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British Journal of Anaesthesia Feb 2018These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital... (Review)
Review
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4 National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
Topics: Adult; Airway Management; Anesthesia; Critical Care; Critical Illness; Emergencies; Humans; Intubation, Intratracheal
PubMed: 29406182
DOI: 10.1016/j.bja.2017.10.021 -
JAMA Jun 2018The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.
IMPORTANCE
The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear.
OBJECTIVE
To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet.
DESIGN, SETTING, AND PATIENTS
The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection.
INTERVENTIONS
Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376).
MAIN OUTCOMES AND MEASURES
The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia.
RESULTS
Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.
CONCLUSIONS AND RELEVANCE
In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.
TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT02902146.
Topics: Academic Medical Centers; Adult; Emergency Service, Hospital; Emergency Treatment; Female; Humans; Intubation, Intratracheal; Kaplan-Meier Estimate; Male; Middle Aged; Treatment Outcome
PubMed: 29800096
DOI: 10.1001/jama.2018.6496 -
Respiratory Care Jun 2014Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The... (Review)
Review
Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intubation technique in the perioperative environment is direct laryngoscopy with orotracheal tube insertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology. Careful patient evaluation, advanced planning, equipment preparation, system redundancy, use of checklists, familiarity with airway algorithms, and availability of additional help when needed during OR intubations have resulted in exceptional success and safety. Airway difficulties during intubation outside the controlled environment of the OR are more frequent and more serious. Translating the intubation processes practiced in the OR to intubations outside the perioperative setting should improve patient safety. This paper considers each step in the OR intubation process in detail and proposes ways of incorporating perioperative procedures into intubations outside the OR. Management of the physiologic impact of intubation, lack of readily available specialized equipment and experienced help, and planning for transfer of care following intubation are all challenges during these intubations.
Topics: Humans; Intubation, Intratracheal; Laryngoscopy; Medical History Taking; Monitoring, Physiologic; Operating Rooms; Patient Safety; Physical Examination; Risk Factors
PubMed: 24891194
DOI: 10.4187/respcare.02802 -
International Journal of Environmental... Mar 2022Best practices for management of COVID-19 patients with acute respiratory failure continue to evolve. Initial debate existed over whether patients should be intubated in...
BACKGROUND
Best practices for management of COVID-19 patients with acute respiratory failure continue to evolve. Initial debate existed over whether patients should be intubated in the emergency department or trialed on noninvasive methods prior to intubation outside the emergency department.
OBJECTIVES
To determine whether emergency department intubations in COVID-19 affect mortality.
METHODS
We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test and required endotracheal intubation during their hospital course between 1 March 2020 and 1 June 2020. Patients were divided into two groups based on location of intubation: early intubation in the emergency department or late intubation performed outside the emergency department. Clinical and demographic information was collected including comorbid medical conditions, qSOFA score, and patient mortality.
RESULTS
Of the 131 COVID-19-positive patients requiring intubation, 30 (22.9%) patients were intubated in the emergency department. No statistically significant difference existed in age, gender, ethnicity, or smoking status between the two groups at baseline. Patients in the early intubation cohort had a greater number of existing comorbidities (2.5, = 0.06) and a higher median qSOFA score (3, ≤ 0.001). Patients managed with early intubation had a statistically significant higher mortality rate (19/30, 63.3%) compared to the late intubation group (42/101, 41.6%).
CONCLUSION
COVID-19 patients intubated in the emergency department had a higher qSOFA score and a greater number of pre-existing comorbidities. All-cause mortality in COVID-19 was greater in patients intubated in the emergency department compared to patients intubated outside the emergency department.
Topics: COVID-19; Humans; Intubation, Intratracheal; Records; Retrospective Studies; SARS-CoV-2
PubMed: 35270767
DOI: 10.3390/ijerph19053075 -
The Cochrane Database of Systematic... Jun 2017Neonatal endotracheal intubation is a common and potentially life-saving intervention. It is a mandatory skill for neonatal trainees, but one that is difficult to master... (Review)
Review
BACKGROUND
Neonatal endotracheal intubation is a common and potentially life-saving intervention. It is a mandatory skill for neonatal trainees, but one that is difficult to master and maintain. Intubation opportunities for trainees are decreasing and success rates are subsequently falling. Use of a stylet may aid intubation and improve success. However, the potential for associated harm must be considered.
OBJECTIVES
To compare the benefits and harms of neonatal orotracheal intubation with a stylet versus neonatal orotracheal intubation without a stylet.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and previous reviews. We also searched cross-references, contacted expert informants, handsearched journals, and looked at conference proceedings. We searched clinical trials registries for current and recently completed trials. We conducted our most recent search in April 2017.
