Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU.

BACKGROUND: Reintubation is associated with significant morbidity and mortality. The reintubation rate in surgical ICUs (SICUs) is ∼10% nationally but was 17.0% in our SICU. The objective of this study was to determine if the reintubation rate could be reduced with a protocol for extubation assessment and post-extubation care consisting of standardized extubation criteria and targeted interventions for patients at high risk for reintubation. METHODS: Standardized extubation criteria for all SICU patients were identified via literature review and best-practice guidelines. High reintubation risk criteria were identified (age ≥ 65 years, chronic cardiopulmonary disease, ≥ 4 days intubated, emergency intubation, and fluid balance ≥ 5 liters) through a literature review and 13-month retrospective review of reintubations in our institution's SICU. Patients meeting at least one criterion putting them at higher risk for reintubation received interventions including post-extubation high-flow nasal cannula for 24 hours and algorithm-guided respiratory therapy. RESULTS: During the 12-month period following protocol implementation, 36 of 402 extubations resulted in reintubations (9.0% vs. 17.0% preintervention, p < 0.001). Among all extubations, 305 (75.9%) were identified as high risk. Among reintubated patients, 34 (94.4%) met high-risk criteria. The mortality rate for reintubated patients was 40.0%, compared to 3.3% in those not reintubated (p < 0.001). The high-risk screening tool had a negative predictive value of 98%. CONCLUSION: A multifaceted and pragmatic extubation and post-extubation care protocol significantly reduced one SICU's reintubation rate. This protocol can be easily implemented in any SICU to improve patient outcomes following extubation.

An assessment of introducers used for airway management.

Different introducers are available to assist with tracheal intubation. Subtle differences in the design of introducers can have a marked effect on safety and performance. The Difficult Airway Society's Airway Device Evaluation Project Team proposal states that devices should only be purchased for which there is at least a case-control study on patients assessing airway devices. However, resources are not currently available to carry out a case-control study on all introducers available on the market. This study comprised a laboratory and manikin-based investigation to identify introducers that could be suitable for clinical investigation. We included six different introducers in laboratory-based assessments (design characteristics) and manikin-based assessments involving the participation of 30 anaesthetists. Each anaesthetist attempted placement in the manikin's trachea with each of the six introducers in a random order. Outcomes included first-time insertion success rate; insertion success rate; number of attempts; time to placement; and distance placed. Each anaesthetist also completed a questionnaire. First-time insertion success rate depended significantly on the introducer used (p = 0.0016) and varied from 47% (Armstrong and P3) to 77% (Intersurgical and Frova). Median time to placement (including oesophageal placement) varied from 10 s (Eschmann and Frova) to 20 s (P3) (p = 0.0025). Median time to successful placement in the trachea varied from 9 s (Frova) to 22 s (Armstrong) (p = 0.037). We found that the Armstrong and P3 devices were not as acceptable as other introducers and, without significant improvements to their design and characteristics, the use of these devices in studies on patients is questionable. The study protocol is suitable for differentiating between different introducers and could be used as a basis for assessing other types of devices.

Establishing quality indicators for pre-hospital advanced airway management: a modified nominal group technique consensus process.

BACKGROUND: Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. METHODS: We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. RESULTS: Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. CONCLUSIONS: We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta-analysis.

Videolaryngoscopes are thought to improve glottic view and facilitate tracheal intubation compared with the Macintosh direct laryngoscope. However, we currently do not know which one would be the best choice in most patients undergoing anaesthesia. We designed this systematic review with network meta-analyses to rank the different videolaryngoscopes and the Macintosh direct laryngoscope. We conducted searches in PubMed and a further five databases on 11 January 2021. We included randomised clinical trials with patients aged ≥16 years, comparing different videolaryngoscopes, or videolaryngoscopes with the Macintosh direct laryngoscope for the outcomes: failed intubation; failed first intubation attempt; failed intubation within two attempts; difficult intubation; percentage of glottic opening seen; difficult laryngoscopy; and time needed for intubation. We assessed the quality of evidence according to GRADE recommendations and included 179 studies in the meta-analyses. The C-MAC and C-MAC D-Blade were top ranked for avoiding failed intubation, but we did not find statistically significant differences between any two distinct videolaryngoscopes for this outcome. Further, the C-MAC D-Blade performed significantly better than the C-MAC Macintosh blade for difficult laryngoscopy. We found statistically significant differences between the laryngoscopes for time to intubation, but these differences were not considered clinically relevant. The evidence was judged as of low or very low quality overall. In conclusion, different videolaryngoscopes have differential intubation performance and some may be currently preferred among the available devices. Furthermore, videolaryngoscopes and the Macintosh direct laryngoscope may be considered clinically equivalent for the time taken for tracheal intubation. However, despite the rankings from our analyses, the current available evidence is not sufficient to ensure significant superiority of one device or a small set of them over the others for our intubation-related outcomes.

