Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Dean, Preston; Hoehn, Erin F.; Geis, Gary L.; Frey, Mary; Cabrera-Thurman, Mary K.; Kerrey, Benjamin T.; Yin, Zhang; Stalets, Erika; Zackoff, Matthew; Maxwell, Andrea; Pham, Tena M; Lautz, Andrew J.

doi:10.1111/acem.14128

Cited by 9 publications

(14 citation statements)

References 34 publications

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“…Recently, there has been an increasing awareness of the importance of the physiologically difficult airway, which may increase the risk of AEs independent of any anatomic difficulty. [4][5][6][7] Critically ill patients are at high risk of hypoxemia, hypotension, and cardiac arrest because of deranged physiology that is often exacerbated during or resulting from airway management. 5,8 Hypoxemia and hypotension are particularly hazardous risks for cardiac arrest.…”

Section: Introductionmentioning

confidence: 99%

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Pacheco¹,

Hurst²,

Patanwala³

et al. 2021

W J Emerg Med

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Introduction: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014-June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. Results: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference =-10.3%, 95% confidence interval (CI),-14.8% to-5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference =-10.7%, 95% CI,-17.3% to-4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference =-21.4%, 95% CI,-27.0% to-16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21-0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19-0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11-0.33]. Conclusion: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials. [

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Section: Introductionmentioning

confidence: 99%

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Pacheco¹,

Hurst²,

Patanwala³

et al. 2021

W J Emerg Med

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“…A total of 11 studies with 14,424 intubations were included in the final analyses. 2 7 8 9 11 12 13 14 15 16 17 The search strategy for these studies is outlined in Fig. 1 .…”

Section: Resultsmentioning

confidence: 99%

“…Previous studies have identified hypotension, hypoxemia, lower pH, and systemic ventricular dysfunction, recent cardiorespiratory arrest, status asthmaticus, and the need for multiple intubation attempts to be associated with increased risk of peri-intubation risk of cardiorespiratory arrest. 7,8,12,14,15 Previous studies have identified the use of ketamine to be associated with decreased risk of peri-intubation cardiorespiratory arrest. 11 The transition from negative pressure to positive pressure ventilation is associated with a significant change in physiology.…”

Section: Discussionmentioning

confidence: 99%

Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review

Loomba

Patel

Kunnel

et al. 2022

J Pediatr Intensive Care

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Endotracheal intubation is associated with an increased risk of cardiorespiratory arrest. Various factors modulate the risk of peri-intubation cardiorespiratory arrest. The primary objective of this study was to determine the risk of peri-intubation cardiorespiratory arrest in pediatric patients in a hospital setting, and the secondary objective was to determine the effect of various factors on the peri-intubation cardiorespiratory arrest risk. A systematic review was performed to identify eligible manuscripts. Studies were deemed appropriate if they included pediatric patients in a hospital setting not exclusively intubated for an indication of cardiorespiratory arrest. Data were extracted from studies deemed eligible for inclusion. A pooled risk of cardiorespiratory arrest was determined. A Bayesian linear regression was conducted to model the risk of cardiorespiratory arrest. All data used in this were study-level data. A total of 11 studies with 14,424 intubations were included in the final analyses. The setting for six (54.5%) studies was the emergency department. The baseline adjusted risk for peri-intubation cardiorespiratory arrest in pediatric patients was 3.78%. The mean coefficient for a respiratory indication for intubation was −0.06, indicating that a respiratory indication for intubation reduced the per-intubation cardiorespiratory arrest risk by 0.06%. The mean coefficient for use of ketamine was 0.07, the mean coefficient for use of a benzodiazepine was −0.14, the mean coefficient for use of a vagolytic was −0.01, and the mean coefficient for use of neuromuscular blockade was −0.40. Pediatric patients during the peri-intubation period have the risk of developing cardiorespiratory arrest. The pooled findings demonstrate associations that seem to highlight the importance of maintaining adequate systemic oxygen delivery to limit this risk.

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“…Atracurium was used in one underpowered RCT that failed to detect a clinically relevant difference 21 . Suxamethonium was addressed in two observational studies 27,32 . In summary, use of a neuromuscular blocking agent increases the success of tracheal intubation and reduces the incidence of complications such as laryngospasm.…”

Section: Methodsmentioning

confidence: 99%

“…Seven RCTs, [18][19][20][21][22][23][24] 13 (five retrospective, eight prospective) observational studies, [25][26][27][28][29][30][31][32][33][34][35][36][37] and one systematic review 38 were identified that examined different sedation or anaesthesia regimens (Supplementary Tables S2 and S3, http://links.lww.com/EJA/A891). The age of patients included in the RCTs ranged from 26 weeks to 3 yr, and included a total of 486 patients.…”

Section: Pico 2 Preparation For Airway Management and Pharmacological...mentioning

confidence: 99%

Airway management in neonates and infants

Disma,

Asai,

Cools

et al. 2023

European Journal of Anaesthesiology

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Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong ‘1’ or weak ‘2’ recommendation with high ‘A’, medium ‘B’ or low ‘C’ quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

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Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Cited by 9 publications

References 34 publications

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review

Airway management in neonates and infants

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