better with VL, while more experienced providers perform better with DL. In this era of decreased clinical training opportunities, VL may serve as a useful tool to teach residents and other novice health care providers.

Urgent intubation without neuromuscular blocking agents and the risk of tracheostomy

Neuromuscular blocking agents play a significant role in improving the success rate for urgent intubation, although there is limited evidence about the effect on subsequent outcomes, such as the incidence of tracheostomy. In this retrospective cohort study, we aimed to examine the association between avoidance of neuromuscular blocking agents for urgent tracheal intubation and incidence of tracheostomy among patients in the intensive care unit (ICU). The setting of this study was an eight-bed ICU at a tertiary-care hospital in Okayama, Japan. We included patients who underwent urgent tracheal intubation at the emergency department or the ICU and were admitted to the ICU between April 2013 and November 2017. We extracted data on methods and medications of intubation, predictors for difficult intubation, Cormack-Lehane grade, patient demographics, primary diagnoses, reintubation. We estimated odds ratios and their 95% confidence intervals for elective tracheostomy during the ICU stay using logistic regression models. Of 411 patients, 46 patients underwent intubation without neuromuscular blocking agents and 61 patients underwent tracheostomy. After adjusting for potential confounders, patients who avoided neuromuscular blocking agents had more than double the odds of tracheostomy (odds ratio 2.59, 95% confidence interval 1.06-6.34, p value = 0.04). When stratifying the subjects by risk status for tracheostomy, the association was more pronounced in high-risk group, while we observed less significant association in the low-risk group. Avoidance of neuromuscular blocking agents for urgent intubation increases the risk of tracheostomy among emergency patients, especially those who have a higher risk for tracheostomy.

Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department

To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study-the second Japanese Emergency Airway Network (JEAN-2) Study-from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31-0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28-0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31-0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.

Factors associated with successful rescue intubation attempts in the emergency department: an analysis of multicenter prospective observational study in Japan

Aim

It remains unclear whether physicians should change intubation approaches after the failed first attempt. We aimed to determine the rescue intervention approaches associated with a higher success rate at the second attempt in the emergency department (ED).

Methods

We analyzed the data from a prospective, multicenter, observational study – the second Japanese Emergency Airway Network Study. The current analysis included all patients who underwent emergency intubation from February 2012 through November 2017. We defined a rescue intubation attempt as a second intubation attempt with any change in intubation approaches (i.e., change in methods, devices, or intubators) from the failed first attempt. The outcome measure was second‐attempt success.

Results

Of 2,710 patients with a failed first attempt, 43% underwent a second intubation attempt with changes in intubation approach (i.e., rescue intubation). Rescue intubation attempts were associated with a higher second‐attempt success rate compared to non‐rescue intubation attempts (adjusted odds ratio [OR], 1.78; 95% confidence interval [CI], 1.50–2.12). The rescue intubation approaches associated with a higher second‐attempt success were changes from non‐rapid sequence intubation (RSI) to RSI (adjusted OR, 2.04; 95% CI, 1.12–3.75), from non‐emergency medicine (EM) residents to EM residents (adjusted OR, 2.02; 95% CI, 1.44–2.82), and from non‐EM attending physicians to EM attending physicians (adjusted OR, 2.82; 95% CI, 2.14–3.71).

Conclusions

In this large multicenter study, rescue interventions were associated with a higher second‐attempt success rate. The data also support the use of RSI and backup by EM residents or EM attending physicians to improve the airway management performance after a failed attempt in the ED.

Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study

OBJECTIVES

Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization.

METHODS

We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED.

RESULTS

Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1-0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24-2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93-0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04-0.56, p < 0.01) were independent prognostic variables.

CONCLUSIONS

We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization.

