Alexis F Turgeon, Pierre C Nicole, Claude A Trépanier, Sylvie Marcoux, Martin R Lessard
Cricoid pressure does not increase the rate of failed intubation by direct laryngoscopy in adults.
Anesthesiology. 2005 Feb;102(2):315-9.
Abstract/Text
BACKGROUND: Cricoid pressure (CP) is applied during induction of anesthesia to prevent regurgitation of gastric content and pulmonary aspiration. However, it has been suggested that CP makes tracheal intubation more difficult. This double-blind randomized study evaluated the effect of CP on orotracheal intubation by direct laryngoscopy in adults.
METHODS: Seven hundred adult patients undergoing general anesthesia for elective surgery were randomly assigned to have a standardized CP (n = 344) or a sham CP (n = 356) during laryngoscopy and intubation. After anesthesia induction and complete muscle relaxation, a 30-s period was allowed to complete intubation with a Macintosh No. 3 laryngoscope blade. The primary endpoint was the rate of failed intubation at 30 s. The secondary endpoints included the intubation time, the Cormack and Lehane grade of laryngoscopic view, and the Intubation Difficulty Scale score.
RESULTS: Groups were similar for demographic data and risk factors for difficult intubation. The rates of failed intubation at 30 s were comparable for the two groups: 15 of 344 (4.4%) and 13 of 356 (3.7%) in the CP and sham CP groups, respectively (P = 0.70). The grades of laryngoscopic view and the Intubation Difficulty Scale score were also comparable. Median intubation time was slightly longer in the CP group than in the sham CP group (11.3 and 10.4 s, respectively, P = 0.001).
CONCLUSIONS: CP applied by trained personnel does not increase the rate of failed intubation. Hence CP should not be avoided for fear of increasing the difficulty of intubation when its use is indicated.
U McNelis, A Syndercombe, I Harper, J Duggan
The effect of cricoid pressure on intubation facilitated by the gum elastic bougie.
Anaesthesia. 2007 May;62(5):456-9. doi: 10.1111/j.1365-2044.2007.05019.x.
Abstract/Text
Tracheal tube impingement is common during gum elastic bougie facilitated intubation and a 90 degrees anti-clockwise rotation of the tube usually relieves it. We detail a case where this manoeuvre failed in the presence of cricoid pressure. We investigated the effect of cricoid pressure on gum elastic bougie facilitated intubation in 120 patients randomly allocated to receive sham cricoid pressure (n = 60) or 30 N cricoid pressure (n = 60). Impingement occurred in 23/60 (38%) with sham cricoid pressure and 36/60 (60%) with 30 N cricoid pressure (p < 0.025). Only females showed an increase in impingement with cricoid pressure: 29% sham cricoid pressure vs 63% 30 N cricoid pressure, p < 0.01, whereas the impingement in males was approximately 60% in both groups. Ninety degree anti-clockwise rotation of the tube was successful in all 23 patients (100%) with sham cricoid pressure and in 32/36 patients (89%) with 30 N cricoid pressure. Releasing cricoid pressure relieved the obstruction in the four cases where 90 degrees anti-clockwise rotation of the tube failed. Impingement is common and 90 degrees anti-clockwise rotation is highly effective in both the presence and absence of cricoid pressure. In a small number of cases, cricoid pressure may cause the manoeuvre to fail.
E L Hartsilver, R G Vanner
Airway obstruction with cricoid pressure.
Anaesthesia. 2000 Mar;55(3):208-11.
Abstract/Text
Cricoid pressure may cause airway obstruction. We investigated whether this is related to the force applied and to the technique of application. We recorded expired tidal volumes and inflation pressures during ventilation via a face-mask and oral airway in 52 female patients who were anaesthetised and about to undergo elective surgery. An inspired tidal volume of 900 ml was delivered using a ventilator. Ventilation was assessed under five different conditions: no cricoid pressure, backwards cricoid pressure applied with a force of 30 N, cricoid pressure applied in an upward and backward direction with a force of 30 N, backwards cricoid pressure with a force of 44 N and through a tracheal tube. An expired tidal volume of < 200 ml was taken to indicate airway obstruction. Airway obstruction did not occur without cricoid pressure, but did occur in one patient (2%) with cricoid pressure at 30 N, in 29 patients (56%) with 30 N applied in an upward and backward direction and in 18 (35%) patients with cricoid pressure at 44 N. Cricoid pressure applied with a force of 44 N can cause airway obstruction but if cricoid pressure is applied with a force of 30 N, airway obstruction occurs less frequently (p = 0.0001) unless the force is applied in an upward and backward direction.
