Implementation and Outcomes of a Difficult Airway Code Team Composed of Anesthesiologists in a Korean Tertiary Hospital: A Retrospective Analysis of a Prospective Registry

BACKGROUND

In 2017, we established an airway call (AC) team composed of anesthesiologists to improve emergency airway management outside the operating room. In this retrospective analysis of prospectively collected data from the airway registry, we describe the characteristics of patients attended to and practices by the AC team during the first 4 years of implementation.

METHODS

All AC team activations in which an airway intervention was performed by the AC team between June 2017 and May 2021 were analyzed.

RESULTS

In all, 359 events were analyzed. Activation was more common outside of working hours (62.1%) and from the intensive care unit (85.0%); 36.2% of AC activations were due to known or anticipated difficult airway, most commonly because of acquired airway anomalies (n = 49), followed by airway edema or bleeding (n = 32) and very young age (≤ 1 years; n = 30). In 71.3% of the cases, successful intubation was performed by the AC team at the first attempt. However, three or more attempts were performed in 33 cases. The most common device used for successful intubation was the videolaryngoscope (59.7%). Tracheal intubation by the AC team failed in nine patients, who then required surgical airway insertion by otolaryngologists. However, there were no airway-related deaths.

CONCLUSIONS

When coupled with appropriate assistance from an otolaryngologist AC system, an AC team composed of anesthesiologists could be an efficient way to provide safe airway management outside the operating room.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0006643.

Management of traumatic laryngotracheal separation: Case series and review

Laryngotracheal separation injuries are a rare but serious condition, as survival from such injuries relies on proper airway management. As a result, recommendations for management have been based on small case reports and expert opinion. We reviewed our last 10 years of experience with managing laryngotracheal separation injuries and identified 6 cases for chart review. Awake tracheostomy or videolaryngobronchoscopy was used in each case to initially obtain the airway. Surgical repair was then performed immediately using nonabsorbable monofilament suture or a miniplate, and a low fenestrated tracheostomy was placed. All of our patients who followed up were decannulated, eating regular diets, and had satisfactory voice quality at 3 months postoperatively. Review of the literature revealed that, while management strategies have changed over time, treatment still varies widely depending on surgeon preference and the details of each injury. Outcomes from our series suggest that our described techniques and management strategies can be used with good outcomes. We believe that this is due to securing a safe airway, early surgical intervention with no unnecessary tissue dissection, effective reconstruction of the airway, and the fenestrated tracheostomy technique.

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic

BACKGROUND

This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).

METHODS AND FINDINGS

Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).

CONCLUSION

There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial

BACKGROUND

Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy.

METHODS

In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432.

FINDINGS

Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028).

INTERPRETATION

Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications.

FUNDING

Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

[Airway management in preclinical emergency anesthesia with respect to specialty and education]

BACKGROUND AND OBJECTIVE

Difficult airway management is a key skill in preclinical emergency medicine. A lower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system.

MATERIAL AND METHODS

In a retrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared.

RESULTS

The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed a reduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased.

CONCLUSION

The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.

Airway physical examination tests for detection of difficult airway management in apparently normal adult patients

BACKGROUND

The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear.

OBJECTIVES

The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation.

SEARCH METHODS

We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals, conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results.

SELECTION CRITERIA

We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard. Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target condition was difficult airway, with one of the following reference standards: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation.

DATA COLLECTION AND ANALYSIS

We performed screening and selection of the studies, data extraction and assessment of methodological quality (using QUADAS-2) independently and in duplicate. We designed a Microsoft Access database for data collection and used Review Manager 5 and R for data analysis. For each index test and each reference standard, we assessed sensitivity and specificity. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where possible, we performed meta-analyses to calculate pooled estimates and compare test accuracy indirectly using bivariate models. We investigated heterogeneity and performed sensitivity analyses.