SELECTION CRITERIA
All randomised, quasi-randomised, and cluster-randomised controlled trials comparing use versus non-use of a stylet in neonatal orotracheal intubation.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed results of searches against predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used the standard methods of the Cochrane Collaboration, as documented in the Cochrane Handbook for Systemic Reviews of Interventions, and of the Cochrane Neonatal Review Group.
MAIN RESULTS
We included a single-centre non-blinded randomised controlled trial that reported a total of 302 intubation attempts in 232 infants. The median gestational age of enrolled infants was 29 weeks. Paediatric residents and fellows performed the intubations. We judged the study to be at low risk of bias overall. Investigators compared success rates of first-attempt intubation with and without use of a stylet and reported success rates as similar between stylet and no-stylet groups (57% and 53%) (P = 0.47). Success rates did not differ between groups in subgroup analyses by provider level of training and infant weight. Results showed no differences in secondary review outcomes, including duration of intubation, number of attempts, participant instability during the procedure, and local airway trauma. Only 25% of all intubations took less than 30 seconds to perform. Study authors did not report neonatal morbidity nor mortality. We considered the quality of evidence as low on GRADE analysis, given that we identified only one unblinded study.
AUTHORS' CONCLUSIONS
Current available evidence suggests that use of a stylet during neonatal orotracheal intubation does not significantly improve the success rate among paediatric trainees. However, only one brand of stylet and one brand of endotracheal tube have been tested, and researchers performed all intubations on infants in a hospital setting. Therefore, our results cannot be generalised beyond these limitations.
Topics: Gestational Age; Humans; Infant; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Intubation, Intratracheal; Pediatrics
PubMed: 28640930
DOI: 10.1002/14651858.CD011791.pub2 -
Respiratory Care Jul 2020Endotracheal intubation is a common procedure performed by respiratory therapists (RTs). The purpose of this study was to describe current RT intubation practices in...
BACKGROUND
Endotracheal intubation is a common procedure performed by respiratory therapists (RTs). The purpose of this study was to describe current RT intubation practices in North Carolina through the use of a survey instrument.
METHODS
A survey was developed by the authors using REDCap. The survey was sent via email to all licensed RTs in North Carolina. Information collected included respondent demographics, intubation practices (including training and skill maintenance), and attitudes about RT intubation practices.
RESULTS
Of the 411 respondents, 68% intubated at their facility, representing 81 unique institutions. RTs who performed intubation were more likely to be from community hospitals and less likely to be from level 1 trauma centers. Respondents reported intubating adult (91%), pediatric (61%), and neonatal (65%) patients. The most common areas in which RTs reported performing intubation were the adult ICU (80%), emergency department (76%), outside the operating room for emergencies (76%), neonatal ICU (43%), the delivery room (45%), and pediatric ICU (25%). The median (interquartile range) number of supervised intubations required to be considered competent was 5 (3-5). The most common numbers of intubations required to be considered competent were 5 (32%), 3 (26%), 10 (16%), 2 (4%), and 0 (3%). The perceived number of intubations to achieve competence was 6 (range 5-10) and did not differ based on years of experience. Most respondents believed their RT intubation program was safe (93%) and effective (91%), and that RTs were well-trained (81%), that their intubation skills were objectively evaluated (66%), and that RTs receive sufficient feedback on performance (68%).
CONCLUSIONS
RTs in North Carolina frequently performed intubation and had high confidence in their programs. Further studies are needed to establish standardized training for endotracheal intubation, document success rates for intubations, and evaluate the use of video laryngoscopy by RTs.
Topics: Adult; Allied Health Personnel; Child; Emergencies; Emergency Service, Hospital; Humans; Intubation, Intratracheal; Laryngoscopes; Medical Staff, Hospital; Respiratory Therapy
PubMed: 32156790
DOI: 10.4187/respcare.07338 -
Anesthesia and Analgesia Oct 2022Because intubation-mediated cervical spine and spinal cord injury are likely determined by intubation force magnitude, understanding the determinants of intubation force...
BACKGROUND
Because intubation-mediated cervical spine and spinal cord injury are likely determined by intubation force magnitude, understanding the determinants of intubation force magnitude is clinically relevant. With direct (Macintosh) laryngoscopy, when glottic view is less favorable, anesthesiologists apply greater force. We hypothesized that, when compared with direct (Macintosh) laryngoscopy, intubation force with an optical indirect laryngoscope (Airtraq) would be less dependent on glottic visualization.
METHODS
Using data obtained in a prior clinical study, we tested whether the slope of the intubation force versus glottic view relationship differed between intubations performed in 14 patients who were intubated twice, once with a Macintosh and once with an Airtraq videolaryngoscope. Slopes were compared using least-squares linear regression and robust regression.