Advancing emergency airway management practice and research

Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

Augmented reality glasses improve adherence to evidence-based intubation practice

Background: The risk of failing or delaying endotracheal intubation in critically ill patients has commonly been associated with inadequate procedure preparation. Clinicians and trainees in simulation courses for tracheal intubation are encouraged to recall the steps of how to intubate in order to mitigate the risk of a failed intubation. The purpose of this study was to assess the effectiveness of using optical head mounted display augmented reality (AR) glasses as an assistance tool to perform intubation simulation procedure. Methods: A total of 32 subjects with a mean age of 30±7.8, AR (n₁=15) vs non-augmented reality(non-AR) (n₂=17). The majority were males (n=22, 68.7%). Subjects were randomly assigned into two groups: the AR group and the non-AR group. Both groups reviewed a video on how to intubate following the New England Journal of Medicine (NEJM) intubation guidelines. The AR group had to intubate using the AR glasses head mount display compared to the non-AR where they performed regular intubation. Results: The AR group took longer median (min, max) time (seconds) to ventilate than the non-AR group (280 (130,740) vs 205 (100,390); η ² =1.0, p=0.005, respectively). Similarly, there was a higher percent adherence of NEJM intubation checklist (100% in the AR group vs 82.4% in the non-AR group; η²=1.8, p<0.001). Conclusion: The AR glasses showed promise in assisting different health care professionals on endotracheal intubation simulation. Participants in the AR group took a longer time to ventilate but scored 100% in the developed checklist that followed the NEJM protocol. This finding shows that the AR technology can be used in a simulation setting and requires further study before clinical use.

The incidence of post-intubation hypertension and association with repeated intubation attempts in the emergency department

BACKGROUND

Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension.

METHODS

This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs.

RESULTS

Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11-2.18; adjusted P = 0.01).

CONCLUSIONS

We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.

Comparison of video laryngoscopy versus direct laryngoscopy for intubation in emergency department patients with cardiac arrest: A multicentre study

AIM

To compare the tracheal intubation performance between video laryngoscopy (VL) and direct laryngoscopy (DL) in patients with cardiac arrest in the ED.

METHODS

This is an analysis of the data from a prospective, multicentre study of 15 EDs in Japan. We included consecutive adult patients with cardiac arrest who underwent intubation with VL or DL from 2012 through 2016. The primary outcome was first-attempt success. The secondary outcomes were glottic visualisation assessed with Cormack grade (1 vs. 2-4) and occurrence of oesophageal intubation. To examine the between-device difference in outcome risks, we analysed the whole data and 1:1 propensity score matched data.

RESULTS

Among 9694 patients who underwent intubation in the EDs, 3360 cardiac arrests (35%) were included in the analysis (90% were non-traumatic cardiac arrests). The first-attempt success rate was higher in the VL group compared to those in the DL (78% vs 70%; unadjusted OR 1.61 [95%CI 1.26-2.06] P < 0.001). This association remained significant after adjusting for six potential confounders and within-ED clustering (adjusted OR 1.33 [95%CI 1.03-1.73] P = 0.03). VL use was also associated with a better glottic visualisation (adjusted OR 3.84 [95%CI 2.81-5.26] P < 0.001) and lower rate of oesophageal intubation (adjusted OR 0.45 [95%CI 0.24-0.85] P = 0.01) compared to DL. These results were consistent in the propensity score matched analysis.

CONCLUSIONS

Based on large multicentre prospective data of ED patients with cardiac arrest, the use of VL was associated with a higher first-attempt success rate compared to DL, with a better glottic visualisation and lower oesophageal intubation rate.

Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy

OBJECTIVE

The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts.

METHODS

This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program.

RESULTS

After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], -4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, -.41 to -.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19).

CONCLUSION

Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.

[Systematic analysis of airway registries in emergency medicine]

BACKGROUND

A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications.

METHODS

A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care.

RESULTS

A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%.

CONCLUSION

This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.

