Airway Management Research
Update
December 5, 2014
Calvin A. Brown III, MD
Cheryl Lynn Horton, MD
Medical Director, Urgent Care
Attending Physician, Emergency Medicine
Brigham and Women’s Hospital
Harvard Medical School
Attending Physician
Emergency Medicine
Kaiser Permanente
© 2014 Airway Management Education Center
Welcome
• Welcome to the Airway Management Research Update
Webinar
• Disclosures
Faculty Name
Company
Nature of Financial
Relationship
Calvin A. Brown III, MD
Airway Management
Education Center
Speaker
Cheryl Lynn Horton, MD
Airway Management
Education Center
Speaker
•
Financial Relationships: Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee,
honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually
associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on
advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person
involved in the CME activity to include financial relationships of a spouse or partner.
© 2014 Airway Management Education Center
Accreditation Statement
•
This activity has been planned and implemented in accordance with the
Essential Areas and policies of the Accreditation Council for CME (ACCME)
through the joint providership of Hospital Physician Partners and Airway
Management Education Center. Hospital Physician Partners is accredited by
the ACCME to provide CME for physicians.
•
Hospital Physician Partners designates this live activity for a maximum of 1.0
AMA PRA Category 1 Credit.™ Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
•
This continuing education activity is approved by First Airway LLC, an
organization accredited by the Continuing Education Coordinating Board for
Emergency Medical Services (CECBEMS). CECBEMS Activity #: 14-FirstAirF5-QAR0214 CEH Number and Type: 1.0 Advanced. Provider: First Airway,
LLC #: FirstAir6610
© 2014 Airway Management Education Center
Objectives
At the conclusion of this webinar, you should be able
to:
– Describe the latest research in airway
management
– Apply the findings to your practice
© 2014 Airway Management Education Center
Agenda
•
•
•
•
•
•
Pre-test
Case 1
Case 2
Q&A
Post-test Questions
Evaluation upon exit from presentation
© 2014 Airway Management Education Center
First,
A Short Pre-Test
© 2014 Airway Management Education Center
Pre -Test Question 1
All of the following methods are appropriate
for pre-oxygenation for RSI EXCEPT:
A.
B.
C.
D.
Facemask oxygen with reservoir at 15L/min
NC oxygen at 4L/min
Unassisted breathing through an Ambu bag
BL-PAP
© 2014 Airway Management Education Center
Pre -Test Question 2
As compared to SGA device insertion, for
patients with out-of-hospital cardiac arrest,
pre-hospital intubation has:
A.
B.
C.
D.
Higher rates of ROSC
Higher rates of survival to hospital discharge
Less favorable neurologic outcomes
Variable outcomes depending upon the
intubator
© 2014 Airway Management Education Center
Pre -Test Question 3
Which of the following is true regarding the
GlideScope:
A. The glottic view is usually worse than with DL
B. You cannot intubate a patient with airway
bleeding
C. Trainees improve their first-attempt success
with GVL over time
D. Time to tube placement is faster compared to
DL
© 2014 Airway Management Education Center
Pre -Test Question 4
Using ultrasound to confirm correct ETT
placement in pediatric patients is:
A.
B.
C.
D.
Highly sensitive
Operator dependent
Difficult to perform
A poor test and should not be used
© 2014 Airway Management Education Center
Let’s get started…
• 6 new studies today
• Followed by the Airway Article of the Year
finalists and winner
Now on to Case #1…
© 2014 Airway Management Education Center
Case #1
• EMS:
68 yo man with history HTN, HL, DM and prior
heart attacks, found unresponsive in bed by wife
after taking a nap. 911 called. Wife was advised
to feel for a pulse and then start chest
compressions.
© 2014 Airway Management Education Center
Case continued…
• Upon your arrival:
– Pulseless & apneic
– PEA on the monitor
– Chest compressions resumed
– Bag-valve mask ventilation is initiated
– 1 mg epinephrine administered
– Blood glucose: 137 mg/dL
© 2014 Airway Management Education Center
Case continued…
• What’s next…
– 8 minutes from the hospital
– Paramedic is at the patient’s side with:
•
•
•
•
Direct laryngoscope and ETT
Laryngeal Mask Airway (SGA device)
Bag-valve mask
Non-rebreather mask
How should we manage the
airway?
© 2014 Airway Management Education Center
How should we manage the airway?
A. Intubation using direct laryngoscopy
B. Supraglottic airway device insertion
C. Bag mask ventilation
D. Non-rebreather
Are there any studies to help
answer this question?
© 2014 Airway Management Education Center
Tiah L et al. Does pre-hospital endotracheal intubation improve survival
among adults with non- traumatic out-of-hospital cardiac arrest? A systematic
review. West J Emerg Med 2014;15(7):749.