MAIN RESULTS

We included 133 (127 cohort type and 6 case-control) studies involving 844,206 participants. We evaluated a total of seven different prespecified index tests in the 133 studies, as well as 69 non-prespecified, and 32 combinations. For the prespecified index tests, we found six studies for the Mallampati test, 105 for the modified Mallampati test, six for the Wilson risk score, 52 for thyromental distance, 18 for sternomental distance, 34 for the mouth opening test, and 30 for the upper lip bite test. Difficult face mask ventilation was the reference standard in seven studies, difficult laryngoscopy in 92 studies, difficult tracheal intubation in 50 studies, and failed intubation in two studies. Across all studies, we judged the risk of bias to be variable for the different domains; we mostly observed low risk of bias for patient selection, flow and timing, and unclear risk of bias for reference standard and index test. Applicability concerns were generally low for all domains. For difficult laryngoscopy, the summary sensitivity ranged from 0.22 (95% confidence interval (CI) 0.13 to 0.33; mouth opening test) to 0.67 (95% CI 0.45 to 0.83; upper lip bite test) and the summary specificity ranged from 0.80 (95% CI 0.74 to 0.85; modified Mallampati test) to 0.95 (95% CI 0.88 to 0.98; Wilson risk score). The upper lip bite test for diagnosing difficult laryngoscopy provided the highest sensitivity compared to the other tests (P < 0.001). For difficult tracheal intubation, summary sensitivity ranged from 0.24 (95% CI 0.12 to 0.43; thyromental distance) to 0.51 (95% CI 0.40 to 0.61; modified Mallampati test) and the summary specificity ranged from 0.87 (95% CI 0.82 to 0.91; modified Mallampati test) to 0.93 (0.87 to 0.96; mouth opening test). The modified Mallampati test had the highest sensitivity for diagnosing difficult tracheal intubation compared to the other tests (P < 0.001). For difficult face mask ventilation, we could only estimate summary sensitivity (0.17, 95% CI 0.06 to 0.39) and specificity (0.90, 95% CI 0.81 to 0.95) for the modified Mallampati test.

AUTHORS' CONCLUSIONS

Bedside airway examination tests, for assessing the physical status of the airway in adults with no apparent anatomical airway abnormalities, are designed as screening tests. Screening tests are expected to have high sensitivities. We found that all investigated index tests had relatively low sensitivities with high variability. In contrast, specificities were consistently and markedly higher than sensitivities across all tests. The standard bedside airway examination tests should be interpreted with caution, as they do not appear to be good screening tests. Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties. Given the paucity of available data, future research is needed to develop tests with high sensitivities to make them useful, and to consider their use for screening difficult face mask ventilation and failed intubation. The 27 studies in 'Studies awaiting classification' may alter the conclusions of the review, once we have assessed them.

Cricothyrotomy in Helicopter Emergency Medical Service Transport

OBJECTIVE

Airway management is a requisite skill set for helicopter emergency medical service (HEMS) providers. Cricothyrotomy is a potentially lifesaving skill that is used when other airway maneuvers fail. The authors reviewed all transports by a helicopter program in which cricothyrotomy was performed to assess the frequency, success, and technique.

METHODS

This was a retrospective chart review of air medical patient records from an electronic medical record system over a 112-month period.

RESULTS

During the study period, 22,434 patients were transported, 13 (.057%) of whom underwent cricothyrotomy. The typical patient was a male trauma victim with a mean Glasgow Coma Score of 5 transported from an accident scene with a mean age of 34.3 years. Six (46%) of the patients were alive at 24 hours. All patients (13/100%) received attempted endotracheal intubation; the mean number of attempts per patient was 2. The success rate was 100% with all patients ventilated via cricothyrotomy.

CONCLUSION

This study shows cricothyrotomy is a rarely performed skill but that HEMS providers are able to successfully learn the skill with proper training and oversight.

Postoperative fasting after general anaesthesia: A survey of French anaesthesiology practices

BACKGROUND

Preoperative fasting is well codified worldwide. In contrast, the literature on the postoperative fasting (POF) is scarce, leading to potentially wide discrepancies among anaesthesiology practices. This survey assessed French POF practices.

METHODS

From March 2013 to January 2014, a survey was conducted among anaesthesiologists, members of the French Society of Anaesthesiology and Intensive Care Medicine (SFAR). The POF durations of either fluid or solid food intake was assessed according to airway management procedures (endotracheal intubation [EI] or laryngeal mask [LMA]) and age of the patients (adult or paediatric).

