Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study.

INTRODUCTION: Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways. METHODS: We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016-December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI). RESULTS: Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts. CONCLUSION: Analysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.

Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study.

BACKGROUND: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. METHODS: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. RESULTS: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. CONCLUSIONS: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

Comparing Emergency Department First-Attempt Intubation Success With Standard-Geometry and Hyperangulated Video Laryngoscopes.

STUDY OBJECTIVE: It is unclear whether laryngoscopy using a standard-geometry blade shape, able to obtain both direct and indirect views, is associated with different first-attempt success or adverse events during emergency intubation compared with using a hyperangulated blade capable of indirect laryngoscopy only. We sought to compare first-attempt intubation success between patients intubated with a standard geometry video laryngoscope versus a hyperangulated video laryngoscope. METHODS: We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first attempt at oral intubation was performed with a standard-geometry or hyperangulated video laryngoscope. We used multiple logistic regression to determine whether blade shape was independently associated with first-attempt intubation success. RESULTS: During the study period, 11,927 of 19,071 intubation encounters met inclusion criteria, including 7,255 (61%) with a standard blade and 4,672 (39%) with a hyperangulated blade. Unadjusted analysis revealed higher success with a standard-geometry blade, 91.9% versus 89.2% (absolute difference 2.7% [95% confidence interval 1.6% to 3.8%]; odds ratio for standard-geometry laryngoscope compared with hyperangulated laryngoscope 1.37 [95% confidence interval 1.21 to 1.55]). The logistic regression model, however, demonstrated no association between blade shape and first-attempt success (adjusted odds ratio for standard-geometry laryngoscopy compared with hyperangulated laryngoscopy 1.32 [95% confidence interval 0.81 to 2.17]). CONCLUSION: In this large registry of patients intubated with video laryngoscopy in the emergency department, we observed no association between blade shape (standard-geometry versus hyperangulated laryngoscope) and first-attempt intubation success after adjusting for confounding variables.

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

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.

Factors associated with post-intubation sedation after emergency department intubation: A Report from The National Emergency Airway Registry.

BACKGROUND: Previous work has suggested low rates of post-intubation sedation in patients undergoing endotracheal intubation (ETI) in the emergency department (ED) with limited data examining factors associated with sedation use. Utilizing a national database; we sought to determine the frequency of post-intubation sedation and associated factors. METHODS: We performed a retrospective analysis of a prospectively collected database (National Emergency Airway Registry (NEAR) from 25 EDs from January 1, 2016 to December 31, 2017). Patients were considered to have received post-intubation sedation if they received any of the following medications within 15 min of ETI completion; propofol, midazolam, diazepam, ketamine, etomidate, fentanyl, and morphine. We calculated odds ratios for post-intubation sedation. RESULTS: Of the 11,748 eligible intubations, 9099 received post-intubation sedation (77.5%) while 2649 did not (22.5%). Pre-intubation hypotension (odds ratio; 95% confidence Interval) (0.27; 0.24-0.31) and post-intubation hypotension (0.27; 0.24-0.31) were associated with lower odds of post-intubation sedation. Patients with a medical indication compared to a traumatic indication for ETI had higher odds of receiving post-intubation sedation (1.16; 1.05-1.28) as did those that underwent rapid sequence intubation (15.15; 13.56-16.93). Use of succinylcholine was associated with a higher odd of post-intubation sedation compared to a long-acting neuromuscular blocking agent (i.e. rocuronium or vecuronium) (1.89; 1.68-2.12). CONCLUSION: Post-intubation sedation rates in NEAR are higher than previously reported and multiple factors including the indication for intubation and succinylcholine use, are associated with higher odds of receiving post-intubation sedation.

Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations.