• Literature review
• Out-of-hospital cardiac arrests between 19802013
• Compared ETT vs SGA device insertion
• 5 studies included: 303,348 patients
– 1 Japanese study: 281,522 patients
© 2014 Airway Management Education Center
ETI vs SGA:
Does
Pre-Hospital
Endotracheal
Intubation
Improve
Survival?
Figure
2a. Associations
of pre-hospital
advanced
airways
• ROSC:
[endotracheal intubation (ETI) versus supraglottic airways (SGA)]
with return of spontaneous circulation.
DISCUSSION
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Resuscitation using an Impedanc
an early versus
delayed study
by Wangreview
et al.
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a systematic
received
comparedthat
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SGA
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and other patient outcomes among ad
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DISCUSSION
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We conducted
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ex
differences
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the
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hospital
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In
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Figure 2b. Associations of pre-hospital advanced airways
however, the direction of results seemed to favo
[endotracheal intubation (ETI) versus supraglottic airways (SGA)]
39
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o
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Figure 2b. Associations of pre-hospital advanced airways
Figure
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[endotracheal
intubationof(ETI)
versus supraglottic
airways (SGA)]
[endotracheal
intubation
versus supraglottic airways (SGA)]
with survival to
hospital (ETI)
admission.
with return of spontaneous circulation.
• Survival to Hospital Discharge:
difference between ETI and SGA.
et al.39 and Kajino et al.40
For neurological orof
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We conducted a systematic review to exam
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Figure
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airway
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• Favorable Neurologic Outcome:
Review of the Japanese study
Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival
in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.
How should we manage the airway?
A. Intubation using direct laryngoscopy
B. Supraglottic airway device insertion
C. Bag mask ventilation
D. Non-rebreather
© 2014 Airway Management Education Center
What if we were in Scotland?
Wimalasena YH et al. Comparison of factors associated with desaturation in
prehospital emergency anaesthesia in primary and secondary retrievals. Emerg
Med J. Published Online First: 12 November 2014
• Scottish emergency medical service
• Physicians performing the intubations at the
scene or at other medical facilities prior to transfer
• 335 rapid sequence intubations performed
between 2008-2012
• Evaluated rates of hypoxia and hypotension
© 2014 Airway Management Education Center
Wimalasena YH et al. Emerg Med J. Published Online First: 12 November 2014
• The Results:
– Hypoxia: 15.4% of patients
– Hypotension: 7.9% of patients
• Multivariate Analysis:
– Only Cormack & Lehane III or IV view was a
risk factor for desaturation
© 2014 Airway Management Education Center
What does this mean?
• Prehospital intubations are technically challenging
procedures for any provider
• Many studies show no benefit to pre-hospital
intubation
• Focus: Rapid transport to the hospital and
oxygenation by bag-mask ventilation or
supraglottic airway device
© 2014 Airway Management Education Center
You get to the hospital and bag mask
ventilation becomes more difficult…what do
you do to confirm proper ETT placement?
A.
B.
C.
D.
Listen for bilateral breath sounds
Place ETCO2 detector
Place patient on an ETCO2 monitor
Direct laryngoscopy to visualize the ETT
through the cords
© 2014 Airway Management Education Center
Now we can add one more maneuver…
Tracheal Rapid Ultrasound Saline Test (TRUST)
• 42 children with correct (endotracheal) and
incorrect (endobronchial) ETT placement
• Linear probe at level suprasternal notch
Tube confirmation confirmed
by fiberoptic bronchoscopy.
Tessaro MO et al. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming
correct endotracheal tube depth in children. Resuscitation 2014 Sep.
© 2014 Airway Management Education Center
Tracheal Rapid Ultrasound Saline Test (TRUST)
Probe marker
to the right
No ETT
What you see under
the probe
Endobronchial tube placement
acoustic shadowing from air
Tessaro MO et al. Resuscitation 2014 Sep.
No ETT - normal anatomy
under probe
Correct ETT placement
visualize structures
deep to the ETT
• The Results:
– Sensitivity: 99%
– PPV: 97%
Specificity: 96%
NPV: 99%
– Time to Visualization: 1-15 sec (mean, 4s)
Tessaro MO et al. Resuscitation 2014 Sep.
Tube confirmation confirmed
by fiberoptic bronchoscopy.
© 2014 Airway Management Education Center
What does this mean?
• Use ultrasound to confirm ETT depth to help verify
ETT placement
• It is quick, accurate and easy to do
© 2014 Airway Management Education Center
Case #2: Uh oh!
68 year old obese patient with ankylosing
spondylitis on steroids arrives via EMS confused,
febrile and tachypneic. Temp is 102.8, RR 40,
BP is 102/62, HR 104r. Oxygen saturation is
84% on non-rebreather. Lungs have rales and
rhonchi in both bases. His neck doesn’t move! He
keeps trying to take his FM oxygen off and is
getting worse in front of you…
How could you improve pre-intubation
oxygen status?