RESULTS

Seven hundred and fifty-four surveys were returned (67% from public hospital practitioners and 33% from private hospital and clinic practitioners). The majority of anaesthesiologists allowed fluid intake 2h after EI and immediately after discharge from PACU following LMA. For solid food resumption, it was 2h for children and 4h for adults after EI and 2h for both children and adults after LMA. Regardless of the airway management procedures, fasting was permitted immediately after PACU discharge more frequently in public than in private hospitals (36% vs. 33%, P<0.05). Four hours after the end of surgery, the rate was significantly higher in private than in public hospitals (93% vs. 89 %, P<0.001).

CONCLUSIONS

All in all, POF lasted less than 4hours after surgery regardless of airway management. They were shorter with regard to fluid intake, paediatric patients and LMA in comparison with solid food, adult patients and EI respectively.

Supraglottic jet oxygenation and ventilation-assisted fibre-optic bronchoscope intubation in patients with difficult airways

A difficult airway may lead to hypoxia and brain damage. The WEI Nasal Jet Tube (WNJ) is a new nasal pharyngeal tube that applies supraglottic jet oxygenation and ventilation (SJOV) for patients during tracheal intubation without the need for mask ventilation. We evaluated the effectiveness and safety of SJOV-assisted fibre-optic bronchoscopy (FOB) using the WNJ in the management of difficult tracheal intubations. A total of 50 adult patients with Cormack-Lehane grade ≥3 and general anesthesia with tracheal intubation were randomly assigned to either the laryngeal mask airway (LMA) or WNJ groups. The primary outcome was the percentage of patients with SpO₂ values lower than 94 % during intubation. The proportion of successful intubations, total time of intubation, and associated complications were also recorded. The percentage of patients with SpO₂ values lower than 94 % during intubation was significantly higher in the LMA group (25 % in the LMA vs. 0 % in the WNJ, P = 0.01). Although there were no statistically significant differences in the total success rates of intubation, the first-attempt success rate was significantly higher in the WNJ group (100 vs. 79.2 %, P = 0.02). The total time required for intubation with the WNJ was shorter than that of the LMA (73.4 vs. 99.5 s, P < 0.001), although the duration of fibre-optic intubation was similar. The incidence of complications was similar between the two groups. SJOV-assisted FOB using the WNJ improved oxygenation and successful tracheal intubation in the management of difficult airways. This technique can be used as an alternative approach to improve success and minimize hypoxia during difficult airway management.

Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use

BACKGROUND

Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT).

METHODS

Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed.

RESULTS

Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%.

CONCLUSION

An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase thepotential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Out-of-hospital pediatric airway management in the United States

OBJECTIVE

The objective of this study was to characterize pediatric out-of-hospital airway management interventions, success rates, and complications in the United States using the 2012 National Emergency Medical Services Information System (NEMSIS) dataset.

METHODS

In 2012, NEMSIS collected data from Emergency Medical Services (EMS) encounters in 40 states. We included all patients less than 18 years of age and identified all patients who had airway interventions including endotracheal intubation (ETI), bag-valve-mask ventilation (BVM), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) and alternate airways (Combitube, King LT, Laryngeal Mask Airway (LMA), esophageal obturator airway, and cricothyroidotomy). Success and complication rates were analyzed and compared across pediatric age groups, by race, ethnicity, clinical condition, and geographic region.

RESULTS

We identified a total of 949,301 pediatric patient care events in the NEMSIS 2012 dataset. 4.5% had airway management procedures (42,936 events). Invasive airway management or ventilation (ETI, cricothyroidotomy, alternate airway, CPAP/BiPAP, BVM and other ventilation) took place in 1.5% of patient care events (14,107). Of those who had invasive airway management, 29.9% were less than 1 year of age, 58.1% were male, 42.3% were white, and 83.6% were in urban areas. ETI occurred in 3124 of patient care events (329 per 100,000; 95% CI 318-341). Overall success of ETI was 81.1% (95% CI 79.7-82.6). Lower success was noted in patients with cardiac arrest (75.5%, 95% CI 72.6-78.3) and those aged 1-12 months (72.1%, 95% CI 68.3-75.6).

CONCLUSIONS

Out-of-hospital pediatric advanced airway procedures were infrequently performed. Success rates are lowest in patients aged 1-12 months.