Associations of obesity with tracheal intubation success on first attempt and adverse events in the emergency department: An analysis of the multicenter prospective observational study in Japan

Obesity is deemed to increase the risk of difficult tracheal intubation. However, there is a dearth of research that examines the relationship of obesity with intubation success and adverse events in the emergency department (ED). We analyzed the data from a prospective, observational, multicenter study—the Japanese Emergency Airway Network (JEAN) 2 study from 2012 through 2016. We included all adults (aged ≥18 years) who underwent tracheal intubation in the ED. Patients were categorized into three groups according to their body mass index (BMI): lean (<25.0 kg/m²), overweight (25.0–29.9 kg/m²), and obesity (≥30.0 kg/m²). Outcomes of interest were intubation success on the first attempt and intubation-related adverse events. Of 6,889 patients who are eligible for the analysis, 5,370 patients (77%) were lean, 1,177 (17%) were overweight, and 342 (4%) were obese. Compared to the lean patients, the intubation success rates were significantly lower in the overweight and obese patients (70.9% in lean, 66.4% in overweight, and 59.3% in obese patients; P<0.001). In the multivariable analysis, compared to the lean patients, overweight (adjusted odds ratio [OR], 0.85; 95%CI, 0.74–0.98) and obese (adjusted OR, 0.62; 95%CI, 0.49–0.79) patients had a significantly lower success rate on the first attempt. Additionally, obesity was significantly associated with a higher risk of adverse events (adjusted OR, 1.62; 95%CI, 1.23–2.13). Based on the data from a multicenter prospectively study, obesity was associated with a lower success rate on the first intubation attempt and a higher risk of adverse event in the ED.

Comparison of Xenon with LED illuminant in difficult and inhalation injury airway scenario: A randomized crossover manikin study

PURPOSE

The purpose of this study was to compare the effectiveness of a Xenon halogen with a light-emitting diode (LED) laryngoscope light handle in a difficult airway scenario, as well as in an inhalation injury airway scenario that combines a difficult airway and a limited view.

METHODS

We recruited forty-two anesthetists into a randomized crossover trial. Each performed tracheal intubation (TI) with a Xenon halogen and a LED light handle in the two manikin scenarios. The primary endpoint was the "time to intubate". Other endpoints were the "time to vocal cords", the "time to ventilate", the rate of successful intubation, the number of intubation attempts, the Cormack-Lehane score, the number of optimization maneuvers, the number of audible dental click sounds indicating dental damage and subjective impressions.

RESULTS

In the difficult airway scenario, no significant differences in the recorded intubation times were observed. In the inhalation injury airway scenario, the intubation times were significantly shorter using the LED light handle. Regarding the subjective values, the LED illuminant enabled a significant better view and illumination of the oropharyngeal space and the vocal cords, in both manikin scenarios.

CONCLUSION

The LED laryngoscope light handle did not affect the recorded intubation times in the simulated difficult airway scenario, but provided significant advantages in the inhalation injury airway scenario that combines a difficult airway with a limited view caused by a sooted pharynx. We therefore hypothesize, that the LED illuminant might be beneficial in the airway management of burn patients with severe inhalation injury.

Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016

OBJECTIVES

Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan.

METHODS

We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016.

RESULTS

We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (P_trend=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (P_trend<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (P_trend<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (P_trend=0.02). By contrast, the rate of adverse events did not change significantly over time (P_trend=0.06).

CONCLUSION

By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.

Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study

BACKGROUND

Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance.

INTRODUCTION

We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network.

MATERIALS AND METHODS

Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics.

RESULTS

Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia.

DISCUSSION

The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success.

CONCLUSIONS

Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.

Factors Associated with First-Pass Success in Pediatric Intubation in the Emergency Department

Introduction

The objective of this study was to investigate the factors associated with first-pass success in pediatric intubation in the emergency department (ED).

Methods

We analyzed the data from two multicenter prospective studies of ED intubation in 17 EDs between April 2010 and September 2014. The studies prospectively measured patient’s age, sex, principal indication for intubation, methods (e.g., rapid sequence intubation [RSI]), devices, and intubator’s level of training and specialty. To evaluate independent predictors of first-pass success, we fit logistic regression model with generalized estimating equations. In the sensitivity analysis, we repeated the analysis in children <10 years.

