Association Between Difficult Airway Predictors and Failed Prehosptial Endotracheal Intubation

Gaither, Joshua B; Stolz, Uwe; Ennis, Joshua; Moiser, Jarrod; Sakles, John C.

doi:10.1016/j.amj.2015.06.001

Cited by 12 publications

(14 citation statements)

References 14 publications

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“…Factors known to increase the risk of a difficult intubation include: body mass index [40, airway edema, history of head and neck tumor or surgery, prior difficult intubation, cervical spine immobility, bleeding, vomit, large tongue, and tracheostomy [1]. As a result of improved optical airway devices, such as the video laryngoscope, the successful management of difficult airways in the ED has increased [2], and the number of surgical airways performed in the ED has dramatically decreased [3,4].…”

Section: Discussionmentioning

confidence: 99%

Parapharyngeal abscess with tracheal deviation

et al. 2017

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A 41-year-old man presented to the Emergency Department (ED) with right-sided neck pain and swelling over the prior 48 h. He had a history of poor dentition and recent dental extractions. He was taking clindamycin for the infection and hydrocodone for pain. On examination, the patient was febrile and slightly confused. He had a hoarse voice, difficulty handling secretions, and significant induration and erythema of the right side of the face which extended down into the neck.

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Section: Discussionmentioning

confidence: 99%

Parapharyngeal abscess with tracheal deviation

et al. 2017

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“…Based on previous work evaluating difficult airways, the data elements in the form included patient demographics, patient characteristics, difficult airway characteristics, procedural characteristics, and techniques used to successfully intubate the patient (Table 1). 9,10,12,16 Upon completion of the custom form, the form was automatically forwarded, without patient or agency identifiers, to the study investigators. We then entered data into a spreadsheet for data analysis (Microsoft Excel, Redmond, WA).…”

Section: Methodsmentioning

confidence: 99%

“…cervical collar in place or “other”); gag reflex present; trismus/jaw clenched; neck or facial trauma; inability to palpate the landmarks of the neck (e.g., cricoid cartilage or thyromental distance); or fluid in the airway (e.g. blood or emesis) 9,10,12,16,18. Providers were asked (yes or no) if they felt the intubation was difficult.…”

Section: Methodsmentioning

confidence: 99%

“…Previous works have identified multiple factors associated with difficult ETI in a variety of acute care settings including the prehospital setting, intensive care unit, and emergency department 9–13. Although predictors and resultant treatment pathways have been identified, we are unaware of any externally validated, simplified identification tools for prehospital providers, identifying those factors most predictive of difficult ETI 9,10,14.…”

Section: Introductionmentioning

confidence: 99%

“…Although predictors and resultant treatment pathways have been identified, we are unaware of any externally validated, simplified identification tools for prehospital providers, identifying those factors most predictive of difficult ETI 9,10,14. Given the adverse events associated with ETI efforts, rapid identification of difficult ETI through such a tool could help to improve the safety of prehospital airway management.…”

Section: Introductionmentioning

confidence: 99%

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Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation

Carlson¹,

Hostler²,

Guyette³

et al. 2017

WestJEM

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IntroductionEndotracheal intubation (ETI) in the prehospital setting poses unique challenges where multiple ETI attempts are associated with adverse patient outcomes. Early identification of difficult ETI cases will allow providers to tailor airway-management efforts to minimize complications associated with ETI. We sought to derive and validate a prehospital difficult airway identification tool based on predictors of difficult ETI in other settings.MethodsWe prospectively collected patient and airway data on all airway attempts from 16 Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January 2011 to October 2014. Cases that required more than two ETI attempts and cases where an alternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETI attempt were categorized as “difficult.” We used a random allocation sequence to split the data into derivation and validation subsets. Using backward elimination, factors with a p<0.1 were included in the multivariable regression for the derivation cohort and then tested in the validation cohort. We used this model to determine the area under the curve (AUC), and the sensitivity and specificity for each cut point in both the derivation and validation cohorts.ResultsWe collected data on 1,102 cases with 568 in the derivation set (155 difficult cases; 27%) and 534 in the validation set (135 difficult cases; 25%). Of the collected variables, five factors were predictive of difficult ETI in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): Glasgow coma score [GCS] >3 (2.15, 1.19–3.88), limited neck movement (2.24, 1.28–3.93), trismus/jaw clenched (2.24, 1.09–4.6), inability to palpate the landmarks of the neck (5.92, 2.77–12.66), and fluid in the airway such as blood or emesis (2.25, 1.51–3.36). This was the most parsimonious model and exhibited good fit (Hosmer-Lemeshow test p = 0.167) with an AUC of 0.68 (95% CI [0.64–0.73]). When applied to the validation set, the model had an AUC of 0.63 (0.58–0.68) with high specificity for identifying difficult ETI if ≥2 factors were present (87.7% (95% CI [84.1–90.8])).ConclusionWe have developed a simple tool using five factors that may aid prehospital providers in the identification of difficult ETI.

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