G Hocking, F L Roberts, M E Thew
Airway obstruction with cricoid pressure and lateral tilt.
Anaesthesia. 2001 Sep;56(9):825-8.
Abstract/Text
We studied the effect of cricoid pressure and lateral tilt on airway patency during ventilation by facemask in a simulated obstetric setting. The lungs of 50 patients were ventilated by facemask and Guedel airway using a Nuffield Penlon 200 ventilator and Bain system with standard settings. Expired tidal volumes and peak inspiratory pressures were recorded for 10 breaths in each of four combinations: supine with no cricoid pressure, supine with cricoid pressure, 15 degrees lateral tilt with no cricoid pressure and 15 degrees lateral tilt with cricoid pressure. The timing of cricoid pressure was randomised and blinded to all observers. In both supine and tilted positions, cricoid pressure produced a reduction in tidal volume (p < 0.001) and an increase in peak inspiratory pressure (p < 0.001). Cricoid pressure with lateral tilt did not produce any additional airway obstruction to that in the supine position. Complete airway obstruction (tidal volume < 200 ml) resulted on three occasions, all with cricoid pressure applied.
Volker Dörges, Volker Wenzel, Peer Knacke, Klaus Gerlach
Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients.
Crit Care Med. 2003 Mar;31(3):800-4. doi: 10.1097/01.CCM.0000054869.21603.9A.
Abstract/Text
OBJECTIVE: Endotracheal intubation is the gold standard for providing emergency ventilation, but acquiring and maintaining intubation skills may be difficult. Recent reports indicate that even in urban emergency medical services with a high call volume, esophageal intubations were observed, requiring either perfect intubation skills or development of alternatives for emergency ventilation.
DESIGN: Simulated emergency ventilation in apneic patients employing four different airway devices that used small tidal volumes.
SETTING: University hospital operating room.
SUBJECTS: Forty-eight ASA I/II patients who signed written informed consent before being enrolled into the study.
INTERVENTIONS: In healthy adult patients without underlying respiratory or cardiac disease who were breathing room air before undergoing routine induction of surgery, 12 experienced professional paramedics inserted either a laryngeal mask airway (n = 12), Combitube (n = 12), or cuffed oropharyngeal airway (n = 12) or placed a face mask (n = 12) before providing ventilation with a pediatric (maximum volume, 700 mL) self-inflating bag with 100% oxygen for 3 mins.
MEASUREMENTS AND MAIN RESULTS: In three of 12 cuffed oropharyngeal airway patients, two of 12 laryngeal mask airway patients, and one of 12 Combitube patients, oxygen saturation fell below 90% during airway device insertion, and the experiment was terminated; no oxygenation failures occurred with the bag-valve-mask. Oxygen saturation decreased significantly (p <.05) during insertion of the Combitube and laryngeal mask but not with the bag-valve-mask and cuffed oropharyngeal airway; however, oxygen saturation increased after 1 min of ventilation with 100% oxygen. No differences in tidal lung volumes were observed between airway devices.
CONCLUSIONS: Paramedics were able to employ the laryngeal mask airway, Combitube, and cuffed oropharyngeal airway in apneic patients with normal lung compliance and airways. In this population, bag-valve-mask ventilation was the most simple and successful strategy. Small tidal volumes applied with a pediatric self-inflating bag and 100% oxygen resulted in adequate oxygenation and ventilation.
SOS-KANTO study group
Comparison of arterial blood gases of laryngeal mask airway and bag-valve-mask ventilation in out-of-hospital cardiac arrests.
Circ J. 2009 Mar;73(3):490-6. Epub 2009 Feb 4.
Abstract/Text
BACKGROUND: Focusing on the efficacy of successful ventilation during cardiopulmonary resuscitation (CPR) with alternative airways, previous reports investigated various parameters such as success rate, tidal volume, incidence of regurgitation, etc. However, there are few investigations of arterial blood gases (ABG) during CPR with alternative airways, especially the laryngeal mask airway (LMA).
