Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit

Khandelwal, Nita; Khorsand, Sarah; Mitchell, Steven H.; Joffe, Aaron M.

doi:10.1213/ane.0000000000001184

Cited by 76 publications

(52 citation statements)

References 21 publications

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“…In addition to potentially affecting intubation difficulty, some have suggested that an upright position might have other clinically important benefits, such as decreasing risk of aspiration [13]. A recent study of emergent intubations in the ward and ICU settings found lower rates of complications, including aspiration, hypoxemia, and esophageal intubation, when intubating in the upright compared to the supine positions [14].…”

Section: Discussionmentioning

confidence: 99%

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position

et al. 2016

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. (2016). Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Internal and Emergency Medicine, 1-6. https://doi.org/10.1007/s11739-016-1481-z Novice Upright Intubation 2 Abstract: There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0 degrees) and upright (head of bed elevated at 45 degrees) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5%) and 123 upright attempts (97.6%; p = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6% vs. 87.8%, p = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.

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Section: Discussionmentioning

confidence: 99%

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position

et al. 2016

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“…Thus, once the decision is made to induce the patient for endotracheal intubation, the patient does not always need to be supine. 26,27 Thus, practitioners should be comfortable intubating patients in the head-up position. If this is the plan, it should be announced to the team.…”

Section: Achieving Better Airway Teamwork Outside the Operating Roommentioning

confidence: 99%

“…[31][32][33] Hemodynamics permitting, a sitting position can also ameliorate patient respiratory distress, reduce the risk of aspiration, and avoid complications associated with endotracheal intubation. 27 For patients with a nasogastric tube, airway intervention should be avoided until the stomach is emptied. If the nasogastric tube is not already present, placing one for this purpose should be considered.…”

Section: R: Reset Resistmentioning

confidence: 99%

Airway management outside the operating room: how to better prepare

Brindley

Beed

Law

et al. 2017

Can J Anesth/J Can Anesth

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Airway management outside the operating room is associated with increased risks compared with airway management inside the operating room. Moreover, airway management-whether in the intensive care unit, emergency department, interventional radiology suite, or general wards-often requires mastery of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. The 2015 Difficult Airway Society Guidelines encourage the airway team to ''stop and think''. This article provides a practical review of how that evidence applies during emergency airway management outside of the operating room. To counter the challenges of airway management outside the operating room, we offer a mnemonic that combines both technical and non-technical insights summarized using the seven letters of the word PREPARE (P: pre-oxygenate/position; R: reset/resist; E: examine/explicit; P: plan A/B; A: adjust/ attention; R: remain/review; E: exit/explore). We hope it can unite potentially disparate personnel with a structure that allows them to make acute decisions, coordinate action, and communicate unequivocally. This multidisciplinary publication also hopes to encourage common understanding and language between anesthesiologists and non-anesthesiologists about the perils of airway management outside the operating room and the importance of airway teamwork.Résumé La gestion des voies aériennes en dehors de la salle d'opération est associée à une augmentation des risques, comparativement à leur gestion à l'intérieur de la salle d'opération. De plus, la gestion des voies aériennes -que ce soit en unité de soins intensifs, aux urgences, dans une unité de radiologie interventionnelle ou dans un service général -nécessite souvent une maîtrise face, tout d'abord, aux voies aériennes compliquées sur le plan anatomique, mais aussi face aux voies aériennes difficiles à gérer sur le plan physiologique et en situation. Les lignes directrices 2015 de la DAS (Difficult Airway Society) encouragent l'équipe de prise en charge des voies aériennes à « faire une pause et réfléchir ». Cet article fournit une synthèse pratique de l'application des données probantes au cours de la gestion des voies aériennes en urgence, en dehors de la salle d'opération. Pour faire face aux défis de la gestion des voies aériennes en dehors de la salle d'opération, nous proposons un moyen mnémotechnique qui combine des points techniques et non techniques, résumés dans les sept lettres du mot PRÉ PARE (P : préoxygéner/position; R : reprendre/ résister; E : examiner/expliquer; P : plan A/plan B; A : adapter/attention; R : rester/revoir; E : explorer/quitter). Nous espérons que cela peut rassembler des personnels potentiellement disparates dans une structure qui leur permette de prendre des décisions, coordonner leurs

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“…Furthermore, as adjunctive strategies such as ramp positioning (12)(13)(14) and apneic oxygenation (15,16) have become increasingly recognized as potentially beneficial, a continuous training curriculum provides opportunities for evaluating trainees' knowledge of these techniques and reinforcing their incorporation into airway management.…”

Section: Discussionmentioning

confidence: 99%

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

Malo¹,

Hypes²,

Cristan³

et al. 2018

Southwest J Pulm Crit Care

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Background: Intubation in critically ill patients remains a highly morbid procedure, and the optimal approach is unclear. We sought to improve the safety of intubation by implementing a simulation curriculum and monitoring performance with an airway registry. Methods and Methods: This is a prospective, single-center observational study of all intubations performed by the medical intensive care unit (ICU) team over a five-year period. All fellows take part in a simulation curriculum to improve airway management performance and minimize complications. An airway registry form is completed immediately after each intubation to capture relevant patient, operator, and procedural data. Results: Over a five-year period, the medical ICU team performed 1411 intubations. From Year 1 to Year 5, there were significant increases in first-attempt success (72.6 vs. 88.0%, p<0.001), use of video laryngoscopy (72.3 vs. 93.5%, p<0.001), and use of neuromuscular blocking agents (73.5 vs. 88.4%, p<0.001). There were concurrent decreases in rates of desaturation (25.6 vs. 17.1%, p=0.01) and esophageal intubations (5 vs. 1%, p=0.009). Low rates of hypotension (8.3%) and cardiac arrest (0.6%) were also observed. Conclusions: The safety of intubation in critically ill patients can be markedly improved through joint implementation of an airway registry and simulation curriculum.

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Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit

Abstract: Placing patients in a back-up head-elevated position, compared with supine position, during emergency tracheal intubation was associated with a reduced odds of airway-related complications.

Cited by 76 publications

References 21 publications

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position

Airway management outside the operating room: how to better prepare

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

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