Search

The aim of this study was to determine if use of a standardized airway data collection sheet can survey airway management practices in an emergency department. Success rates and trends from the authors' facility have been benchmarked against the National Emergency Airway Registry (NEAR). This study included all patients requiring invasive airway management during a 21-month period (July 1, 2005, through March 31, 2007). An audit form was developed and implemented to collect data on intubations. During the study period, 224 patients required invasive airway control. Of all airways managed by emergency medicine residents, the intubation success rate was 99% (200/203; 95% confidence interval [CI] = 96%-100%), with 3% of those (6/203; 95% CI = 1%-6%) requiring more than 3 attempts; 3 patients (1%; 95% CI = 0%-4%) could not be intubated and required a surgical airway. Use of an airway registry based on the NEAR registry as a benchmark of rates and types of successful intubation allows comparison of airway practices.

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. [ABSTRACT FROM AUTHOR]

Summary: Bougie impingement during tracheal intubation can increases the likelihood of prolonged intubation time, failed intubation and airway trauma. A flexible tip bougie may overcome this problem, which can occur when using a non‐channelled, hyperangulated videolaryngoscope with a standard bougie. This randomised controlled study compared standard and flexible tip bougies using a non‐channelled videolaryngoscope (C‐MAC® D‐blade) in 160 patients. The primary outcome measure was the modified intubation difficulty scale score. Secondary outcome measures were: laryngoscopy time; total tracheal intubation time; first attempt success rate; and postoperative sore throat verbal rating score. The median (IQR [range]) modified intubation difficulty scale scores for standard bougie and flexible tip bougie were 1 (0–2[0–5]) and 0 (0–1[0–3]), respectively (p = 0.001). There was no significant differences in laryngoscopy time, total tracheal intubation time, first attempt success rate and postoperative sore throat between the two groups. Both the flexible tip and standard bougies can be used with a high first attempt success rate for tracheal intubation using a C‐MAC D‐blade videolaryngoscope. The flexible tip bougie demonstrated a significantly better modified intubation difficulty scale score and lower incidence of bougie impingement. [ABSTRACT FROM AUTHOR]

Background: An optimal endotracheal tube curve can be a key factor in successful intubation using the GlideScope videolaryngoscope. Aims: This study aimed to evaluate the effects of tube tip‐modified stylet curve on the intubation time in children. Methods: Children aged 1‐5 years were randomly assigned to either the standard curve (group S, n = 60) or tip‐modified curve (group T, n = 60) groups. In group S, the endotracheal tube curve was similar to that in the GlideScope. In group T, a point approximately 1.5 cm from the tube tip was additionally angled to the left by 15°‐20°. The primary outcome was the total intubation time, and the secondary outcomes were incidence of successful intubation in the first attempt, number of additional manipulations of the stylet curve, and visual analog scale (VAS) score for the easiness of intubation. Results: The mean total intubation time was significantly longer in group S than that in group T (13.9 [10.8] vs. 9.0 [3.4] sec, mean difference, 4.9 s; 95% confidence interval [CI], 2.0‐7.8; p =.001). All patients in group T were successfully intubated in the first attempt, whereas those in group S were not (100% vs. 93.3%, relative risk [RR], 0.11; 95% CI, 0.01‐2.02; p =.1376). Three patients in group S could be intubated after modifying the ETT curve similar to that in group T. Operators reported that tracheal intubation was easier in group T than in group S (median [interquartile range] for VAS; 1 [1‐2] vs. 2 [1‐3]; p <.001). Conclusions: Having additional angle of the endotracheal tube tip to the left could be a useful technique to facilitate directing and advancing endotracheal tube into the vocal cords. [ABSTRACT FROM AUTHOR]

Objective Many EDs have begun to evaluate their airway performance. The first-pass success ( FPS) rate is a commonly used marker of proficiency, and has been associated with rates of adverse events. The aim of this systematic review and meta-analysis is to quantify the ED FPS rates and summarise the rates of adverse events associated with endotracheal intubation. Methods A structured literature search was performed through MEDLINE and EMBASE. Research published since 2000 was included if it prospectively collected data on all patients intubated in the ED and reported the FPS rates. Data on demographics, indication, FPS rates, adverse events, proportion by RSI and proportion by emergency medicine doctors were extracted. Pooled mean FPS rates were estimated using a random effects model. Results The literature search generated 21 162 articles. Full-text review identified 16 publications for meta-analysis. This included a total of 42 081 intubations from 83 institutions, in 10 countries. The FPS rate was 84.1% (95% confidence interval [ CI] 80.1-87.4] in the ' ED-All' group and 81.8% (95% CI 76.3-86.2) in the 'Trauma-Only' group. The incidence rates of commonly reported adverse events were hypoxia 6.4% (95% CI 2.5-11.9), hypotension 3.0% (95% CI 1.5-4.9), oesophageal intubation 3.5% (95% CI 2.3-4.9), greater than three attempts 0.8% (95% CI 0.4-1.4), cricothyrotomy 0.3% (95% CI 0.1-0.5) and peri-intubation cardiac arrest 0.6% (95% CI 0.2-1.0). Conclusion Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance. [ABSTRACT FROM AUTHOR]