METHODS AND RESULTS: A prospective multicenter study, non-randomized control trial compared ABG on hospital admission of patients resuscitated by emergency medical service personnel with a bag-valve-mask (BVM) with those using a LMA in witnessed cardiac-verified out-of-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia. According to the Utstein template, 173 cases of LMA and 200 of BVM both placed by paramedics were enrolled. The median arterial pH was statistically higher in the LMA group than in the BVM group (7.117 vs 7.075, P=0.02). There was no difference in the median value of PaCO(2) (52.9 vs 55.3, P=0.06) and PaO(2) (64.6 vs 71.9, P=0.56).
CONCLUSIONS: LMA does not greatly benefit the respiratory status of patients such as in this study population. Delayed placement of a LMA will be recommended to achieve minimally interrupted chest compression in an out-of-hospital CPR protocol for witnessed VF cases following shock.
Richard Schalk, Christian Byhahn, Felix Fausel, Andreas Egner, Dieter Oberndörfer, Felix Walcher, Leo Latasch
Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes.
Resuscitation. 2010 Mar;81(3):323-6. doi: 10.1016/j.resuscitation.2009.11.007. Epub 2009 Dec 16.
Abstract/Text
CONCEPT: Endotracheal intubation (ETI) is considered to be the gold standard of prehospital airway management. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers less experienced in ETI. We prospectively evaluated the feasibility of laryngeal tubes used by paramedics and emergency physicians for out-of-hospital airway management.
MATERIAL AND METHODS: During a 24-month period, all cases of prehospital use of the laryngeal tube disposable (LT-D) and laryngeal tube suction disposable (LTS-D) within five operational areas of emergency medical services were recorded by a standardised questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time and personal level of experience.
RESULTS: Of 157 prehospital intubation attempts with the LT-D/LTS-D, 152 (96.8%) were successfully performed by paramedics (n=70) or emergency physicians (n=87). The device was used as initial airway (n=87) or rescue device after failed ETI (n=70). The placement time was < or =45s (n=120), 46-90s (n=20) and >90s (n=7). In five cases the time needed was not specified. The number of placement attempts was one (n=123), two (n=25), three (n=2) and more than three (n=2). The majority of users (61.1%) were relative novices with no more than five previous laryngeal tube placements.
CONCLUSION: The LT-D/LTS-D represents a reliable tool for prehospital airway management in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced with ETI or as a rescue device when ETI has failed.
Copyright 2009 Elsevier Ireland Ltd. All rights reserved.
B J Stone, P J Chantler, P J Baskett
The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway.
Resuscitation. 1998 Jul;38(1):3-6.
Abstract/Text
The risk of gastric regurgitation and subsequent pulmonary aspiration is a recognised complication of cardiac arrest--a risk which may be further increased by the resuscitative procedure itself. The purpose of this study was to compare the incidence of gastric regurgitation between the bag valve mask (BVM) and laryngeal mask airway (LMA). The resuscitation data collection forms of 996 patients who underwent in-hospital cardiopulmonary resuscitation over a 3.5 year period were reviewed. Of these, 199 patients were excluded from the study because there was no airway management involving a BVM or LMA. The incidence and timing of regurgitation was studied in the remaining 797 patients. Regurgitation was recorded to have occurred at some stage in 180 of these patients (22.6%). However, 84 regurgitated prior to CPR (46.7% of those patients who regurgitated). These patients were excluded from further analysis as regurgitation could not have been affected by any form of ventilation. Of the remaining 713 patients, BVM ventilation was used in 636 cases. In 170 of these the LMA was also used following the BVM. Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%. The LMA was used during resuscitation in 256 cases of which 170 had BVM ventilation prior to the LMA. Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%. The study confirms experience reported in earlier studies that when an LMA is used as a first line airway device, regurgitation is relatively uncommon.
C J Rumball, D MacDonald
The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest.
Prehosp Emerg Care. 1997 Jan-Mar;1(1):1-10.
Abstract/Text
PURPOSE: A prehospital study was conducted to assess and compare three alternative airway devices and the oral airway for use by non-Advanced Life Support emergency medical assistants (EMAs).