RESULTS
The slope of the intubation force (N) versus glottic view (%) relationship with the Macintosh (-0.679 [standard error {SE}, 0.147]) was significantly more negative than that of the Airtraq (-0.076 [SE, 0.246]). The least-squares regression difference in slopes was -0.603 (SE, 0.287); P = .046. The robust regression difference in slopes was -0.747 (SE, 0.187); P = .0005. Thus, when compared with the Macintosh, intubation force magnitude with Airtraq laryngoscopy was less dependent on glottic visualization.
CONCLUSIONS
Previously, we reported that intubation force with the Airtraq was less in magnitude compared with the Macintosh. Our current study adds that intubation force also is less dependent on glottic view with Airtraq compared with the Macintosh.
Topics: Cervical Vertebrae; Equipment Design; Glottis; Humans; Intubation, Intratracheal; Laryngoscopes; Laryngoscopy
PubMed: 35551148
DOI: 10.1213/ANE.0000000000006082 -
Singapore Medical Journal Mar 2022General anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia...
INTRODUCTION
General anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia and aspiration. The aim of this retrospective review was to define the incidence of failed and difficult intubation in parturients undergoing general anaesthesia for Caesarean delivery at a high-volume obstetric hospital in Singapore.
METHODS
All parturients who underwent Caesarean delivery under general anaesthesia from 2013 to 2016 were identified and their medical records were reviewed to extract pertinent data. Difficult intubation was defined as 'requiring more than one attempt at intubation or documented as such, based on the opinion of the anaesthetist'. A failed intubation was defined as 'inability to intubate the trachea, with subsequent abandonment of intubation as a means of airway management'.
RESULTS
Records of 660 Caesarean sections under general anaesthesia were extracted. The mean age of the parturients was 32.1 ± 5.5 years and the median body mass index was 27.5 (interquartile range 24.6-31.1) kg/m. Rapid sequence induction with cricoid pressure was employed for all patients, with thiopentone and succinylcholine being administered for 91.2% and 98.1% of patients, respectively. There were 33 difficult intubations among 660 patients, yielding an incidence of 5.0%. Junior trainees performed about 90% of all intubations and 28 (84.8%) out of 33 difficult intubations. Repeat intubations were performed by senior residents/fellows (57.1%) and consultants (14.3%). No instance of failed intubation was reported.
CONCLUSION
The local incidence of difficult obstetric intubation was one in 20. No failure of intubation was observed.
Topics: Adult; Airway Management; Anesthesia, General; Cesarean Section; Female; Humans; Intubation, Intratracheal; Pregnancy; Retrospective Studies
PubMed: 32798358
DOI: 10.11622/smedj.2020118 -
Emergency Medicine Journal : EMJ Jul 2022Emergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated...
BACKGROUND
Emergency tracheal intubation during major trauma resuscitation may be associated with unrecognised endobronchial intubation. The risk factors and outcomes associated with this issue have not previously been fully defined.
METHODS
We retrospectively analysed adult patients admitted directly from the scene to the ED of a single level 1 trauma centre, who received either prehospital or ED tracheal intubation prior to initial whole-body CT from January 2008 to December 2019. Our objectives were to describe tube-to-carina distances (TCDs) via CT and to assess the risk factors and outcomes (mortality, length of intensive care unit stay and mechanical ventilation) of patients with endobronchial intubation (TCD <0 cm) using a multivariable model.
RESULTS
We included 616 patients and discovered 26 (4.2%) cases of endobronchial intubation identified on CT. Factors associated with an increased risk of endobronchial intubations were short body height (OR per 1 cm increase 0.89; 95% CI 0.84 to 0.94; p≤0.001), a high body mass index (OR 1.14; 95% CI 1.04 to 1.25; p=0.005) and ED intubation (OR 3.62; 95% CI 1.39 to 8.90; p=0.006). Eight of 26 cases underwent tube thoracostomy, four of whom had no evidence of underlying chest injury on CT. There was no statistically significant difference in mortality or length of stay although the absolute number of endobronchial intubations was small.
CONCLUSIONS
Short body height and high body mass index were associated with endobronchial intubation. Before considering tube thoracostomy in intubated major trauma patients suspected of pneumothorax, the possibility of unrecognised endobronchial intubation should be considered.
Topics: Adult; Emergency Medical Services; Humans; Intubation, Intratracheal; Retrospective Studies; Risk Factors; Trachea
PubMed: 34376465
DOI: 10.1136/emermed-2021-211786 -
The Cochrane Database of Systematic... Jun 2018Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.
OBJECTIVES
To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.
SEARCH METHODS
We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.
SELECTION CRITERIA
RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.
DATA COLLECTION AND ANALYSIS
Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.
MAIN RESULTS
The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.
AUTHORS' CONCLUSIONS
Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.
Topics: Humans; Infant, Newborn; Intubation, Intratracheal; Laryngoscopes; Laryngoscopy; Randomized Controlled Trials as Topic; Resuscitation; Time Factors
PubMed: 29862490
DOI: 10.1002/14651858.CD009975.pub3