43 Awake Intubations in the Emergency Department: A Report from the National Emergency Airway Registry

Abstract

Study Objectives: Awake intubations are commonly performed in the OR for high-risk airways and include the use of topical anesthesia often augmented by lowerdose sedative agents. The rate of use of "awake" techniques, indications, devices employed, and outcomes are not known in ED populations. We sought to describe the current spectrum of awake intubation practices in the ED setting and report success rates, devices used, and rescue techniques in this population.Methods: We analyzed data from the National Emergency Airway Registry (NEAR), a multicenter prospective observational registry of 25 community and academic emergency departments. Patients with an awake intubation attempt, defined by use of topical airway anesthesia, between January 1, 2016 and December 31, 2018 were included. We report univariate descriptive data as proportions with clusteradjusted 95% confidence intervals (CIs).Results: Of 19,071 discrete patient encounters, an awake technique was used on first attempt in 82 (0.4%) patients. The median patient age was 59 years (IQR 46-67) and 27 (33%) were female. Angioedema (32%) and non-angioedema airway obstruction (31%) were the most common indications. Emergency physicians performed 90% of first attempts. The most common initial devices were a flexible endoscope (78%) followed by the GlideScope video laryngoscope (7%). A nasal route was used in 56 (68%) cases. A combination of sedative and topical medications were used in 42 (51%) cases, while topical anesthesia alone was used in 40 (49%) cases. The most common sedative used was ketamine (41%). The first-attempt success rate for all awake intubations was 85% (95% CI [76%-95%]). Nasal first attempts were successful in 91% (95% CI [80%-97%]) versus 73% of oral first attempts (95% CI [52%-88%]). Success with flexible endoscopes via nasal and oral routes was 93% (95% CI ) and 50%, (95% CI [19%-81%]), respectively. Rigid video laryngoscopes via oral route were successful in 8 of 9 patients (89%, 95% CI [45%-100%]). First-attempt success among those receiving only topical agents was 90% (95% CI [70%-98%]); among those with topical plus sedative agent use first-attempt success was 81% (95% CI [64%-92%]). The most common device used for rescue technique was a flexible endoscope, which was used in 5 of 12 cases (47%). Hypoxia was the most common adverse event and occurred in 10 cases (12%). One patient required a rescue surgical airway. Ultimate success was 100%.Conclusion: Awake intubations in the ED are uncommon and are done most often in patients with airway swelling or obstruction. Emergency physicians performed the majority of first intubation attempts with high first-attempt success. Nasal and oral routes with flexible and rigid video laryngoscopic equipment were used. Rescue cricothyroidotomy was performed once.

First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry

“…First-attempt intubations using intubating laryngeal mask airways, bronchoscopes, digital intubation, and nonorotracheal routes (ie, nasal and surgical airways) were excluded, since these are infrequently performed in the ED and often indicative of atypical circumstances, such as the use of the nasal route for bronchoscopyassisted intubation. 18,19 Pediatric cases were excluded, since blood pressure is age-specific, and preintubation systolic blood pressure was collected categorically in the registry with adult-specific cutoffs (Supplemental Digital Content, Supplemental We defined difficult airway type, the independent variable, using mechanistic theory. Variables defining ADAs and PDAs were considered if available in NEAR, may contribute to difficult intubation or poor intubation outcomes, and apparent before induction (Table 1).…”

“…Similarly, we excluded awake and flexible fiberoptic intubations, since these occur infrequently in NEAR. 19,37 Intubator-specific skill and experience with ADA and PDA characteristics was unknown and may have affected measured outcomes. Lastly, most intubations were performed by residents in the ED; therefore, the results may not be generalizable to all clinicians and practice settings.…”

Airway Management of Suspected Traumatic Brain Injury Patients in the Emergency Room

“…The emergency team must consider the risk and benefit of both techniques in an individual patient. 16 17 All trauma patients must be considered to have cervical spine injury unless proved otherwise. During endotracheal intubation, the flexion at lower cervical joints and extension at atlantooccipital joints is achieved to align the oropharyngeal and laryngeal axes to visualize the vocal cord.…”