METHOD: A modified randomized crossover design was used. The Pharyngeal Tracheal Lumen Airway (PTL), the laryngeal mask (LM), and the esophageal tracheal Combitube (Combi) were compared objectively for success of insertion, ventilation, and arterial blood gas and spirometry measurements performed upon hospital arrival. Subjective assessment was carried out by EMAs and receiving physicians at the time of device use, and an eight-question comparative evaluation of all devices was completed by EMAs at study conclusion. A comparative cost analysis was performed. Operating room training was compared with mannequin training for the LM. Autopsy findings and survival to hospital discharge were analyzed. The study took place in four non-ALS communities over four and a half years, and involved 470 patients in cardiac and/or respiratory arrest. EMAs had automatic external defibrillator training but no endotracheal intubation skills.
RESULTS: Successful insertion and ventilation: Combi, 86%; PTL, 82%; LM, 73% (p = 0.048). No significant difference was found for objective measurements of ventilatory effectiveness (ABGs and spirometry). Significant comparative differences in subjective evaluation were found.
CONCLUSIONS: The PTL, LM, and Combi appear to offer substantial advances over the OA/BVM system. Although the most costly, the Combitube was associated with the least problems with ventilation and was the most preferred by a majority of EMAs.
Ron M Walls, Calvin A Brown, Aaron E Bair, Daniel J Pallin, NEAR II Investigators
Emergency airway management: a multi-center report of 8937 emergency department intubations.
J Emerg Med. 2011 Oct;41(4):347-54. doi: 10.1016/j.jemermed.2010.02.024. Epub 2010 Nov 9.
Abstract/Text
OBJECTIVE: Emergency department (ED) intubation personnel and practices have changed dramatically in recent decades, but have been described only in single-center studies. We sought to better describe ED intubations by using a multi-center registry.
METHODS: We established a multi-center registry and initiated surveillance of a longitudinal, prospective convenience sample of intubations at 31 EDs. Clinicians filled out a data form after each intubation. Our main outcome measures were descriptive. We characterized indications, methods, medications, success rates, intubator characteristics, and associated event rates. We report proportions with 95% confidence intervals and chi-squared testing; p-values < 0.05 were considered significant.
RESULTS: There were 8937 encounters recorded from September 1997 to June 2002. The intubation was performed for medical emergencies in 5951 encounters (67%) and for trauma in 2337 (26%); 649 (7%) did not have a recorded mechanism or indication. Rapid sequence intubation was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. The first method chosen was successful in 95%, and intubation was ultimately successful in 99%. Emergency physicians performed 87% of intubations and anesthesiologists 3%. Several other specialties comprised the remaining 10%. One or more associated events were reported in 779 (9%) encounters, with an average of 12 per 100 encounters. No medication errors were reported in 6138 rapid sequence intubations. Surgical airways were performed in 0.84% of all cases and 1.7% of trauma cases.
CONCLUSION: Emergency physicians perform the vast majority of ED intubations. ED intubation is performed more commonly for medical than traumatic indications. Rapid sequence intubation is the most common method of ED intubation.
Copyright © 2011 Elsevier Inc. All rights reserved.
Takahiro Suzuki, Mayu Aono, Naoko Fukano, Makiko Kobayashi, Shigeru Saeki, Setsuro Ogawa
Effectiveness of the timing principle with high-dose rocuronium during rapid sequence induction with lidocaine, remifentanil and propofol.
J Anesth. 2010 Apr;24(2):177-81. doi: 10.1007/s00540-010-0880-y. Epub 2010 Feb 26.
Abstract/Text
PURPOSE: The main purpose of this study was to examine the effectiveness of the timing principle with 1 mg kg(-1) rocuronium for rapid sequence intubation. As secondary outcomes, propofol and lidocaine with or without remifentanil were examined to note their effects on the cardiovascular responses to laryngoscopy and intubation.