© 2014 Airway Management Education Center
To maximize his pre-oxygenation I would:
A. Bag assist with an Ambu bag
B. Add nasal cannula
C. I wouldn’t try to increase his Sa02, I’d push
Sux and “rock n’ roll”
D. Administer ketamine followed by BiPAP
© 2014 Airway Management Education Center
© 2014 Airway Management Education Center
A Dose of Ketamine Can Facilitate Pre-oxygenation
Before Emergency Intubation
Weingart SD et al.
Delayed sequence intubation: A prospective observational study . Ann Emerg Med
2014 Oct 22; [e-pub ahead of print] .
•
•
•
•
Prospective multicenter study (ED and ICU pts)
62 patients requiring escalating pre-oxygenation
Uncooperative with pre-oxygenation attempts
Dissociative dose of Ketamine (1mg/kg) IV
• Pre and post DSI oxygenation
• Adverse events
© 2014 Airway Management Education Center
A Dose of Ketamine Can Facilitate Pre-oxygenation
Before Emergency Intubation
Weingart SD et al.
Delayed sequence intubation: A prospective observational study . Ann Emerg Med
2014 Oct 22; [e-pub ahead of print] .
• Mode of oxygenation differed
• 23 FM oxygen
• 39 CPAP
• Mean increase in 02 sat from 90-99%
• Two not intubated (asthma)
• No adverse events reported
• Apnea, cardiac arrest, vomiting with aspiration
• All high risk patients increased post-DSI sats
© 2014 Airway Management Education Center
A Dose of Ketamine Can Facilitate Pre-oxygenation
Before Emergency Intubation
Weingart SD et al.
Delayed sequence intubation: A prospective observational study. Ann Emerg Med
2014 Oct 22; [e-pub ahead of print].
•
•
•
•
Specialized environment
Small numbers
Convenience sample
Would require further study (RCT)
© 2014 Airway Management Education Center
What does this mean?
• Robust pre-oxygenation prolongs safe apnea
• Some patients are difficult to fully preoxygenate
• In the right setting and with trained providers,
ketamine-facilitated pre-oxygenation is an
option  more to come on this for sure!
© 2014 Airway Management Education Center
Case #2 continued
As you get ready to give Ketamine, the RT
says “How are you going to keep him from
desaturating after you push the intubation
medications? I have this new device which I
have heard can help…want to try it?”
© 2014 Airway Management Education Center
© 2014 Airway Management Education Center
You say…
A. What the heck is that thing?
B. Great idea! The evidence suggests this can
be helpful.
C. Not sure, never used that before. It looks
like an “OR thing”
D. No, evidence suggests it’s useless
© 2014 Airway Management Education Center
High flow nasal cannula for prevention of
desaturation
Patel A, et al. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a
physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia
2014 Nov [Epub ahead of print]
•
•
•
•
•
Observational cross-sectional study in the UK
25 difficult intubations (obesity and stridulous)
Pre-oxygenated HOB at 40 degrees (70L/min)
Intubated at HOB 20 degrees with NC in place
Look at apnea time and rates of desaturation (<90%)
© 2014 Airway Management Education Center
© 2014 Airway Management Education Center
High flow nasal cannula for prevention of
desaturation
Patel A, et al. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a
physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia
2014 Nov [Epub ahead of print]
•
Results:
• Median apnea time was 14 minutes
• Median Mallampati was Class 3
• No hypoxemia < 90%
• Promoted exchange of carbon dioxide
• No other hypoxia-related complications (dysrhythmia,
etc.)
© 2014 Airway Management Education Center
© 2014 Airway Management Education Center
High flow nasal cannula for prevention of
desaturation
Patel A, et al. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a
physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia
2014 Nov [Epub ahead of print]
•
Limitations:
•Tough to translate to ED practice at this point
•Would it impede conventional laryngoscopy?
© 2014 Airway Management Education Center
What does this mean?
• Preventing rapid desaturation is safer for patients
• High flow NC  stents open airway, flushes gases &
provides oxygen
• Device may be awkward for emergency airway
management. Focus on robust pre and intraprocedural oxygenation.
• Routine part of RSI
© 2014 Airway Management Education Center
Questions?
© 2014 Airway Management Education Center
Case #2 continued
You have given ketamine and BL-PAP is
started. The third year resident says, hey can I
intubate this one. I want to use the GlideScope
thingy…
You can’t mess around with this airway BUT
she is a third year resident so she should be
good with GVL….right?
© 2014 Airway Management Education Center
You say…
A. Sure, you should have a very good FPS rate
as a senior resident.
