Emergency Airway Management:

1
Emergency Airway Management History, Current
Practice, and Future Directions Sitges, Spain
September 2003
Erik D. Barton, MD, MS, FACEP, FAAEM University
of Utah Health Sciences Center
2
Outline

• History of airway management
• Rapid Sequence Intubation
• Experience in NEAR
• Future Directions

3
Rapid Sequence Intubation
History of Airway Management in the USA

• Laryngoscopy 1907
• ED intubation approx 1965
• BNTI and Brutane methods of choice
• 1969 U of Cincinnati EM Residency
• 1971 First use of NMB reported in ED
• 1980s Growth of RSI
• 1997 ACEP Policy Statement on RSI
• 1997 NEAR

4
Rapid Sequence Intubation
1980s and 1990s

• Many battles between specialties
• Fear, hesitation among EPs
• Cricothyrotomy rates 15-22
• RSI from rare to standard of care

5
EM in the U.S.

• Pre-1968 untrained physicians, triage to
  service, poor or no supervision of house staff
• Sickest, highest-risk patients cared for by least
  competent physicians
• Need is recognized for organization and
  improvement in care

6
Rapid Sequence Intubation
Today

• RSI required training in EM Residencies
• Widespread use of RSI
• Prehospital RSI

7
Rapid Sequence Intubation
Definition
The virtually simultaneous administration of a
potent sedative agent and a neuromuscular
blocking agent to induce unconsciousness and
motor paralysis for tracheal intubation.
8
Rapid Sequence Intubation

• Just like Skydiving.
• Skydiving is lethal unless one deploys a
  parachute
• RSI is lethal unless you rescue the
  airway!

9
Rapid Sequence Intubation

• Just like Skydiving.
• Redundancy of safety (primary backup)
• Planned, stepwise approach to primary system
• Simple, fast backup system
• Attention to monitoring
• Equipment vigilance
• Levitan, RM. Ann Emerg Med. 20034281-87.

10
Rapid Sequence Intubation
Definition Incorporates

• Patient has a full stomach
• Preoxygenation
• No interposed ventilation
• Sellicks maneuver

11
Rapid Sequence Intubation
Time to Desaturation
12
The Decision to Intubate
Four Reasons for Intubation

• Airway maintenance or protection
• Failure to ventilate
• Failure to oxygenate
• Anticipated clinical course

13
Rapid Sequence Intubation
The Six Ps of RSI
Preparation Preoxygenation Pretreatment Paralysis
with Sedation Protection Placement
14
Rapid Sequence Intubation
Advantages of RSI

• Rapid control of the airway
• Minimizes risk of aspiration
• Highest success rates
• Lowest complication rates
• Optimal intubating conditions
• Adaptable to patient condition
• Can mitigate adverse effects

15
Rapid Sequence Intubation
Succinylcholine

• Still the ED NMB of choice
• Rapid effect
• Short duration
• Generally well tolerated
• A few important side effects

16
Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers

• Plan in advance
• Systematic approach essential
• Equipment
• Training
• remember Skydiving!!

17
Rapid Sequence Intubation
Failed Attempt
Rescue Maneuvers

• The first rescue from failed intubation is
  bagging.
• The first rescue from failed bagging is better
  bagging.
• Rescue devices

18
Rapid Sequence Intubation
How do we know that RSI really works?
19
The Science of Airway Management

• The problems
• Self-reporting
• Emergency conditions
• Multiple factors influence each course
• highly variable
• operator dependent
• Jargon not standardized

Wang, HE. Acad Emerg Med. 200310644-5.
20
NEAR
6294 ED Intubations from the second report of
the ongoing National Emergency Airway Registry
Study (NEAR II)
21