METHODS: Thirty patients were randomly allocated to one of two groups of 15 patients each: a lidocaine-treated group (L) and a lidocaine/remifentanil-treated group (LR). Thirty seconds after lidocaine 1 mg kg(-1) with or without infusion of remifentanil 1 microg kg(-1) min(-1), all patients received a bolus of rocuronium 1 mg kg(-1). Shortly afterwards, patients were given propofol 2-2.5 mg kg(-1). Intubating conditions and cardiovascular responses were observed 60 s after rocuronium. The time to spontaneous recovery of visible train-of-four (TOF) counts of 4 was observed at the thumb during 1.0-1.5% end-tidal sevoflurane and remifentanil anesthesia.
RESULTS: All patients had excellent or good intubating conditions. Hypertension and tachycardia during laryngoscopy were well prevented in group LR, whereas they were significantly observed in group L. The times to reappearance of TOF counts of 4 were comparable in all groups [mean (SD); 63.6 (8.6) min in group L and 63.5 (11.6) min in group LR].
CONCLUSION: Application of the timing principle with 1 mg kg(-1) rocuronium is beneficial for rapid tracheal intubation. Co-administered lidocaine, remifentanil and propofol can definitely suppress cardiovascular responses during laryngoscopy and intubation.
Jeffrey J Perry, Jacques S Lee, Victoria A H Sillberg, George A Wells
Rocuronium versus succinylcholine for rapid sequence induction intubation.
Cochrane Database Syst Rev. 2008 Apr 16;(2):CD002788. doi: 10.1002/14651858.CD002788.pub2. Epub 2008 Apr 16.
Abstract/Text
BACKGROUND: Patients requiring emergency endotracheal intubation often require a rapid sequence induction (RSI) intubation technique to protect against aspiration or increased intracranial pressure, or to facilitate intubation. Succinylcholine is the most commonly used muscle relaxant because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This meta-analysis is an update since our initial Cochrane systematic review in 2003.
OBJECTIVES: To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made based on dose of rocuronium, narcotic use, emergency versus elective intubation, age and induction agent. The primary outcome was excellent intubation conditions. The secondary outcome was acceptable conditions.
SEARCH STRATEGY: In our initial systematic review we searched all databases until March 2000. We have updated that search and searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007 issue 3), MEDLINE (1966 to June Week 3 2007), EMBASE (1988 to 2007 Week 26) for randomized controlled trials or controlled clinical trials relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.
SELECTION CRITERIA: We included all trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, main outcomes of intubation conditions).
DATA COLLECTION AND ANALYSIS: Two authors (JP, JL or VS) independently extracted data and assessed methodological quality for allocation concealment. We combined the outcomes in RevMan using relative risk (RR) with a random-effects model.
MAIN RESULTS: In our initial systematic review we identified 40 studies and included 26. In this update we identified a further 18 studies and included 11. In total, we identified 58 potential studies; 37 were combined for meta-analysis. Overall, succinylcholine was superior to rocuronium, RR 0.86 (95% confidence interval (95% CI) 0.80 to 0.92) (n = 2690). In the group that used propofol for induction, the intubation conditions were superior with succinylcholine (RR 0.88, 95% CI 0.80 to 0.97) (n = 1183). This is contrary to our previous meta-analysis results where we reported that intubation conditions were superior in the rocuronium group when propofol was used. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.
AUTHORS' CONCLUSIONS: Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions.
Adam Herbstritt, Keith Amarakone
Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation?
Emerg Med J. 2012 Mar;29(3):256-8. doi: 10.1136/emermed-2012-201100.4.
Abstract/Text
A short-cut review was carried out to establish whether rocuronium is as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation (RSI). A total of 94 papers was found using the reported search, of which seven represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that rocuronium is as effective as succinylcholine at facilitating laryngoscopy during RSI.
Salvatore Silvestri, George A Ralls, Baruch Krauss, Josef Thundiyil, Steven G Rothrock, Amy Senn, Eric Carter, Jay Falk
The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Ann Emerg Med. 2005 May;45(5):497-503. doi: 10.1016/j.annemergmed.2004.09.014.
Abstract/Text
STUDY OBJECTIVE: We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system.
METHODS: This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring.
RESULTS: Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%).
CONCLUSION: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.
Stefek Grmec
Comparison of three different methods to confirm tracheal tube placement in emergency intubation.
Intensive Care Med. 2002 Jun;28(6):701-4. doi: 10.1007/s00134-002-1290-x. Epub 2002 Apr 30.