OBJECTIVES: With respect to first-attempt intubation success, the pediatric literature demonstrates either clinical equipoise or superiority of direct laryngoscopy (DL) when compared to video laryngoscopy (VL). Furthermore, it is unknown how VL compares to DL, when DL is "augmented" by maneuvers, such as optimal external laryngeal manipulation (OELM), upright or ramped positioning, or the use of the bougie. The objective of our study was to compare first-attempt success between VL and all DL, including "augmented DL" for pediatric intubations. METHODS: We analyzed the National Emergency Airway Registry database of intubations of patients < 16 years. Variables collected included patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics, adjusted for clustering by center. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. In a planned sensitivity analysis, a propensity-adjusted analysis for first-attempt success and a subgroup analysis of children < 2 years was also performed. RESULTS: Of 625 analyzable pediatric encounters, 294 (47.0%, 95% confidence interval [CI] = 25.1% to 69.0%) were DL; 332 (53.1%, 95% CI = 31.0% to 74.9%) were VL. Median age was 4 years (interquartile range = 1 to 10 years); 225 (36.0%, 95% CI = 30.8% to 41.2%) were < 2 years. Overall first-pass success was 79.6% (95% CI = 74.1% to 84.9%). VL first-pass success was 278/331 (84.0%) versus 219/294 for DL (74.5%), adjusted for clustering (odds ratio [OR] = 1.7, 95% CI = 1.3 to 2.5). Multivariable regression showed that VL yielded a higher odds of first-attempt success than DL augmented by OELM or use of a bougie (adjusted OR = 5.5, 95% CI = 1.7 to 18.1). Propensity-adjusted analyses supported the main results. Subgroup analysis of age < 2 years also demonstrated VL superiority (OR = 2.0, 95% CI = 1.1 to 3.3) compared with DL. Adverse events were comparable in both univariate and multivariable analysis. CONCLUSIONS: When compared to DL, VL was associated with higher first-pass success in this pediatric population, even in the subgroup of patients < 2 years, as well as when DL was augmented. There were no differences in adverse effects between DL and VL.

Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study.

OBJECTIVE: Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation. METHODS: We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR). We compared characteristics and outcomes for adult patients intubated orotracheally in SP and NSP positions with either a direct or video laryngoscope. We report odds ratios (OR) with 95% confidence interval (CI) for categorical variables and interquartile ranges with 95% CI for continuous variables. Our primary outcome was first-attempt intubation success and secondary outcomes were glottic views and peri-intubation adverse events. RESULTS: Of 11,480 total intubations, 5.8% were performed in NSP. The NSP group included significantly more obese patients (OR = 2.2 [95% CI = 1.9-2.6]) and patients with a suspected difficult airway (OR = 1.8 [95% CI = 1.6-2.2]). First-pass success (adjusted OR = 1.1 [95% CI = 0.9-1.4]) and overall rate of grade I glottic views (OR = 1.1 [95% CI = 0.9-1.2]) were similar between groups while NSP had a significantly higher rate of grade I views when direct laryngoscopy was employed (OR = 1.27 [95% CI = 1.04-1.54]). NSP was associated with higher odds of any adverse event (OR = 1.4 [95% CI = 1.1-1.7]). CONCLUSIONS: ED providers utilized SP in most ED intubations but were more likely to use NSP for patients who were obese or in whom they predicted a difficult airway. We found no differences in first-pass success between groups but total adverse events were more likely in NSP. A randomized trial comparing patient positioning during intubation in the ED is warranted.

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study.

STUDY OBJECTIVE: Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium. METHODS: We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose. RESULTS: There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose. CONCLUSION: In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.

A 12-month descriptive analysis of emergency intubations at Brooke Army Medical Center: a National Emergency Airway Registry study.

Emergency airway management is a critical skill for military healthcare providers. Our goal was to describe the Emergency Department (ED) intubations at Brooke Army Medical Center (BAMC) over a 12-month period. MATERIAL AND METHODS: Physicians performing endotracheal intubations in the BAMC ED complete data collection forms for each intubation event as part of the National Emergency Airway Registry, including patient demographics, intubation techniques, success and failure rates, adverse events, and patient disposition. We cross-referenced these forms against the numbers of intubation events reported in the ED nursing daily reports to ensure capture of all intubations. Providers completed forms for every intubation within 6 weeks of the procedure. We analyzed data from March 28, 2016, to March 27, 2017. RESULTS: During the study period, providers performed 259 intubations in the BAMC ED. Reasons for intubation were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). Overall, first-attempt success was 83.0%. Emergency medicine residents performed a majority of first attempts (95.0%). Most common devices chosen on first attempt were a video laryngoscope for 143 patients (55.2%) and a direct laryngoscope for 115 patients (44.4%). One patient underwent cricothyrotomy. The 2 most common induction agents were ketamine (59.8%; 95% CI, 55.2%-67.4%) and etomidate (19.3%; 95% CI, 14.7%-24.7%). The most common neuromuscular blocking agents were rocuronium (62.9%; 95% CI, 56.7%-68.8%) and succinylcholine (18.9%; 95% CI, 14.3%-24.2%). CONCLUSION: In the BAMC ED, emergency intubation most commonly occurred for trauma indications using video laryngoscopy with a high first-pass success.

Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study.

BACKGROUND: Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. INTRODUCTION: We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. MATERIALS AND METHODS: Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. RESULTS: Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. DISCUSSION: The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. CONCLUSIONS: Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.