Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room.

BACKGROUND: Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. METHODS: A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. RESULTS: A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). CONCLUSION: Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay.

BACKGROUND: Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. METHODS: We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. RESULTS: 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1-15.8) with a 7.3% ICU-readmission rate. CONCLUSION: Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high.

The application of extracorporeal membrane oxygenation in emergent airway management - a single-center retrospective study.

BACKGROUND: Emergent airway occurrences pose a significant threat to patient life. Extracorporeal membrane oxygenation (ECMO) has been proven to be an effective method for managing emergent airways. METHODS: A retrospective analysis was conducted on all patients receiving ECMO as an adjunct for emergent airway management from January 2018 to December 2022 at the People's Hospital of Zhongshan City. We collected the basic information of the patients, their blood gas data before and after ECMO, the related parameters of ECMO, and the outcome and then analyzed and summarized these data. RESULTS: Six patients, with an average age of 51.0(28-66) years, received veno-venous (VV)- ECMO as an adjunct due to emergent airway issues. The average ECMO support duration was 30.5(11-48) hours. All six patients were successfully weaned off ECMO support, with five (83.3%) being successfully discharged after a hospital stay of 15.5(7-55) days. All six patients underwent VV-ECMO through femoral-internal jugular vein cannulation. Among these, five patients, whose airway obstruction was due to hemorrhage, underwent a non-anticoagulant ECMO strategy with no recorded thrombotic events. CONCLUSIONS: The rapid establishment of ECMO support is aided by the establishment of a standardized ECMO initiation protocol and the formation of a multidisciplinary rapid-response ECMO team, which is particularly crucial for emergent airway management. When airway obstruction results from hemorrhagic factors, the early adoption of a non-anticoagulant ECMO strategy can be considered when implementing VV-ECMO.

Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting. METHODS: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively. RESULTS: Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD = - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05). CONCLUSION: In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.

A Difficult Differential Diagnosis in New Neck Masses: Retropharyngeal Abscess or Malignancy?

Retropharyngeal abscesses (RPAs) are rare in the adult population and rarer without an inciting event or comorbidity such as recent oral surgery, neck infection, or pharyngeal trauma. The definitive treatment is incision and drainage of the abscess. Clinical researchers have recently questioned whether invasive surgical intervention is necessary and posed the question of what role antibiotics play in management. Sequelae of RPAs are severe and include rupture of the abscess, erosion of the carotid artery, thrombophlebitis, and most seriously, airway compromise. We present a case where an atypical presentation of an RPA caused a disagreement among specialists, and the debate of whether the described case represented an abscess or malignancy caused a delay in diagnosis and treatment for the patient. Only after invasive and emergent surgical intervention was a final diagnosis able to be made. This case demonstrates the need for more research and official guidance on the management of new neck masses to hasten diagnosis and prevent devastating outcomes.

Anaphylaxis to Ciprofloxacin Requiring Emergent Surgical Cricothyrotomy.

Although allergies to antibiotics are commonly stated, anaphylactic reactions are uncommonly reported. This is especially the case with reactions to fluoroquinolone antibiotics. Furthermore, airway emergencies are rare. We present a case of ciprofloxacin-induced acute airway obstruction and anaphylaxis, necessitating emergent surgical cricothyrotomy following respiratory distress. LEARNING POINTS: Anaphylactic reactions to fluoroquinolone antibiotics are extremely rare.There are currently no standardized diagnostic tests, making the diagnosis of anaphylaxis challenging and largely based on history alone.Treating clinicians should be aware of this rare, but potentially rapidly fatal adverse drug reaction.

Retropharyngeal Abscess With Severe Airway Compromise Following Anterior Cervical Spine Surgery: A Case Report.

Anterior cervical corpectomy, discectomy, and fusion are common surgical management options for symptomatic cervical radiculopathy and myelopathy. While these procedures are common and well-tolerated, postoperative complications span from mild dysphasia to airway compromise secondary to retropharyngeal or peri-cervical space abscess. These critical patients require robust airway management, which may entail a multidisciplinary approach or airway management in the operating room. We describe a patient who developed airway compromise 10 days following anterior cervical discectomy and fusion with a pre-platysmal abscess and a large retropharyngeal abscess. These abscesses were large enough to cause a mass effect with tracheal deviation. This deviation was severe enough that the patient required awake incision and drainage prior to rapid sequence intubation.

The burden of angioedema on United States emergency departments: 2006-2010.

OBJECTIVES/HYPOTHESIS: Angioedema (AE) is a condition that may prompt a visit to an emergency department (ED), and can quickly progress to airway obstruction. To optimize treatment of AE, it is necessary to understand epidemiology and practice patterns. This study measured the magnitude of AE ED visits and characterized demographics, management, frequency of airway interventions, and mortality. STUDY DESIGN: Analysis of two national data sets. METHODS: From the Nationwide Emergency Department Sample and National Hospital Ambulatory Medical Care Survey, we identified all patients presenting from 2006 to 2010 with a primary diagnosis of AE, characterized by the International Classification of Diseases, Ninth Edition, Clinical Modification code 995.1. The discharges were weighted and stratified by comorbidities, age, treatments, and region. χ2 , t test, and linear regression were employed for comparisons. RESULTS: Total discharges increased from 87,481 (29.3 of 100,000 people) to 111,116 (35.8 of 100,000 people). More females were afflicted (57%), and 41.1% were African American. The majority (83%) of patients were discharged from the ED. Twelve percent of cases were attributed to antihypertensive adverse reaction, and these patients were older (P < .0001, odds ratio [OR] = 1.02), and had more comorbidities (P < .0001, OR = 5.66), hospital admissions (P < .0001, OR = 4.83), and intubations (P < .03, OR = 2.07). Overall, patients required intubation infrequently (<1%) and mortality was low (0.08%). CONCLUSIONS: The AE burden on EDs has increased over time. Patients with adverse reactions to antihypertensives are older, have more comorbidities, and require admission and intubation more frequently. Further investigation is needed to better delineate causation and outcome predictors, and to understand regional practice variance. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:828-834, 2017.

Use of a Novel Airway Kit and Simulation in Resident Training on Emergent Pediatric Airways.

Objective Development of a novel pediatric airway kit and implementation with simulation to improve resident response to emergencies with the goal of improving patient safety. Methods Prospective study with 9 otolaryngology residents (postgraduate years 1-5) from our tertiary care institution. Nine simulated pediatric emergency airway drills were carried out with the existing system and a novel portable airway kit. Response times and time to successful airway control were noted with both the extant airway system and the new handheld kit. Results were analyzed to ensure parametric data and compared with t tests. A Bonferroni adjustment indicated that an alpha of 0.025 was needed for significance. Results Use of the airway kit significantly reduced the mean time of resident arrival by 47% ( P = .013) and mean time of successful intubation by 50% ( P = .007). Survey data indicated 100% improved resident comfort with emergent airway scenarios with use of the kit. Discussion Times to response and meaningful intervention were significantly reduced with implementation of the handheld airway kit. Use of simulation training to implement the new kit improved residents' comfort and airway skills. This study describes an affordable novel mobile airway kit and demonstrates its ability to improve response times. Implications for Practice The low cost of this airway kit makes it a tenable option even for smaller hospitals. Simulation provides a safe and effective way to familiarize oneself with novel equipment, and, when possible, realistic emergent airway simulations should be used to improve provider performance.