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

Abstract

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. [

Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts

“…Even in a recent consensus paper on PHAAM quality indicators, the threshold to terminate an attempt remains undefined and will need further clarification to improve future studies and their interpretations. One solution could be combining FPS with avoiding adverse events for a more clinically relevant variable, as used in some recent studies [ 35 , 37 , 38 ]. Our results also displayed a significant difference in on-scene time between FPS and non-FPS groups.…”

Emergency Airway Management in COVID-19: Comment

“…4 Our study has limitations with the incomplete patientlevel data that may help us truly interpret the physiologic hypoxemia and cardiovascular instability are not normally consequences of airway management, they may complicate physiologically difficult intubation 5 and many COVID patients who fail noninvasive ventilation due to progressive disease fall into that category. Existing evidence suggests that first-pass success may not distinguish between anatomical and physiologically difficult airways, 6 further limiting the ability of the first-pass success metric to detect cardiorespiratory consequences of COVID-19 airway management.…”

Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study

“…Other evidence does not support the protective benefits of the ramp position for obese patients; Pacheco et al . showed that anatomically difficult airways were associated with a reduced ‘FPS without AEs’ rate 30 . Although obesity itself was included in the anatomically difficult category, it was not shown to be independently associated with a change in ‘FPS without AEs’ in the regression model.…”

“…showed that 94.9% of trauma patients presented an anatomically difficult airway, likely due to deformity and obstruction of the airway. Supine positioning can exacerbate these difficult airways, further supporting the use of bed tilt in these patients 30 …”