Airway Management

IMPORTANCE: Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival. OBJECTIVES: To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28...

Mechanical ventilation is the most used short-term life support technique worldwide and is applied daily for a diverse spectrum of indications, from scheduled surgical procedures to acute organ failure. This state-of-the-art review provides an update on the basic physiology of respiratory mechanics, the working principles, and the main ventilatory settings, as well as the potential complications of mechanical ventilation. Specific ventilatory approaches in particular situations such as acute respiratory distress syndrome and chronic obstructive pulmonary disease are detailed along with protective ventilation in patients with normal lungs...

OBJECTIVE: Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model. METHODS: The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies...

BACKGROUND: The oesophageal leak pressure is defined as the pressure which breaks the seal between the cuff of a supraglottic airway and the peri-cuff mucosa, allowing penetration of fluid into the pharynx and the oral cavity. As a consequence, a decrease in this variable increases the risk of reflux and can lead to pulmonary aspiration. The aim of this study was to analyse the effects of cuff overinflation and pressure on the neck on the oesophageal leak pressure of seven supraglottic airways...

BACKGROUND: 911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. METHODS: Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015...

OBJECTIVE: To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA. METHODS: We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial...

OBJECTIVE: Overall survival from out-of-hospital cardiac arrest (OHCA) is less than 10%. After initial bag-valve mask ventilation, 80% of patients receive an advanced airway, either by endotracheal intubation (ETI) or placement of a supraglottic airway (SGA). The objective of this meta-analysis was to compare patient outcomes for these two advanced airway methods in OHCA patients treated by Emergency Medical Services (EMS). METHODS: A dual-reviewer search was conducted in PubMed, Scopus, and the Cochrane Database to identify all relevant peer-reviewed articles for inclusion in the meta-analysis...

STUDY OBJECTIVE: Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. METHODS: We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system...

BACKGROUND: Chest compressions and ventilation are lifesaving tasks during cardio-pulmonary resuscitation (CPR). Besides oxygenation, endotracheal intubation (ETI) during CPR is performed to avoid aspiration of gastric contents. If intubation is difficult or impossible, supraglottic airway devices are utilized. We tested six different airway devices regarding their potential to protect against regurgitation and aspiration during CPR in a randomized experimental human cadaver study. METHODS: Five-hundred ml of 0...

BACKGROUND: During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. METHODS AND RESULTS: Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation...

Clinical question Does delayed sequence intubation (DSI) improve preoxygenation and safety when intubating otherwise uncooperative patients? Article chosen Weingart SD, Trueger S, Wong N, et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med 2015;65(4):349-55. doi:10.1016/j.annemergmed.2014.09.025 OBJECTIVE: To investigate whether the administration of ketamine 3 minutes prior to the administration of a muscle relaxant allows for optimal preoxygenation in uncooperative patients undergoing intubation...

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In critically ill patients, endotracheal intubation is associated with a high risk of complications, including severe hypoxemia and hypotension. The purpose of this review is to discuss the definitions, complications, airway assessment, and patient optimization with respect to these patients. In addition, we present different approaches and techniques to help secure the airway in critically ill patients. We also discuss strategies to help minimize the risk of a difficult or failed airway and to mitigate the severe life-threatening complications associated with this high-risk procedure...

Difficult airway management and maintenance of oxygenation remain the two most challenging tasks for anesthetists, while also being controversial items in terms of clinically based-evidence to support relevant guidelines in the literature. Nevertheless, different expert groups and scientific societies from several countries have published guidelines dedicated to the management of difficult airways. These documents have been demonstrated to be useful in reducing airway management related critical accidents, despite their limited use in litigations and legal issues...

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety and reducing errors as well as for training rescuers in airway management.

Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets...

BACKGROUND: Airway management in a trauma patient can be particularly challenging when both a difficult airway and the need for rapid action collide. The provider must evaluate the trauma patient for airway difficulty, develop an airway management plan, and be willing to act quickly with incomplete information. DISCUSSION: Thorough knowledge of airway management algorithms will assist the emergency physician in providing optimal care and offer a rapid and effective treatment plan...

We report a case of prehospital "cannot intubate" and "cannot ventilate" scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device...

Cricothyrotomy is considered an integral procedure in the practice of emergency medicine. The Accreditation Council for Graduate Medical Education requires residents in emergency medicine to demonstrate proficiency in this skill, but because cricothyrotomy is rarely encountered in the clinical setting, alternative methods to teach this high-stakes procedure become an important curricular component in residency training. We present an innovative and inexpensive method for teaching cricothyrotomy using animal trachea and synthetic skin...

BACKGROUND: Emergency cricothyrotomy is the final lifesaving option in "cannot intubate-cannot ventilate" situations. Fast, efficient and safe management is indispensable to reestablish oxygenation, thus the quickest, most reliable and safest technique should be used. Several cricothyrotomy techniques exist, which can be grouped into two categories: anatomical-surgical and puncture. METHODS: We studied success rate, tracheal tube insertion time and complications of different techniques, including a novel cricothyrotomy scissors technique in human cadavers...