Gunshot wounds to the face: emergency interventions and outcomes

BACKGROUND

Gunshot wounds to the face (GSWF) may produce life-threatening injuries. Our objective is to describe outcomes of and factors related to interventions for urgent airway control (UAC) and urgent bleeding control (UBC) as well as to analyze complications associated with GSWF.

METHODS

This was a retrospective study of 155 GSWF patients who were admitted to two Level 1 academic trauma centers over an 11-year period. Demographic details, injuries sustained, interventions performed, and timing of the interventions were recorded. Morbidity and mortality data were evaluated.

RESULTS

Overall, 115 (74 %) patients suffered isolated GSWF, and none died. Of the 90 (58 %) patients requiring UAC, only three had a cricothyroidotomy. Of the 41 (26 %) patients requiring UBC, only four had angiographic embolization. Intraoral involvement and extrafacial injuries were associated with both UAC and UBC. Overall, 75 patients (48 %) required operations on the bones, eyes, or both. Complications developed in 14 and were treated successfully.

CONCLUSIONS

UAC and UBC are required frequently after GSWF and are associated with intraoral involvement and injuries beyond the face. Simple methods, such as orotracheal intubation and packing, are typically sufficient for successful management. About half of the patients need further surgery, with infrequent morbidity.

Airway management of adult patients without trauma in an ED led by internists

BACKGROUND

Airway management is a key competence in emergency medicine. Patients heavily differ from those in the operating room. They are acutely ill by definition and usually not fasting. Evaluation of risk factors is often impossible. Current literature primarily originates from countries where emergency medicine is an independent specialty. We evaluated intubations in a high-volume emergency department run by internists and comprising its own distinctive intensive care unit.

METHODS

In this prospective, noncontrolled, observational study, we continuously documented all intubations performed at the emergency department. We analyzed demographic, medical, and staff-related factors predicting difficulties during intubation using logistic regression models.

RESULTS

For 73 months, 660 cases were included, 69 (10.5%) of them were without any induction therapy. Two hundred fifty-two (38.2%) patients were female, and their mean age was 59 ± 17 years. Three hundred four (49.9%) had an initial Glasgow Coma Scale of 3. Leading indications were respiratory insufficiency (n = 246; 37.3%), resuscitation (n = 172; 26.1%), and intracranial hemorrhage (n = 75; 11.4%). First attempt was successful in 465 cases (75.1%); alternative airway devices were used in 22 cases (3.3%). Time from the first intubation attempt to a validated airway was 1 minute (interquartile range, 0-2 minutes). Physicians' experience and anatomical risk factors were associated with failure at the first attempt, prolonged intubation, and the need for alternative devices.

CONCLUSIONS

Airway management at the emergency department possesses a high potential of failure. Experience seems to be the key to success.

The effect of body mass index on intubation success rates and complications during emergency airway management

We evaluated the effect of body mass index (BMI) on intubation success rates and complications during emergency airway management. We retrospectively analyzed an airway registry at an academic medical center. The primary outcomes were the incidence of difficult intubation and complication rates, stratified by BMI. We captured 1,075 (98 %, 1,075/1,102; 95 % CI 97-99) intubations. Four hundred twenty-six patients (40 %) had a normal BMI, 289 (27 %) were overweight, 261 (25 %) were obese, and 77 (7 %) were morbidly obese. In a multivariate analysis, obesity (OR 1.90; 95 % CI 1.04-3.45; p = 0.04), but not morbid obesity (OR 2.18; 95 % CI 0.95-4.99; p = 0.07), predicted difficult intubation. BMI was not predictive of post-intubation complications. Airway management in the morbidly obese differed when compared with lean patients, with less use of rapid sequence intubation and increased use of fiberoptic bronchoscopy in the former. During emergency airway management, difficult intubation is more common in obese patients, and morbidly obese patients are more commonly treated as potentially difficult airways.

Analysis of prehospital endotracheal intubation performed by emergency physicians: retrospective survey of a single emergency medical center in Japan

OBJECTIVES

Advanced airway management in the prehospital setting is a serious issue in Japan because emergency medical technicians are not authorized to perform such management, whereas physicians-who are authorized to perform advanced airway management-do not usually engage in prehospital emergency medical activity. The purpose of this investigation was to investigate the success rate for endotracheal intubation (ETI) procedures and other methods of airway management employed by physicians in the prehospital setting in a single institution, as well as to examine the risk factors associated with difficult or failed endotracheal intubation (D/F ETI).

