Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success.

STUDY OBJECTIVE: Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS: We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS: After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION: Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry.

BACKGROUND: In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations. METHODS: We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test. RESULTS: Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic). CONCLUSIONS: Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.

Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU.

OBJECTIVES: To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN: Prospective multicenter interventional quality improvement study. SETTING: Ten PICUs in North America. PATIENTS: Patients undergoing tracheal intubation in the PICU. INTERVENTIONS: VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS: The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS: Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.

Sedative Dose for Rapid Sequence Intubation and Postintubation Hypotension: Is There an Association?

STUDY OBJECTIVE: For patients with hemodynamic instability undergoing rapid sequence intubation, experts recommend reducing the sedative medication dose to minimize the risk of further hemodynamic deterioration. Scant data support this practice for etomidate and ketamine. We sought to determine if the dose of etomidate or ketamine was independently associated with postintubation hypotension. 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 intubation attempt was facilitated with etomidate or ketamine. We used multivariable modeling to determine whether drug dose in milligrams per kilogram of patient weight was independently associated with postintubation hypotension (systolic blood pressure < 100 mm Hg). RESULTS: We analyzed 12,175 intubation encounters facilitated by etomidate and 1,849 facilitated by ketamine. The median drug doses were 0.28 mg/kg (interquartile range [IQR] 0.22 mg/kg to 0.32 mg/kg) for etomidate and 1.33 mg/kg (IQR 1 mg/kg to 1.8 mg/kg) for ketamine. Postintubation hypotension occurred in 1,976 patients (16.2%) who received etomidate and in 537 patients (29.0%) who received ketamine. In multivariable models, neither the etomidate dose (adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.90 to 1.01) nor ketamine dose (aOR 0.97, 95% CI 0.81 to 1.17) was associated with postintubation hypotension. Results were similar in sensitivity analyses excluding patients with preintubation hypotension and including only patients intubated for shock. CONCLUSION: In this large registry of patients intubated after receiving either etomidate or ketamine, we observed no association between the weight-based sedative dose and postintubation hypotension.

First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study.

STUDY OBJECTIVE: We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training. METHODS: We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device. RESULTS: Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1. CONCLUSION: Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.

Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study.

BACKGROUND: Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE: We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS: We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS: Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION: Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study.

INTRODUCTION: Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS: The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS: Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS: EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility.

OBJECTIVE: It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success. METHODS: In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome. RESULTS: Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19). CONCLUSION: In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.

Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL). METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects. RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events. CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.

Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators.

OBJECTIVES: To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN: Multicenter time-series study. SETTING: PICUs in the United States. PATIENTS: All patients received tracheal intubations in ICUs. INTERVENTIONS: We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS: Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry.

STUDY OBJECTIVE: We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and first-pass success. METHODS: We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success. RESULTS: Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval [CI]: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success. CONCLUSION: Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.

Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go.

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

Awake intubations in the emergency department: A report from the National Emergency Airway Registry.

OBJECTIVE: To describe awake intubation practices in the emergency department (ED) and report success, complications, devices used, and rescue techniques using multicenter surveillance. METHODS: We analyzed data from the National Emergency Airway Registry (NEAR). Patients with an awake intubation attempt between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals (CIs). RESULTS: Of 19,071 discrete patient encounters, an awake technique was used on the first attempt in 82 (0.4%) patients. The majority (91%) of first attempts were performed by emergency medicine physicians. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications for an awake intubation attempt. The most common initial device used was a flexible endoscope (78%). Among all awake intubations first-attempt success was achieved in 85% (95% CI [76%-95%]), and peri-intubation complications occurred in 16% (95% CI [9%-26%]). CONCLUSION: Awake intubation in this multicenter cohort of emergency department patients was rare and was performed most often in patients with airway edema or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Further studies are needed to determine optimal emergency airway management in this patient population.

Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department.

BACKGROUND: Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach. OBJECTIVE: We compared first attempt success and complications between ketamine-only, topical anesthesia alone or with low-dose sedation, and RSI approaches. METHODS: We analyzed registry data from the National Emergency Airway Registry, comprising emergency department intubation data from 25 centers from January 2016 to December 2018. We excluded pediatric patients (<14 years of age), those in cardiac and respiratory arrest, or those with an alternate pharmacologic approach (i.e., neuromuscular blocking agent only or nonketamine sedative alone). We analyzed first attempt intubation success and adverse events across the 3 intubation approaches. We calculated differences in outcomes between the ketamine-only and topical anesthesia groups. RESULTS: During the study period, 12,511 of 19,071 intubation encounters met inclusion criteria, including 102 (0.8%) intubated with ketamine alone, 80 (0.6%) who had intubation facilitated by topical anesthesia, and 12,329 (98.5%) who underwent RSI. Unadjusted first attempt success was 61%, 85%, and 90% for the 3 groups, respectively. Hypoxemia (defined as oxygen saturation <90%) occurred in 16%, 13%, and 8% of patients during the first attempt, respectively. At least 1 adverse event occurred in 32%, 19%, and 14% of the courses of intubation for the 3 groups, respectively. In comparing the ketamine-only and topical anesthesia groups, the difference in first pass success was -24% (95% confidence interval -37% to -12%), and the difference in number of cases with ≥1 adverse event was 13% (95% confidence interval 0-25%), both favoring the topical anesthesia group. CONCLUSION: Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.

Emergency Department Intubations in Patients With Angioedema: A Report from the National Emergency Airway Registry.

BACKGROUND: Angioedema, a localized swelling of subcutaneous and submucosal tissues, may involve the upper airway. A subset of patients presenting for emergent evaluation of angioedema will require intubation. Little is known about airway management practices in patients with angioedema requiring intubation in the emergency department (ED). OBJECTIVE: To describe airway management practices in patients intubated for angioedema in the ED. METHODS: We analyzed data from the National Emergency Airway Registry. All patients with an intubation attempt for angioedema between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with cluster-adjusted 95% confidence intervals. RESULTS: Of 19,071 patient encounters, intubation was performed for angioedema in 98 (0.5%). First-attempt success was achieved in 81%, with emergency physicians performing the procedure in 94% of encounters. The most common device used was a flexible endoscope (49%), and 42% of attempts were via a nasal route. Pharmacologic methods included sedation with paralysis (61%), topical anesthesia with or without sedation (13% and 13%, respectively), and sedation only (10%). Among 19 (19%) patients requiring additional attempts, intubation was achieved on second attempt in 10 (53%). The most common adverse events were hypotension (13%) and hypoxemia (12%). Cricothyrotomy occurred in 2 patients (2%). No deaths were observed. CONCLUSIONS: Angioedema was a rare indication for intubation in the ED setting. Emergency physicians achieved first-attempt success in 81% of encounters and used a broad range of intubation devices and methods, including flexible endoscopic techniques. Cricothyrotomy was rare, and no ED deaths were reported. © 2021 Elsevier Inc.

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.

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.

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.

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. DESIGN: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. SETTINGS: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036). CONCLUSIONS: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease-Are Cardiac ICUs Safer?

OBJECTIVES: Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. DESIGN: Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). SETTING: Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. PATIENTS: Children with medical or surgical cardiac disease who underwent intubation in an ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002). CONCLUSIONS: In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.