6294 Intubations from the National Emergency
Airway Registry
Methods Prospective, observational study from
8/97 to 4/00 of 26 teaching hospitals in the U.S.
during the second phase of the ongoing National
Emergency Airway Registry (NEAR II) study.
22
6294 Intubations from the National Emergency
Airway Registry
Current Status 33 Centers Registered with
NEAR 30 Centers Actively Submitting Data gt10,000
Intubations Entered in NEAR I NEAR II NEAR III
23
6294 Intubations from the National Emergency
Airway Registry
NEAR II 30 Participating Centers Brigham and
Womens Hospital St. Lukes-Roosevelt
Hospital Erie County Medical Center Dartmouth-Hit
chcock Med Ctr The Childrens Hospital-Boston Univ
ersity of Louisville St. Francis Hospital UCSD
Medical Center University of Arizona Highland
General Hospital Georgetown Univ Medical
Center North Carolina Wake Medical Maricopa
Medical Center Lady Lourdes Hospital UC Davis
Medical Center Stanford University George
Washington University Mount Auburn
Hospital Christiana Care Health Systems Singapore
General Hospital Massachusetts General
Hospital Newport Hospital Emory
Peachtree University of Alabama
24
6294 Intubations from the National Emergency
Airway Registry
RESULTS
25
6294 Intubations from the National Emergency
Airway Registry
Personnel Performing ED Intubations
26
6294 Intubations from the National Emergency
Airway Registry
Demographics of Cases Indication Cases Female
Male Unknown Trauma 1605 (22) 349 (22) 1059
(65) 97 (3) Medical 4286 (72) 1740 (40) 2194
(51) 352 (9) Not Provided 277 (6) 84 (2) 166
(3) 27 (1) TOTAL 6294 (100) 1642 (36) 2545
(55) 415 (9)
27
6294 Intubations from the National Emergency
Airway Registry
Oral RSI 4377 (69) Oral no meds 1088
(17) Oral induction without paralysis 427 (7
) Nasal awake with topical 206 (3) Nasal
no meds 69 (1) Nasal induction without
paralysis 45 Surgical crico/tracheotomy
39 (0.6) Other 16 Oral awake with
topical 21 Unknown
5 TOTAL 6294
28
6294 Intubations from the National Emergency
Airway Registry
1st Course Success Rates Medical
Trauma Oral RSI 99.8 97.7 Oral no
meds 94.7 96.3 Oral induction without
paralysis 95.0 93.7 Nasal awake with
topical 97.2 98.1 Nasal no
meds 91.3 45.4 Nasal induction without
paralysis 97.0 100 Oral awake with
topical 93.7 N/A Other 50.0 100 Surg
ical cricothyrotomy 60.0 68.7 Unknown 50.
0 N/A TOTAL 94.7 96.2
29
6294 Intubations from the National Emergency
Airway Registry
Success Rates by Intubator First pass
Overall EM 84.7 98.5 Anesthesia
93.5 93.5 Other 64.9 97.4 Attending
EM 90.2 97.9 PGY 3 or 4 87.2
98.4 PGY 1 or 2 77.5 98.7 Other 81
.1 98.5
30
NEAR

• Other Studies
• Analysis of failed intubations and rescue
  techniques
• - Bair, AE, et al. J Emerg Med.
  200223131-40.
• Sedative agents facilitate intubations with NMB
• - Sivilotti, MLA, et al. Acad Emerg Med.
  200310612-20.
• Underdosing of midazolam in 92 of adults, 56
  of kids - Sagarin, MJ, et al. Acad Emerg
  Med. 200310329-38.
• Benchmarking intubation data for North American
  EM residents - Sagarin, MJ, et al. Ann Emerg
  Med. 2004.

31
6294 Intubations from the National Emergency
Airway Registry
Immediate Complications
Method IC Oral RSI
11.3 Oral no meds 9.2 Oral
induction without paralysis 16.5 Nasal
awake with topical 37.5
32
Airway Definitions
Complications

• What defines a complication?
• Unplanned event
• Negative consequences
• Not reversible
• Injury to the patient
• Unrelated to underlying disease
• What about corrected errors?

33
Airway Definitions
Technical Problems

• Mainstem Intubation
• Detected Esophageal Intubation
• Tube Obstruction
• Self Extubation
• Cuff Leak
• Other
• Medication error
• Equipment failure

34
Airway Definitions
Physiologic Alterations

• Cardiac Arrest
• Dysrhythmia
• Pneumomediastinum
• Other
• Hypotension
• Hypoxemia
• Severe bleeding
• Seizure
• Subcutaneous emphysema
• Tension pneumothorax

35
Airway Definitions
True Complications

• Aspiration
• Laryngospasm
• Dental Trauma
• Epistaxis
• Vocal Cord Avulsion
• Malignant Hyperthermia
• Undetected Esophageal intubation
• Other
• Lip laceration
• Emesis
• Trismus

36
6294 Intubations from the National Emergency
Airway Registry
Airway Events
Method TPR PAR TCR Oral RSI 7.4 1.1 2
.8 Oral no meds 5.0 2.0 2.2 Oral
induction 9.4 1.2 5.9 Nasal
25 4.2 8.3 Cricothyrotomy 33 16.7 8.3
37
The Science of Airway Management
The Future

• Standardize the jargon
• What is an intubation attempt?
• Immediate vs. long-term complications
• Difficult airway assessments
• Rapid and predictive
• Universally applied

38
The Science of Airway Management
The Future

• Unbiased reporting systems
• Large-scale data collection (web)
• Standardized reporting tools
• NEAR III and IV
• Data analysis
• Trends and outcomes
• New devices/technologies

39
Thank you!
Questions? www.theairwaysite.com www.near.edu