It's that time again — my annual review of the most interesting contributions to the emergency airway literature from the past year, one that delivered quite a few interesting articles to help emergency physicians feel more comfortable with airway techniques.
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Preoxygenation, Reoxygenation, and Delayed Sequence Intubation in the Emergency Department
J Emerg Med
2010; Apr 7 (epub)
I continue to believe this is the most critical yet underappreciated step in airway management, particularly for patients that begin hypoxemic. But we have done a disservice by emphasizing the avoidance of positive-pressure ventilation.
In addition to noninvasive positive pressure ventilation and rapid sequence airway (RSA), Weingart has now added delayed sequence intubation (DSI) to the mix. In this technique, ketamine is given to facilitate a period of planned positive pressure ventilation using bag-mask or ventilator-mask ventilation, prior to administering a paralytic and completing the intubation procedure.
DSI is worth considering for hypoxemic patients who will not cooperate with optimal preoxygenation strategies. Too bad this was not published somewhere with wider readership.
Cricothyrotomy Technique Using Gum-Elastic Bougie is Faster than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab
Hill C, et al
Acad Emerg Med
Colleagues and I previously published a case report on the bougie-aided cricothyrotomy, which we have found to be a life-saving technique, and it is now the primary approach we teach in our Airway911 courses. (Air Med J 2009;28:191.) These investigators have validated that this is indeed a faster technique without additional complications. Learn it!
Association between Arterial hyperoxia Following Resuscitation from Cardiac Arrest and In-Hospital Mortality
Kilgannon JH, et al
There is now a growing body of literature to demonstrate that high oxygen levels are as damaging as low levels, at least for post-code and traumatic brain injury patients. Of course, we still don't know exactly what constitutes “just right,” but in this study, a PaO2 of 60 to 300 was optimal. For now, I am now trying to employ the lowest FiO2 that gives me a normal saturation.
Face Mask Ventilation in Edentulous Patients: A Comparison of Mandibular Groove and Lower Lip Placement
Racine SX, et al
Despite innovation in alternative laryngoscopy and extraglottic airways, bag-valve-mask ventilation (BVMV) remains a critical skill in emergency medicine. Edentulous patients are often easy to intubate, but are often very challenging to BVMV. Common tricks are to replace the dentures, if available, or to place gauze fluffs in the cheeks. This simpler approach just requires moving the mask. Pull up the article to see the illustrations.
Emergency Department Management of the Airway in Obese Adults
Dargin J, Medzon R
Ann Emerg Med
The Complexities of Tracheal Intubation with Direct Laryngoscopy and Alternative Intubation Devices
Levitan RM, et al
Ann Emerg Med
2010;Jul 29 (epub)
Rapid Sequence Induction and Intubation: Current Controversy
El-Orbany M, Connolly LA
Dargin and Medzon have contributed a must-read article on managing the airway in obese patients. Levitan and colleagues have generated a very interesting article comparing the mechanics of intubation with direct laryngoscopy and the newer visualization devices. Included among the technical discussion are some very useful pearls for using the different devices. El-Orbany and Connolly offer the anesthesia perspective on common emergency medicine debates such as choice of induction agent, premedications, and cricoid pressure. I don't agree with all of their conclusions, but it is interesting reading.
Tracheal Intubation Following Training with the GlideScope Compared to Direct Laryngoscopy
Ayoub CM, et al
Even though I believe that traditional laryngoscopy will disappear over the next 10 years, for now I am still concerned about the loss of these skills as more airways are managed with video devices. This study is slightly reassuring because it demonstrates that training with a video device improves subsequent traditional direct laryngoscopy, most likely by improving recognition of glottic structures.
Learning Curves for Bag-and-Mask Ventilation and Orotracheal Intubation: An Application of the Cumulative Sum Method
Komatsu R, et al
Only nine of 15 interns achieved an 80 percent success rate at intubation after a median of 35 procedures. Yikes! This is yet more evidence that if many practitioners should not even be attempting intubation, and should instead be moving directly to an extraglottic device.
The Easytube for Airway Management in Prehospital Emergency Medicine
Chenaitia H, et al
At this point, we have a number of excellent extraglottic airway devices available. The primary problem is getting emergency physicians and EMS providers to use them. This small study serves to familiarize EPs with a new, dual-lumen, retroglottic airway that will likely replace the Combitube for those that prefer this type of device. Advantages include a broader size range (down to 3-feet tall rather than 4), less traumatic insertion, nonlatex construction, and the ability to pass fiberoptics. That being said, there is substantial competition from the Laryngeal Tube and a variety of laryngeal airways that are easier to use, and offer a broader choice of sizes.
Cricoid Pressure and Laryngeal Manipulation in 402 Pre--Hospital Emergency Anesthetics: Essential Safety Measure or Hindrance to Rapid Safe Intubation?
Harris T, et al
While this paper muddies the water a bit on whether external laryngeal manipulation (ELM) or backwards-upwards-rightwards-pressure (BURP) should be taught (we have previously discounted BURP in favor of ELM), the most interesting finding is that reduction of cricoid pressure improved the view 50 percent of the time. Appropriately managing neck pressure remains critical to direct laryngoscopy.
Comparison of Traditional Versus Video Laryngoscopy in Out-of-Hospital Tracheal Intubation
Wayne MA, McDonnell M
Prehosp Emerg Care
While many EDs have begun to invest in video intubation technology, the cost has been too great for most EMS services so data have been limited. Medic One has now demonstrated what we all anticipated: Video technology improves intubation time and the number of attempts by paramedics. If only the cost would come down!
Advanced Airway Management Does Not Improve Outcome of Out-of-Hospital Cardiac Arrest
Arslan Hanif M, et al
Acad Emerg Med
This is the latest in a growing body of literature blasting invasive airway management, particularly intubation, in cardiac arrest patients. While the study is limited, the results are dramatics: An odds ratio for survival to discharge of 4.5 when patients were bagged, not tubed. This is important info not only for those of us who direct EMS agencies; we should put this same info to use when patients code in the hospital.
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