METHODS

We performed a retrospective survey of patients treated in the prehospital setting by emergency physicians of the Hyogo Emergency Medical Center from 2004 to 2011. Patients were divided into two groups: a cardiopulmonary arrest (CPA) group and a non-CPA group. Data on cases of D/F ETI were obtained, and risk factors for these two groups were identified using univariate and statistical analysis.

RESULTS

During the investigation period, ETI was attempted in the prehospital setting on 742 eligible patients; in 30 (4.04 %) of these cases, the attempts at ETI proved difficult or failed. Of those 30 patients, 13 patients received a surgical airway (attempts to provide a surgical airway failed in two patients), a blind ETI was performed in four, a video-assisted airway device was used in another four, and esophageal intubation was performed in four patients. Bag-valve ventilation alone was performed in one patient. The incidence of D/F ETI was higher in the non-CPA group than in the CPA group (6.27 vs. 2.63 %: p < 0.05). Facial or neck injury was a risk factor for D/F ETI in the prehospital setting in the CPA group (odds ratio 7.855; 95 % CI 1.754-36.293: p = 0.042). On the other hand, no risk factors for D/F ETI in the prehospital setting in the non-CPA group were identified.

CONCLUSION

The success rate for ETI performed by physicians in the prehospital setting at a single emergency medical center was high, and the incidence of D/F ETI was 4.31 %. The success rate for ETI in the CPA group was greater than that in the non-CPA group.

Pneumonia in the elderly hospitalized in the Department of Veteran Affairs Health Care System

Pneumonia is a major cause of hospital admissions and deaths worldwide. Our aim was to examine the trends in admissions for pneumonia in the Department of Veterans Affairs (VA). We examined data for the fiscal years 2002 through 2007 on patients aged 65 years and older hospitalized with pneumonia by using VA administrative databases. The numbers of hospital admissions for pneumonia were relatively stable during this period. However, length of hospital stay and 30- and 90-day mortality decreased during this period. The proportion of patients admitted to the intensive care unit remained relatively constant, but fewer received mechanical ventilation; there was substantial increase in noninvasive ventilation. In the VA, pneumonia-related admissions are being managed more effectively even as the overall number of admissions remains stable.

Advanced airway management does not improve outcome of out-of-hospital cardiac arrest

BACKGROUND

The goal of out-of-hospital endotracheal intubation (ETI) is to reduce mortality and morbidity for patients with airway and ventilatory compromise. Yet several studies, mostly involving trauma patients, have demonstrated similar or worse neurologic outcomes and survival-to-hospital discharge rates after out-of-hospital ETI. To date, there is no study comparing out-of-hospital ETI to bag-valve-mask (BVM) ventilation for the outcome of survival to hospital discharge among nontraumatic adult out-of-hospital cardiac arrest (OOHCA) patients.

OBJECTIVES

The objective was to compare survival to hospital discharge among adult OOHCA patients receiving ETI to those managed with BVM.

METHODS

In this retrospective cohort study, the records of all OOHCA patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The type of field airway provided, age, sex, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether the arrest was witnessed, site of arrest, return of spontaneous circulation (ROSC), survival to hospital admission, comorbid illnesses, and survival to hospital discharge were noted. A univariate odds ratio (OR) was first computed to describe the association between the type of airway and survival to hospital discharge. A multivariable logistic regression analysis was performed, adjusting for rhythm, bystander CPR, and whether the arrest was witnessed.

RESULTS

A cohort of 1,294 arrests was evaluated. A total of 1,027 (79.4%) received ETI, while 131 (10.1%) had BVM, 131 (10.1%) had either a Combitube or an esophageal obturator airway, and five (0.4%) had incomplete prehospital records. Fifty-five of 1,294 (4.3%) survived to hospital discharge; there were no survivors in the Combitube/esophageal obturator airway cohort. Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3-8.9; p<0.0001).

CONCLUSIONS

In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA patients.