Diagnostic value of pleural ultrasound to refine endotracheal tube placement in pediatric intensive care unit.

AIM: To assess the diagnostic performance of a simplified lung point-of-care ultrasound (POCUS) to confirm the correct positioning of an endotracheal tube (ETT) in a pediatric intensive care unit (PICU) used to chest radiography (CXR), and to compare the time to obtain the ETT position between POCUS and CXR. METHODS: We conducted a single-center prospective study in critically ill children requiring urgent endotracheal intubation. Esophageal tube malposition was first avoided using auscultation and end-tidal CO2. The ETT position was assessed with CXR and lung POCUS using the lung sliding sign on a pleural window. All of the investigators had to read guidelines and received 1-h training on the technical aspects of lung sliding. The primary objective was the accuracy of POCUS in confirming correct nonselective endotracheal intubation as compared with CXR. RESULTS: A total of 71 patients were included from December 2016 to November 2018. CXR identified proper nonselective ETT placement in 43 of 71 (61%) patients, while the rate for selective intubation was 39%. The sensitivity and specificity of POCUS as compared with CXR were 77% and 68%, respectively. Median time to POCUS was significantly shorter than CXR (2 min to perform POCUS, 10 min to obtain radiographs, p<10-4). CONCLUSION: Pleural ultrasound, although faster than CXR, appears to be inadequate for identifying selective ETT after urgent intubation in a PICU less accustomed to this kind of ultrasound. In this heterogeneous and fragile population, timely POCUS may remain useful at the bedside as compared with auscultation, aiming at guiding optimal ETT placement and reducing respiratory complications, provided by trained physicians.

Comparison of direct laryngoscopy and video-assisted laryngoscopy in pediatric intensive care unit.

Our objective was to compare video-assisted laryngoscopy (VAL) with direct laryngoscopy (DL) for glottic visualization in a pediatric intensive care unit in terms of the success rate in first attempts. Our study included patients aged from 1 month to 18 years who were admitted to the pediatric intensive care unit. We excluded patients with limited neck extension (C-spine immobilization, congenital abnormality), congenital anomalies (e.g., Pierre Robin syndrome, micrognathia, macroglossia), and recent airway surgery. Patients were premedicated before intubation. The time to intubation was defined as the time between the start of anesthesia and completion of intubation. The start of anesthetic induction was defined as the time the sedative was first administered. Completion of intubation was defined as the time that the end-tidal carbon dioxide tension was detected. We evaluated 120 of 135 intubations that met our inclusion criteria; 15 were excluded because in eight cases (53%) non-pediatric intensive care physicians made the initial attempts, and in seven cases (47%) the recorded intubation times were erroneous. We detected significantly higher POGO scores in the VAL group (p<0.001). VAL provided a fuller view of the glottis (Cormack and Lehane grade 1) than DL (p<0.001). Although the intubation attempts in the DL group were significantly higher (two or more attempts), no intubation failures occurred in either group.

Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle.

BACKGROUND: Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months. METHODS: A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts. RESULTS: Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once. CONCLUSIONS: We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.

A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal.

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.

Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department.

