The difficult airway refocused

Sakles, John C.; Pacheco, Garrett S.; Kovács, George; Mosier, Jarrod

doi:10.1016/j.bja.2020.04.008

Cited by 23 publications

(22 citation statements)

References 22 publications

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“…1 Underlying shock, respiratory failure, metabolic acidosis, and other pathophysiological changes substantially increase the risk of adverse peri-intubation events in critically ill patients compared with patients undergoing intubation in the operating room. [1][2][3][4][5][6] Small prospective studies, retrospective analyses, or national level studies [7][8][9] suggest that up to 28% of critically ill patients undergoing tracheal intubation may experience a lifethreatening complication such as severe hypoxemia or hemodynamic instability and 2.7% of procedures are complicated by cardiac arrest. 7,10 In 2011, the Fourth National Audit Project launched in the UK was the first attempt to assess intubationrelated morbidity and mortality at a national level.…”

mentioning

confidence: 99%

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Russotto

Myatra

Laffey

et al. 2021

JAMA

330

178

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Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.OBJECTIVE To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. DESIGN, SETTING, AND PARTICIPANTSThe International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. EXPOSURES Tracheal intubation.MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. RESULTSOf 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. CONCLUSIONS AND RELEVANCEIn this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

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mentioning

confidence: 99%

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Russotto

Myatra

Laffey

et al. 2021

JAMA

330

178

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“… 20 Point-of-care ultrasound is playing an increasing role in physiologic diagnosis and evaluation of targeted management of resuscitation before, during, or after airway management. 21 …”

Section: Prediction Of Difficulty With Airway Managementmentioning

confidence: 99%

“…20 Point-ofcare ultrasound is playing an increasing role in physiologic diagnosis and evaluation of targeted management of resuscitation before, during, or after airway management. 21 Another aspect to enhancing the airway exam in patients with significantly altered anatomy is to identify the location of the cricothyroid membrane (CTM). 22 If visual inspection or palpation fails to identify the CTM location with certainty, it should be identified using ultrasonography and marked, 22,23 with the patient's neck in an extended position.…”

Section: The Enhanced Airway Evaluationmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

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101

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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“…Recently, there has been an increasing awareness of the importance of the physiologically difficult airway, which may increase the risk of AEs independent of any anatomic difficulty. [4][5][6][7] Critically ill patients are at high risk of hypoxemia, hypotension, and cardiac arrest because of deranged physiology that is often exacerbated during or resulting from airway management. 5,8 Hypoxemia and hypotension are particularly hazardous risks for cardiac arrest.…”

Section: Introductionmentioning

confidence: 99%

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

Pacheco¹,

Hurst²,

Patanwala³

et al. 2021

W J Emerg Med

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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. [

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The difficult airway refocused

Cited by 23 publications

References 22 publications

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

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

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