Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department

Sakles, John C.

doi:10.1111/acem.13271

Cited by 14 publications

(11 citation statements)

References 129 publications

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“…It has been hypothesized that bag-mask ventilation increases the risk of aspiration during tracheal intubation. 11,12,29,30 However, previous studies that have evaluated aspiration during bag-mask ventilation have been limited to the examination of anesthetized healthy volunteers, have used epigastric auscultation to detect gastric insufflation as a surrogate for aspiration, and have reported conflicting results. 14,31–36 Given the low incidence of operator-reported aspiration during tracheal intubation of critically ill adults, 7,37,38 determining whether bag-mask ventilation increases the relative risk of aspiration by 50% would require a trial enrolling approximately 4000 patients.…”

Section: Discussionmentioning

confidence: 99%

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

2019

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BACKGROUND Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial. METHODS In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%. RESULTS Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P = 0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P = 0.73). CONCLUSIONS Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)

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Section: Discussionmentioning

confidence: 99%

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

2019

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“…Apnoeic oxygenation may be beneficial where intubation is difficult and time to ventilation is prolonged. It can increase time to desaturation which reduces the incidence of desaturation and the frequency of hypoxic episodes in difficult or prolonged intubations [24][25][26].…”

Section: Discussionmentioning

confidence: 99%

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

Crewdson

Heywoth

Rehn

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia. Methods A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups. Results Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation). Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation. Conclusion Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

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“…Therefore, specific resuscitative measures to optimally oxygenate and perfuse patients requiring emergency airway management should be undertaken prior to intubation. Specific measures to address critical hypoxia include the following: positioning the patient 20° reverse trendelenburg, gastric decompression using a small‐bore oro‐ or nasogastric tube, preoxygenation with positive end‐expiratory pressure (PEEP) and 100% oxygen in spontaneously ventilating patients, oxygenation during apnea with gentle positive pressure ventilation and PEEP, continued oxygenation during laryngoscopy via nasal cannula, and a clear saturation cutoff point for aborting intubation attempts and beginning re‐oxygenation. Specific measures to address impaired perfusion include the following: acute circulatory support with fluid bolus or peripheral inotrope infusion, dose adjustment of induction agent, advanced preparation of bolus‐dose vasopressor for emergency use, and continuous manual femoral pulse monitoring during intubation in the absence of an arterial line.…”

Section: Is There a Solution?mentioning

confidence: 99%

Emergency intubation of children outside of the operating room

Long

Barrett

Peters

et al. 2020

Pediatric Anesthesia

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Intubation of children outside of the operating room is performed infrequently and is often associated with life‐threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non‐operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi‐disciplinary team training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance all reduce life‐threatening intubation‐related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient‐centered care delivery.

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Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department

Cited by 14 publications

References 129 publications

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

Emergency intubation of children outside of the operating room

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