B. No, GVL is a fad. I’m old school!
C. Sorry, trainee intubators can’t use the
GlideScope because first attempt success is
only 60%
D. No, GVL doesn’t work in patients with
reduced cervical spine mobility
© 2014 Airway Management Education Center
Do Emergency Medicine Trainees get better with the
GlideScope over time?
Sakles JC, et al. Learning curves for direct laryngoscopy and GlideScope video
laryngoscopy in an emergency medicine residency. West J Emerg Med 2014 Oct 29;
• Prospective observational single center registry
• 1613 intubations: 1035  DL and 578  GVL
• Patient characteristics similar
– Primary outcome  First attempt success
© 2014 Airway Management Education Center
Do Emergency Medicine Trainees get better with the
GlideScope over time?
Sakles JC, et al. Learning curves for direct laryngoscopy and GlideScope video
laryngoscopy in an emergency medicine residency. West J Emerg Med 2014 Oct 29;
Results:
• Mixed effect analysis
• Controlled for confounders
– Cardiac arrest, presence and number of difficulty airway
markers
– DL first attempt success constant at ~70%
– GVL improved (74%, 84%, 90%)
© 2014 Airway Management Education Center
Do Emergency Medicine Trainees get better with the
GlideScope over time?
Sakles JC, et al. Learning curves for direct laryngoscopy and GlideScope video laryngoscopy in an
emergency medicine residency. West J Emerg Med 2014 Oct 29;
• Not a randomized trial
• Very low FPS with DL
– Cultural issues around prolonged DL attempts?
– Early recourse to VL?
• Academic institution with interest in airway
management research – applicability?
© 2014 Airway Management Education Center
What does this mean?
• Trainees become more comfortable with GVL over time
– Tricks to overcome with GVL, but once you know those…BINGO!
• DL FPS is low in this study and likely reflects early reliance
on VL and may not represent full DL potential
• Nevertheless, VL is (at its worst) equivalent to DL and likely
better in emergency situations
• First attempts should be made with a VL. Pick a system - use
it and use it often!
© 2014 Airway Management Education Center
Questions?
© 2014 Airway Management Education Center
And now,
The Post-Test Questions
© 2014 Airway Management Education Center
Post-Test Question 1
All of the following methods are appropriate
for preoxygenation for RSI EXCEPT:
A.
B.
C.
D.
Facemask oxygen with reservoir at 15L/min
NC oxygen at 4L/min
Passive breathing through an Ambu bag
BL-PAP
© 2014 Airway Management Education Center
Post-Test Question 1
All of the following methods are appropriate
for preoxygenation for RSI EXCEPT:
A.
B.
C.
D.
Facemask oxygen with reservoir at 15L/min
NC oxygen at 4L/min
Passive breathing through an Ambu bag
BL-PAP
© 2014 Airway Management Education Center
Post-Test Question 2
As compared to SGA device insertion, for
patients with out-of-hospital cardiac arrest,
prehospital intubation has:
A.
B.
C.
D.
Higher rates of ROSC
Higher rates of survival to hospital discharge
Less favorable neurologic outcomes
Variable outcomes depending upon the
intubator
© 2014 Airway Management Education Center
Post-Test Question 2
As compared to SGA device insertion, for
patients with out-of-hospital cardiac arrest,
prehospital intubation has:
A.
B.
C.
D.
Higher rates of ROSC
Higher rates of survival to hospital discharge
Less favorable neurologic outcomes
Variable outcomes depending upon the
intubator
© 2014 Airway Management Education Center
Post-Test Question 3
Which of the following is true regarding the
GlideScope:
A. The glottic view is usually worse than with DL
B. You cannot intubate a patient with airway bleeding
using a GVL
C. Trainees improve their first-attempt success with GVL
over time
D. Time to tube placement is faster compared to DL
© 2014 Airway Management Education Center
Post-Test Question 3
Which of the following is true regarding the
GlideScope:
A. The glottic view is usually worse than with DL
B. You cannot intubate a patient with airway bleeding
using a GVL
C. Trainees improve their first-attempt success with
GVL over time
D. Time to tube placement is faster compared to DL
© 2014 Airway Management Education Center
Post-Test Question 4
Using ultrasound to confirm correct ETT
placement in pediatric patients is:
A.
B.
C.
D.
Highly sensitive
Operator dependent
Difficult to perform
A poor test and should not be used
© 2014 Airway Management Education Center
Post-Test Question 4
Using ultrasound to confirm correct ETT
placement in pediatric patients is:
A.
B.
C.
D.
Highly sensitive
Operator dependent
Difficult to perform
A poor test and should not be used
© 2014 Airway Management Education Center
Final Questions?
© 2014 Airway Management Education Center
Thank you!
© 2014 Airway Management Education Center