Abstract/Text
OBJECTIVES: Verification of endotracheal tube placement is of vital importance, since unrecognized esophageal intubation can be rapidly fatal (death, brain damage). The aim of our study was to compare three different methods for immediate confirmation of tube placement: auscultation, capnometry and capnography in emergency conditions in the prehospital setting.
DESIGN AND SETTING: Prospective study in the prehospital setting.
PATIENTS AND INTERVENTIONS: All adult patients (>18 years) were intubated by an emergency physician in the field. Tube position was initially evaluated by auscultation. Then, capnometry was performed with infrared capnometry and capnography with infrared capnography. The examiners looked for the characteristic CO(2) waveform and value of end-tidal carbon dioxide (EtCO(2)) in millimeters of mercury. Determination of final tube placement was performed by a second direct visualization with laryngoscope. Data are mean +/- SD and percentages.
MEASUREMENTS AND RESULTS: Over a 4year period, 345 patients requiring emergency intubation were included. Indications for intubation included cardiac arrest ( n=246; 71%) and non-arrest conditions ( n=99; 29%). In nine (2.7%) patients, esophageal tube placement occurred. The esophageal intubations were followed by successful endotracheal intubations without complications. The capnometry (sensitivity and specificity 100%) and capnography (sensitivity and specificity 100%) were better than auscultation (sensitivity 94% and specificity 83%) in confirming endotracheal tube placement in non-arrest patients ( p<0.05). Capnometry was highly specific (100%) but not sensitive (88%) for correct endotracheal intubation in patients with cardiopulmonary arrest (capnometry versus auscultation and capnometry versus capnography, p<0.05).
CONCLUSION: Capnography is the most reliable method to confirm endotracheal tube placement in emergency conditions in the prehospital setting.
Taku Takeda, Koichi Tanigawa, Hitoshi Tanaka, Yuri Hayashi, Eiichi Goto, Keiichi Tanaka
The assessment of three methods to verify tracheal tube placement in the emergency setting.
Resuscitation. 2003 Feb;56(2):153-7.
Abstract/Text
We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO(2)) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO(2) monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one false-positive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n=56), auscultation, the ETCO(2), and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P<0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n=81), auscultation, the ETCO(2), and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P<0.05 vs. EDD and ETCO(2)). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO(2) monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO(2) or the EDD are not uncommon, and clinical methods are superior to the use of these devices.
K Tanigawa, T Takeda, E Goto, K Tanaka
The efficacy of esophageal detector devices in verifying tracheal tube placement: a randomized cross-over study of out-of-hospital cardiac arrest patients.
Anesth Analg. 2001 Feb;92(2):375-8.
Abstract/Text
We performed this prospective study to evaluate the efficacy of esophageal detector devices (EDDs), both the bulb and the syringe-type, to indicate positioning of endotracheal tubes (ETTs) in out-of-hospital cardiac arrest patients. Forty-eight adult patients with out-of-hospital cardiac arrest were enrolled. Immediately after tracheal intubation and ETT cuff inflation in the emergency department, the patients were allocated randomly to two cross-over groups. In Group 1 (n = 24), patients underwent a bulb test and a syringe test in sequence. In Group 2 (n = 24), patients underwent a syringe test and a bulb test in sequence. End-tidal carbon dioxide (ETCO(2)) was also monitored. In 56 attempts at tracheal intubation, the bulb, the syringe, and ETCO(2) indicated all eight esophageal intubations. In 48 tracheal intubations, the bulb test correctly indicated 34 tracheal intubations (sensitivity, 70.8%). The syringe test identified 35 tracheal intubations (sensitivity, 72.9%). The results of both tests agreed in 33 tracheal intubations. ETCO(2) was detected in 31 tracheal intubations (sensitivity, 64.6%). No statistical difference was found among the tests. EDDs were less sensitive in detecting tracheal intubation for out-of-hospital cardiac arrest patients. Therefore, proper clinical judgment in conjunction with these devices should be used to confirm ETT placement in these difficult situations.
K Tanigawa, T Takeda, E Goto, K Tanaka
Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients.
Anesthesiology. 2000 Dec;93(6):1432-6.
Abstract/Text
BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients.
METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation).
RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity.
CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.
Anne-Maree Kelly, Debra Kerr, Paul Dietze, Ian Patrick, Tony Walker, Zeff Koutsogiannis
Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose.
Med J Aust. 2005 Jan 3;182(1):24-7.
Abstract/Text
OBJECTIVE: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.
DESIGN: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.
PARTICIPANTS AND SETTING: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.
MAIN OUTCOME MEASURES: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.
RESULTS: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.
CONCLUSION: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology. 2003 May;98(5):1269-77.
Abstract/Text
Joakim Engström, Göran Hedenstierna, Anders Larsson
Pharyngeal oxygen administration increases the time to serious desaturation at intubation in acute lung injury: an experimental study.
Crit Care. 2010;14(3):R93. doi: 10.1186/cc9027. Epub 2010 May 24.
Abstract/Text
INTRODUCTION: Endotracheal intubation in critically ill patients is associated with severe life-threatening complications in about 20%, mainly due to hypoxemia. We hypothesized that apneic oxygenation via a pharyngeal catheter during the endotracheal intubation procedure would prevent or increase the time to life-threatening hypoxemia and tested this hypothesis in an acute lung injury animal model.
METHODS: Eight anesthetized piglets with collapse-prone lungs induced by lung lavage were ventilated with a fraction of inspired oxygen of 1.0 and a positive end-expiratory pressure of 5 cmH2O. The shunt fraction was calculated after obtaining arterial and mixed venous blood gases. The trachea was extubated, and in randomized order each animal received either 10 L oxygen per minute or no oxygen via a pharyngeal catheter, and the time to desaturation to pulse oximeter saturation (SpO2) 60% was measured. If SpO2 was maintained at over 60%, the experiment ended when 10 minutes had elapsed.
RESULTS: Without pharyngeal oxygen, the animals desaturated after 103 (88-111) seconds (median and interquartile range), whereas with pharyngeal oxygen five animals had a SpO2 > 60% for the 10-minute experimental period, one animal desaturated after 7 minutes, and two animals desaturated within 90 seconds (P < 0.016, Wilcoxon signed rank test). The time to desaturation was related to shunt fraction (R2 = 0.81, P = 0.002, linear regression); the animals that desaturated within 90 seconds had shunt fractions >40%, whereas the others had shunt fractions <25%.
CONCLUSIONS: In this experimental acute lung injury model, pharyngeal oxygen administration markedly prolonged the time to severe desaturation during apnea, suggesting that this technique might be useful when intubating critically ill patients with acute respiratory failure.
G Frova, M Sorbello
Algorithms for difficult airway management: a review.
Minerva Anestesiol. 2009 Apr;75(4):201-9. Epub 2008 Oct 23.
Abstract/Text
Difficult airway management and maintenance of oxygenation remain the two most challenging tasks for anesthetists, while also being controversial items in terms of clinically based-evidence to support relevant guidelines in the literature. Nevertheless, different expert groups and scientific societies from several countries have published guidelines dedicated to the management of difficult airways. These documents have been demonstrated to be useful in reducing airway management related critical accidents, despite their limited use in litigations and legal issues. The aim of this review is to compare different airway management guidelines published by the United States, United Kingdom, France, Italy, Germany, and Canada while trying to elucidate the main differences, weaknesses, and strengths for identifying critical concepts in the management of difficult airways.
Walls RM：井上哲夫、近江明文、須崎紳一郎、他訳，緊急気道管理マニュアル，メディカル・サイエンス・インターナショナル， 2003.
A Patel, A Pearce
Progress in management of the obstructed airway.
Anaesthesia. 2011 Dec;66 Suppl 2:93-100. doi: 10.1111/j.1365-2044.2011.06938.x.
Abstract/Text
There is no consensus as to the ideal approach for the anaesthetic management of the adult obstructed airway and there are advocates of awake fibreoptic intubation, inhalational induction and intravenous induction techniques. This review considers the different options available for obstruction at different anatomical levels. Decisions must also be made on the urgency of the required intervention. Particular controversies revolve around the role of inhalational vs intravenous induction of anaesthesia, the use or avoidance of neuromuscular blockade and the employment of cannula cricothyroidotomy vs surgical tracheostomy.
