Feasibility of  upright patient positioning and intubation success rates At two academic EDs

Turner, Jonathan S.; Ellender, Timothy J.; Okonkwo, Enola R.; Stepsis, Tyler M.; Stevens, Andrew C.; Sembroski, Erik G.; Eddy, Christopher S.; Perkins, Anthony J.; Cooper, Dylan

doi:10.1016/j.ajem.2017.02.011

Cited by 49 publications

(59 citation statements)

References 26 publications

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“…In a broad patient cohort undergoing general anesthesia in the operating room, elevating the head was associated with improved glottic view, reduced intubation difficulty, less need for ancillary maneuvers, and shorter intubation times compared with a supine body position or simple head extension . In an observational study of 231 ED intubations performed by residents, the ramped patient position was associated with improved first‐pass success compared to supine positioning . In a retrospective study of 528 emergent in‐hospital intubations, the ramped patient position, compared to supine, was associated with reduced odds of a composite of complications including difficult intubations, esophageal intubations, hypoxemia, or aspiration .…”

Section: Discussionmentioning

confidence: 97%

“…17 In an observational study of 231 ED intubations performed by residents, the ramped patient position was associated with improved first-pass success compared to supine positioning. 18 In a retrospective study of 528 emergent in-hospital intubations, the ramped patient position, compared to supine, was associated with reduced odds of a composite of complications including difficult intubations, esophageal intubations, hypoxemia, or aspiration. 19 Results from randomized trials in both the ICU and the operating room have shown mixed results.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

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Objective The objective was to compare first‐attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A‐DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations. Methods This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A‐DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA‐VL) and standard‐geometry VL (SG‐VL). We report differences in first‐attempt intubation success and peri‐intubation adverse events with cluster‐adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI. Results We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A‐DL or unaided VL on first attempt. A‐DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A‐DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First‐attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A‐DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry‐recorded difficult airway predictors revealed first‐attempt success was higher with all unaided VL compared with any A‐DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA‐VL and SG‐VL compared with any A‐DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score–adjusted odds for first‐attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5). Conclusions Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first‐attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

View full text Add to dashboard Cite

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“…Although intubation is commonly undertaken in the supine position, recent published reports suggest that elevating the patient's head to a more upright position (20–45°) could improve preoxygenation, increase the probability of first‐pass success, and decrease intubation‐related adverse events (e.g., hypoxemia) …”

Section: Preparationmentioning

confidence: 99%

Advancing emergency airway management practice and research

Goto

Hagiwara

et al. 2019

Acute Medicine & Surgery

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Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.

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“…Furthermore, as adjunctive strategies such as ramp positioning (12)(13)(14) and apneic oxygenation (15,16) have become increasingly recognized as potentially beneficial, a continuous training curriculum provides opportunities for evaluating trainees' knowledge of these techniques and reinforcing their incorporation into airway management.…”

Section: Discussionmentioning

confidence: 99%

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

Malo¹,

Hypes²,

Cristan³

et al. 2018

Southwest J Pulm Crit Care

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Background: Intubation in critically ill patients remains a highly morbid procedure, and the optimal approach is unclear. We sought to improve the safety of intubation by implementing a simulation curriculum and monitoring performance with an airway registry. Methods and Methods: This is a prospective, single-center observational study of all intubations performed by the medical intensive care unit (ICU) team over a five-year period. All fellows take part in a simulation curriculum to improve airway management performance and minimize complications. An airway registry form is completed immediately after each intubation to capture relevant patient, operator, and procedural data. Results: Over a five-year period, the medical ICU team performed 1411 intubations. From Year 1 to Year 5, there were significant increases in first-attempt success (72.6 vs. 88.0%, p<0.001), use of video laryngoscopy (72.3 vs. 93.5%, p<0.001), and use of neuromuscular blocking agents (73.5 vs. 88.4%, p<0.001). There were concurrent decreases in rates of desaturation (25.6 vs. 17.1%, p=0.01) and esophageal intubations (5 vs. 1%, p=0.009). Low rates of hypotension (8.3%) and cardiac arrest (0.6%) were also observed. Conclusions: The safety of intubation in critically ill patients can be markedly improved through joint implementation of an airway registry and simulation curriculum.

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Feasibility of upright patient positioning and intubation success rates At two academic EDs

Cited by 49 publications

References 26 publications

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Advancing emergency airway management practice and research

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

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