Background: Difficult intubation, most often due to poor view of the vocal cords on laryngoscopy is an intermittent and often challenging problem for clinically practicing anesthesiologists, maxillofacial surgeons, ear nose, and throat (ENT), emergency, and critical care physicians. Purpose: We present a new approach for facilitating difficult intubation and evaluate its efficacy in a retrospective observational study. Settings and Design: Operating room, emergency department, intensive care unit (ICU), retrospective observational study. Materials and Methods: A semirigid 5.6 Rüsch tracheal tube introducer (bougie) with its soft tip protruding at least 6 cm (=4 digits) beyond the distal end of the tube was used. After its insertion through the larynx under laryngoscopy, the tube was gently advanced upon rotation at 360° clockwise. Statistical Analysis: Descriptive. Results: Anesthesia services were analyzed on 10,363 patients over 12 months. In 2453 patients (23.7%) (Group A) intubated in the usual way, difficulties were encountered in 63 patients (2.6%). They were managed either with tube rotation technique (n = 60) or Bonfils endoscope (n = 3). In contrast, 2807 patients (27.1%) (Group B) were intubated using tube rotation technique with introducer. Difficult intubations occurred only in three patients (0.11%) who could be managed with tube rotation by experienced consultant anesthesiologists. Conclusions: The tube rotation technique for intubation was introduced during the Gulf War and has been practiced for the past 19 years without any obvious damage to the trachea in Germany. However, it should be used only by physicians being well familiar with this technique. In addition, well designed controlled studies are needed. [ABSTRACT FROM AUTHOR]

Objective. To compare the success and ease of bougie-assisted intubation (BAI) with those of traditional endotracheal intubation (ETI) in a simulated difficult airway (20.4 seconds for BAI vs. 16.7 seconds for ETI, p = 0.102). Methods. This was a prospective, randomized, crossover, single-blind study comparing BAI with ETI in a simulated difficult airway. The 35 participants included paramedics, flight nurses, and emergency medicine resident physicians. Participants were already experienced in ETI and received a brief demonstration of BAI. A simulated difficult airway was created using a Laerdal adult intubation manikin. Cervical motion was mechanically limited to provide a grade III Cormack and Lehane glottic view. Participants performed ETI and BAI in randomized order. Successful placement in the trachea and time to successful placement were recorded for both techniques by each participant. After intubating the manikin with both techniques, each participant was asked to complete a Likert-style survey assessing ease of each technique. Results. Of the 35 participants, 27 were successful with both techniques and two failed with both techniques. The remaining six participants all failed at ETI but were able to intubate using BAI. There was significantly greater success in intubating the simulated difficult airway with BAI than with ETI (94% vs. 77%, p = 0.0313). The order of techniques attempted did not influence this conclusion. There was no difference in average time to successful intubation (20.4 seconds for BAI vs. 16.7 seconds for ETI, p = 0.102). Thirty-two (91.4%) of the participants completed the survey regarding ease of performing each technique. Forty-one percent rated the ease of intubation as the same for the two methods, 50% rated BAI as easier, and 9% rated ETI as easier (p = 0.0006). Conclusion. In a simulated difficult airway, BAI has a higher success rate than traditional ETI without increasing the time to successful intubation. Intubators perceive BAI as being easier to perform than traditional ETI in this simulated difficult airway scenario. [ABSTRACT FROM AUTHOR]

A postal survey of the 38 Ambulance Services in the United Kingdom was undertaken to find out what equipment is provided for paramedic crews to aid tracheal intubation and to confirm tracheal placement. The response rate to our survey was 100%. Fourteen (37%) ambulance services provided neither stylet nor bougie to facilitate difficult intubation. The laryngeal mask airway was available to 15 (40%) ambulance services. Seventeen (45%) ambulance services had use of a needle cricothyroidotomy set. Twenty-nine (76%) ambulance services had no type of device other than a stethoscope to confirm tracheal tube placement. This survey showed wide variations in the equipment for airway management available to paramedic crews in the United Kingdom. We recommend provision of a standard set of airway management equipment to all paramedic crews in the United Kingdom together with introduction of appropriate training programmes. [ABSTRACT FROM AUTHOR]

Background: Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). Methods: Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. Results: During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. Conclusions: OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future. [ABSTRACT FROM AUTHOR]