Airway management in pre-hospital critical care: a review of the evidence for a ‘top five’ research priority

Crewdson, Kate; Rehn, Marius; Lockey, David

doi:10.1186/s13049-018-0556-4

Cited by 29 publications

(30 citation statements)

References 74 publications

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“…Endotracheal intubation allows definitive protection of the airway and may optimise oxygenation and ventilation in critically unwell patients [1,2]. Advanced airway interventions, including Pre-Hospital Emergency Anaesthesia (PHEA), are being increasingly performed in the prehospital environment [3][4][5][6] with high procedural success [7,8]. However, severe complications are associated with PHEA including hypoxaemia and cardiovascular instability [9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

“…Although defined inconsistently in the present literature, apnoeic oxygenation may be used as an adjunct to pre-oxygenation by a range of methods [ 24 – 27 ]. Similarly, its application in contemporary UK HEMS practice is unknown [ 3 ]. Identification of the oxygenation strategies being used in UK HEMS practice will allow better understanding of current practice and inform development of future observational or interventional studies.…”

Section: Introductionmentioning

confidence: 99%

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Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey)

Boulton

Mashru²,

Lyon

2020

Scand J Trauma Resusc Emerg Med

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Background Maintaining effective oxygenation throughout the process of Pre-Hospital Emergency Anaesthesia (PHEA) is critical. There are multiple strategies available to clinicians to oxygenate patients both prior to and during PHEA. The optimal pre-oxygenation technique remains unclear, and it is unknown what techniques are being used by United Kingdom Helicopter Emergency Medical Services (HEMS). This study aimed to determine the current pre- and peri-PHEA oxygenation strategies used by UK HEMS services. Methods An electronic questionnaire survey was delivered to all UK HEMS services between 05 July and 26 December 2019. Questions investigated service standard operating procedures (SOPs) and individual clinician practice regarding oxygenation strategies prior to airway instrumentation (pre-oxygenation) and oxygenation strategies during airway instrumentation (apnoeic oxygenation). Service SOPs were obtained to corroborate questionnaire replies. Results Replies were received from all UK HEMS services (n = 21) and 40 individual clinicians. All services specified oxygenation strategies within their PHEA/RSI SOP and most referred to pre-oxygenation as mandatory (81%), whilst apnoeic oxygenation was mandatory in eight (38%) SOPs. The most commonly identified pre-oxygenation strategies were bag-valve-mask without PEEP (95%), non-rebreathable face mask (81%), and nasal cannula at high flow (81%). Seven (33%) services used Mapleson C circuits, whilst there were eight services (38%) that did not carry bag-valve-masks with PEEP valve nor Mapleson C circuits. All clinicians frequently used pre-oxygenation, however there was variability in clinician use of apnoeic oxygenation by nasal cannula. Nearly all clinicians (95%) reported manually ventilating patients during the apnoeic phase, with over half (58%) stating this was their routine practice. Differences in clinician pre-hospital and in-hospital practice related to availability of humidified high flow nasal oxygenation and Mapleson C circuits. Conclusions Pre-oxygenation is universal amongst UK HEMS services and is most frequently delivered by bag-valve-mask without PEEP or non-rebreathable face masks, whereas apnoeic oxygenation by nasal cannula is highly variable. Multiple services carry Mapleson C circuits, however many services are unable to deliver PEEP due to the equipment they carry. Clinicians are regularly manually ventilating patients during the apnoeic phase of PHEA. The identified variability in clinical practice may indicate uncertainty and further research is warranted to assess the impact of different strategies on clinical outcomes.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey)

Boulton

Mashru²,

Lyon

2020

Scand J Trauma Resusc Emerg Med

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“…However, the majority of these studies had small sample sizes and did not adequately evaluate laryngeal mask efficacy. Hence, the effectiveness and safety of its application in pre-hospital emergency patients remains controversial [4][5]. In this study, we included randomized manikin and human studies to compare the ventilation effects of laryngeal masks and endotracheal intubation in pre-hospital emergencies, so as to provide reference for clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Laryngeal mask versus endotracheal intubation for pre-hospital emergency airway management: a meta-analysis of randomized manikin and human studies

Li¹,

Duan²,

Zhang³

et al. 2019

Preprint

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Background Pre-hospital emergency airway management plays an important role in pre-hospital care. Laryngeal masks are increasingly employed for the airway management of pre-hospital critical patients and have achieved promising results. Although several randomized controlled trials have reported benefits, the efficacy of laryngeal masks in pre-hospital emergency airway management compared to endotracheal intubation have not been systematically reviewed.Methods Electronic databases (PubMed, Cochrane Library, Embase, Scopus and CNKI) were searched up to April 2019 for related randomized studies. Outcome indicators were overall intubation success rates, success rates of the initial intubation, insertion time, ventilation efficiency rates, SpO2 rise time and blood gas index. Two investigators selected the trials, extracted the data according to inclusion and exclusion criteria, and assessed the quality of the literature according to the Jada score. The meta-analysis was performed using stata14.0 software.Results We included 9 randomized manikin studies and 31 human studies. Meta-analysis of the manikin studies showed that the overall intubation success rates of the laryngeal mask group [RR=1.10, 95% CI (1.02, 1.18), P<0.05] and the success rates of first intubation [RR=1.25, 95% CI (1.01, 1.55), P <0.05] were significantly higher than the endotracheal intubation group. The insertion time of the laryngeal mask group was also significantly shorter [SMD = -1.53, 95% CI (-1.88, -1.17), P <0.05]. In human studies, excluding the success rates of first intubation and insertion time, the laryngeal mask was superior to endotracheal intubation and improved the patients’ blood gas index and shortened the SpO2 rise time. All the results were statistically significant.Conclusions Compared to endotracheal intubation, laryngeal masks could quickly and effectively improve patient ventilation in pre-hospital emergencies, highlighting its utility for clinical application .

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“…While a significant body of evidence exists to support the practice of emergency airway management in the hospital setting, this may not be directly transferrable to the pre‐hospital phase of patient care. The development of a high‐quality evidence base for PHEA is key to the evolution of pre‐hospital critical care, and this can be facilitated by improvements in data collection and reporting …”

mentioning

confidence: 99%

“…The development of a highquality evidence base for PHEA is key to the evolution of pre-hospital critical care, and this can be facilitated by improvements in data collection and reporting. 3,4 Airway registries have been established to gather and collate data pertaining to airway management in diverse settings such as pre-hospital and retrieval medicine, the ED and the ICU. These registries record demographic information and technical details regarding the performance of the intubation, as well as adverse events and complications.…”

mentioning

confidence: 99%

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre‐hospital and retrieval medicine

Glasheen¹,

Wall²,

Keogh

2019

Emerg Medicine Australasia

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Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre‐hospital emergency anaesthesia is key to the safety and evolution of this common but high‐risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre‐hospital and retrieval medicine, for both research and quality improvement purposes.

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Airway management in pre-hospital critical care: a review of the evidence for a ‘top five’ research priority

Cited by 29 publications

References 74 publications

Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey)

Oxygenation strategies prior to and during prehospital emergency anaesthesia in UK HEMS practice (PREOXY survey)

Laryngeal mask versus endotracheal intubation for pre-hospital emergency airway management: a meta-analysis of randomized manikin and human studies

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre‐hospital and retrieval medicine

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