Results

A total of 293 children aged ≤18 years who underwent ED intubation were eligible for the analysis. The overall first-pass success rate was 60% (95%CI [54%–66%]). In the multivariable model, age ≥10 years (adjusted odds ratio [aOR], 2.45; 95% CI [1.23–4.87]), use of RSI (aOR, 2.17; 95% CI [1.31–3.57]), and intubation attempt by an emergency physician (aOR, 3.21; 95% CI [1.78–5.83]) were significantly associated with a higher chance of first-pass success. Likewise, in the sensitivity analysis, the use of RSI (aOR, 3.05; 95% CI [1.63–5.70]), and intubation attempt by an emergency physician (aOR, 4.08; 95% CI [1.92–8.63]) were significantly associated with a higher chance of first-pass success.

Conclusion

Based on two large multicenter prospective studies of ED airway management, we found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher chance of first-pass success in children. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.

Prospective validation of the modified LEMON criteria to predict difficult intubation in the ED

BACKGROUND

Evidence to predict difficult intubation remains scarce in the emergency department (ED) setting. A previously defined clinical decision rule, the modified LEMON criteria, may provide a reliable and reproducible means of identifying difficult intubations. We aimed to prospectively evaluate the external validity of the modified LEMON criteria in the EDs.

METHODS

We conducted a 13-center prospective observational study, the second Japanese Emergency Airway Network study. We prospectively collected data on all patients undergoing intubations in the ED from February 2012 through September 2014. The primary outcomes were sensitivity, specificity, and predictive values of the modified LEMON criteria for predicting difficult intubation (≥2 attempts by emergency attending physicians or anesthesiologists).

RESULTS

The database recorded a total of 4034 encounters (capture rate, 96%) in the EDs. Of these, 3313 patients (84%) underwent the intubation attempt with a direct laryngoscope and 610 patients (16%) with a video laryngoscope. The proportion of difficult intubation was 5.4% (95% confidence interval [CI], 4.7%-6.2%) in the direct laryngoscope group and 7.4% (95% CI, 5.6%-9.7%) in the video laryngoscope group. The sensitivity was 85.7% (95% CI, 79.3%-90.4%) with direct laryngoscope and 94.9% (95% CI, 83.5%-98.6%) with video laryngoscope. The specificity was 47.6% (95% CI, 47.2%-47.9%) and 40.3% (95% CI, 39.4%-40.6%), respectively. The negative predictive value was 98.2% (95% CI, 97.5%-98.8%) and 99.0% (95% CI, 96.6%-99.7%), respectively.

CONCLUSIONS

In this multicenter prospective study, we found a high sensitivity and a negative predictive value of the modified LEMON criteria for predicting difficult intubation. The modified LEMON might assist ED providers in better identifying difficult intubations.

Impact of Video Laryngoscopy on Advanced Airway Management by Critical Care Transport Paramedics and Nurses Using the CMAC Pocket Monitor

Accurate endotracheal intubation for patients in extremis or at risk of physiologic decompensation is the gold standard for emergency medicine. Field intubation is a complex process and time to intubation, number of attempts, and hypoxia have all been shown to correlate with increases in morbidity and mortality. Expanding laryngoscope technology which incorporates active video, in addition to direct laryngoscopy, offers providers improved and varied tools to employ in management of the advanced airway. Over a nine-year period a helicopter emergency medical services team, comprised of a flight paramedic and flight nurse, intended to intubate 790 patients. Comparative data analysis was performed and demonstrated that the introduction of the CMAC video laryngoscope improved nearly every measure of success in airway management. Overall intubation success increased from 94.9% to 99.0%, first pass success rates increased from 75.4% to 94.9%, combined first and second pass success rates increased from 89.2% to 97.4%, and mean number of intubation attempts decreased from 1.33 to 1.08.