© 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.
K Chen, J Varon, O C Wenker
Malignant airway obstruction: recognition and management.
J Emerg Med. 1998 Jan-Feb;16(1):83-92.
Abstract/Text
Malignant airway obstruction affects up to 80,000 patients annually, many of whom will present acutely to the emergency department (ED). This clinical entity should be sought in any patient presenting to the ED with increasing shortness of breath, recurrent chest infections, hemoptysis, and an inability to lie flat. Interventions suggested in malignant airway obstruction include: maintenance of spontaneous ventilation by avoiding respiratory depressing sedation, muscle relaxants or narcotics; changes in patient's position; avoidance of general anesthesia and positive pressure ventilation, if possible; placement of endotracheal tube beyond the level of obstruction; radiotherapy; corticosteroids; availability of helium-oxygen mixtures, cardiopulmonary bypass, or extracorporeal membrane oxygenation. If time allows, further diagnostic studies will be of assistance in assessing the best therapy before definitive intervention.
Stuart F Reynolds, John Heffner
Airway management of the critically ill patient: rapid-sequence intubation.
Chest. 2005 Apr;127(4):1397-412. doi: 10.1378/chest.127.4.1397.
Abstract/Text
Advances in emergency airway management have allowed intensivists to use intubation techniques that were once the province of anesthesiology and were confined to the operating room. Appropriate rapid-sequence intubation (RSI) with the use of neuromuscular blocking agents, induction drugs, and adjunctive medications in a standardized approach improves clinical outcomes for select patients who require intubation. However, many physicians who work in the ICU have insufficient experience with these techniques to adopt them for routine use. The purpose of this article is to review airway management in the critically ill adult with an emphasis on airway assessment, algorithmic approaches, and RSI.
David C Willms, Ruben Mendez, Vanjah Norman, Joseph H Chammas
Emergency bedside extracorporeal membrane oxygenation for rescue of acute tracheal obstruction.
Respir Care. 2012 Apr;57(4):646-9. doi: 10.4187/respcare.01417.
Abstract/Text
A 39-year-old man experienced total obstruction of a distal tracheal plastic stent by a tumor mass, preventing effective ventilation and resulting in cardiac arrest. Resuscitation by emergency bedside venoarterial extracorporeal membrane oxygenation (ECMO) permitted time to physically remove the obstructing tumor and reestablish successful ventilation and liberation from ventilatory support. We review several other reported cases of emergency ECMO to resuscitate patients with acute airway obstruction.
Michele Blanda, Ugo E Gallo
Emergency airway management.
Emerg Med Clin North Am. 2003 Feb;21(1):1-26.
Abstract/Text
Airway control is one of the most critical interventions required for saving a life. It is essential that practitioners be as well trained as possible in the numerous techniques available to establish airway control. This article reviews some of the available techniques, though other techniques that are not discussed (such as fiberoptic-assisted endotracheal intubation) may also be useful. Perhaps the most important aspect of advanced airway management is the ability to anticipate and prepare for the difficult airway. This article gives numerous options for the difficult airway situation.
箕輪良行：アナフィラキシー徹底ガイド．救急・集中治療 17(8), 2005.
Roger Zoorob, Mohamad Sidani, John Murray
Croup: an overview.
Am Fam Physician. 2011 May 1;83(9):1067-73.
Abstract/Text
Croup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States. Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days. Croup is often caused by viruses, with parainfluenza virus (types 1 to 3) as the most common. However, physicians should consider other diagnoses, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema. Humidification therapy has not been proven beneficial. A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup. Most episodes of croup are mild, with only 1 to 8 percent of patients with croup requiring hospital admission and less than 3 percent of admitted patients requiring intubation.
R Bryan Bell, David S Verschueren, Eric J Dierks
Management of laryngeal trauma.
Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):415-30. doi: 10.1016/j.coms.2008.03.004.
Abstract/Text
Fractures of the larynx are uncommon injuries that may be associated with maxillofacial trauma. Clinicians treating maxillofacial injuries should be familiar with the signs and symptoms of laryngeal fractures and with proper airway management. A timely evaluation of the larynx, rapid airway intervention, and proper surgical repair are essential for a successful outcome.