OBJECTIVE: In response to COVID-19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first-attempt success (FAS) associated with ED intubation. METHODS: An analysis of prospectively collected registry data of all ED intubations over a 3-year period at an Australian Major Trauma Centre. During the first 6 months of the COVID-19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with 'sign-off' for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre-drawn medications. RESULTS: There were 783 patients, 136 in the COVID-19 era and 647 in the pre-COVID-19 comparator group. The rate of hypoxia was higher during the COVID-19 era compared to pre-COVID-19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID-19 vs 22.6% pre-COVID-19, P < 0.001). Other adverse events were similar before and during COVID-19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID-19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). CONCLUSIONS: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.

Emergency Tracheal Intubation in Patients with COVID-19: A Single-center, Retrospective Cohort Study.

INTRODUCTION: The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. METHODS: We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. RESULTS: We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. DISCUSSION: An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.

A simulation-based study evaluating the preparedness of interns' post-anaesthesia rotation in managing a failed obstetric intubation scenario: Is our training good enough?

BACKGROUND: Difficult or failed intubation of obstetric patients may be up to 8 times higher than in general surgical patients. A decline in obstetric intubation opportunities may be a contributing factor, resulting in reduced training opportunities for junior doctors, who therefore do not acquire airway management skills. OBJECTIVES: To assess post-anaesthesia rotation interns' preparedness to manage a difficult/failed obstetric airway scenario. METHODS: We recruited 49 interns, obtained informed consent and individually assessed them on a simulation-based scenario using a high-fidelity manikin. Two independent assessors scored participants using a checklist assessment and a global rating scale. After the simulation-based scenario, participants completed a questionnaire on their internship training, rated the simulation experience and received debriefing. The borderline regression method was used to determine the checklist pass mark. RESULTS: Analysis showed that 40% of interns passed. Correlation between assessors was strong for checklist scores and global ratings. The main reasons for failing were repeated attempts at intubation and failure to optimise the intubating position or conditions. There was concern regarding the infrequent use of a supraglottic airway device as a rescue. Twenty-eight interns had performed <5 general obstetric anaesthetic procedures. CONCLUSIONS: There are concerns regarding adequate anaesthetic preparation for interns to manage a difficult/failed intubation scenario in a full-term pregnancy. Despite the Essential Steps in Managing Obstetric Emergencies (ESMOE) airway module training, which all interns should receive, a high rate of success was not achieved in this study. Simulation-based training and assessment may be a valuable tool to improve intern training and preparedness.

Best Practices to Verify Ongoing Placement of NG or OG Tube After Initial X-ray Confirmation.

BACKGROUND: Many patients in intensive care units (ICU) require nasogastric (NG) or orogastric (OG) tubes. These patients often require a combination of sedatives that can alter level of consciousness and impair cough or gag reflexes. Such factors can lead to NG/OG tube displacement. Using a misplaced tube can lead to aspiration, lung injury, infection, and even death. AIMS: To standardize ongoing verification of NG tube placement practices in our 34-bed Medical-Surgical ICU. METHODS: The Johns Hopkins Nursing Model was utilized to guide this project. A literature review and critical appraisal were performed to establish NG/OG tube best practices. Best practices were implemented and assessed (via a survey and charting audits). RESULTS: Fifteen publications were identified and appraised as Level 4 and 5 sources. Best evidence supported that at the time of radiographic confirmation of the tube site, it should be marked with inedible ink or adhesive tape where it exits the nares; tube location should be checked at 4-hour intervals; and placement/patency should be checked in patients who complain of pain, vomiting, or coughing. Following the practice change, N = 40 nurses indicated improvement in verification of NG/OG tube knowledge, "OK to use" order was verified for 89% of patients, and 63% of tubes were marked with tape at the exit site. LINKING ACTION TO EVIDENCE: Adherence to current, evidence-based strategies for NG/OG tube verification promotes patient safety. Monitoring practice changes is critical to determine whether a best practice is sustained. Electronic health records must be current to guide and support evidence-based nursing practice.

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways.

INTRODUCTION: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). METHODS: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014-June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. RESULTS: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = -10.3%, 95% confidence interval (CI), -14.8% to -5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = -10.7%, 95% CI, -17.3% to -4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = -21.4%, 95% CI, -27.0% to -16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33]. CONCLUSION: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.

Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review.

Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.