Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with ...suspected or confirmed COVID-19 infection.
Summary
The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal ...intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second‐generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the ‘can't intubate, can't oxygenate’ situation and emergency front‐of‐neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post‐induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision‐making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of ...Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest ...(OHCA). The optimal method for OHCA advanced airway management is unknown.
To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA.
Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017.
Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals.
The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events.
Among 3004 enrolled patients (median interquartile range age, 64 53-76 years, 1829 60.9% men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% 95% CI, 0.2%-5.6%; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% 95% CI, 0.3%-6.8%; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% 95% CI, 0.6%-4.8%; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% 95% CI, 0.3%-3.8%; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%).
Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.
ClinicalTrials.gov Identifier: NCT02419573.
The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.
To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the ...initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.
Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.
The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.
A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women 36.3%), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference RD, -0.6% 95% CI, -1.6% to 0.4%). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% 95% CI, 6.3% to 10.2%). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients 77.6% vs 4161 of 4883 patients 85.2% in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients 26.1% in the SGA group vs 1072 of 4372 patients 24.5% in the TI group; adjusted RD, 1.4% 95% CI, -0.6% to 3.4%; aspiration: 729 of 4824 patients 15.1% vs 647 of 4337 patients 14.9%, respectively; adjusted RD, 0.1% 95% CI, -1.5% to 1.8%).
Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.
ISRCTN Identifier: 08256118.
Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for ...airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the ‘difficult airway’ in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.
Effective airway management is a priority in early trauma management. Data on physician pre-hospital tracheal intubation are limited; this study was performed to establish the success rate for ...tracheal intubation in a physician-led system and examine the management of failed intubation and emergency surgical cricothyroidotomy in pre-hospital trauma patients. Failed intubation rates for anaesthetists and non-anaesthetists were compared.
A retrospective database review was conducted to identify trauma patients undergoing pre-hospital advanced airway management between September 1991 and December 2012. The success rate of tracheal intubation and the use and success of rescue techniques were established. Success rates of tracheal intubation by individuals and by speciality were recorded.
The doctor–paramedic team attended 28 939 patients; 7256 (25.1%) required advanced airway management. A surgical airway was performed immediately, without attempted laryngoscopy, in 46 patients (0.6%). Tracheal intubation was successful in 7158 patients (99.3%). Rescue surgical airways were performed in 42 patients, seven had successful insertion of supraglottic devices, and two patients had supraglottic device insertion and a surgical airway. One patient breathed spontaneously with bag-valve-mask support during transfer. All rescue techniques were successful. Non-anaesthetists performed 4394 intubations and failed to intubate in 41 cases (0.9%); anaesthetists performed 2587 intubations and failed in 11 (0.4%) (P=0.02).
This is the largest series of physician pre-hospital tracheal intubation; the success rate of 99.3% is consistent with other reported data. All rescue airways were successful. Non-anaesthetists were twice as likely to have to perform a rescue airway intervention than anaesthetists. Surgical airway rates reported here (0.7%) are lower than most other physician-led series (median 3.1%, range 0.1–7.7%).
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