Emergency Airway Management: History, Current Practice, and Future Directions Sitges, Spain September 2003 Erik D. Barton, MD, MS, FACEP, FAAEM University of Utah Health Sciences Center

Outline History of airway management Rapid Sequence Intubation Experience in NEAR Future Directions

Rapid Sequence Intubation History of Airway Management in the USA Laryngoscopy 1907 ED intubation approx 1965 BNTI and “Brutane” methods of choice 1969: U of Cincinnati EM Residency 1971: First use of NMB reported in ED 1980s: Growth of RSI 1997: ACEP Policy Statement on RSI 1997: NEAR

Rapid Sequence Intubation 1980s and 1990s Many battles between specialties Fear, hesitation among EPs Cricothyrotomy rates 15-22% RSI: from rare to “standard of care”

Pre-1968: untrained physicians, triage to service, poor or no supervision of house staff Sickest, highest-risk patients cared for by least competent physicians Need is recognized for organization and improvement in care EM in the U.S.

Rapid Sequence Intubation Today RSI required training in EM Residencies Widespread use of RSI Prehospital RSI

Rapid Sequence Intubation Definition The virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.

Just like Skydiving…. Skydiving is lethal unless one deploys a parachute… RSI is lethal unless you rescue the airway! Rapid Sequence Intubation

Just like Skydiving…. –Redundancy of safety (primary & backup) –Planned, stepwise approach to primary system –Simple, fast backup system –Attention to monitoring –Equipment vigilance Levitan, RM. Ann Emerg Med. 2003;42: Rapid Sequence Intubation

Definition Incorporates: Patient has a full stomach Preoxygenation No interposed ventilation Sellick’s maneuver

Rapid Sequence Intubation Time to Desaturation

The Decision to Intubate Four Reasons for Intubation Airway maintenance or protection Failure to ventilate Failure to oxygenate Anticipated clinical course

Rapid Sequence Intubation The Six Ps of RSI Preparation Preoxygenation Pretreatment Paralysis with Sedation Protection Placement

Rapid Sequence Intubation Advantages of RSI Rapid control of the airway Minimizes risk of aspiration Highest success rates Lowest complication rates Optimal intubating conditions Adaptable to patient condition Can mitigate adverse effects

Rapid Sequence Intubation Succinylcholine Still the ED NMB of choice Rapid effect Short duration Generally well tolerated A few important side effects

Rapid Sequence Intubation Failed Attempt Plan in advance Systematic approach essential Equipment Training …remember “Skydiving!!” Rescue Maneuvers

Rapid Sequence Intubation The first rescue from failed intubation is bagging. The first rescue from failed bagging is better bagging. Rescue devices Failed Attempt Rescue Maneuvers

How do we know that RSI really works? Rapid Sequence Intubation

The “Science” of Airway Management The problems… Self-reporting Emergency conditions Multiple factors influence each course: highly variable operator dependent “Jargon” not standardized Wang, HE. Acad Emerg Med. 2003;10:644-5.

6294 ED Intubations from the second report of the ongoing National Emergency Airway Registry Study (NEAR II) NEAR

Methods: Prospective, observational study from 8/97 to 4/00 of 26 teaching hospitals in the U.S. during the second phase of the ongoing National Emergency Airway Registry (NEAR II) study Intubations from the National Emergency Airway Registry

Current Status: 33 Centers Registered with NEAR 30 Centers Actively Submitting Data >10,000 Intubations Entered in NEAR I + NEAR II + NEAR III 6294 Intubations from the National Emergency Airway Registry

NEAR II 30 Participating Centers: Brigham and Women’s HospitalSt. Lukes-Roosevelt Hospital Erie County Medical CenterDartmouth-Hitchcock Med Ctr The Children’s Hospital-BostonUniversity of Louisville St. Francis Hospital UCSD Medical Center University of ArizonaHighland General Hospital Georgetown Univ Medical CenterNorth Carolina & Wake Medical Maricopa Medical CenterLady Lourdes Hospital UC Davis Medical CenterStanford University George Washington UniversityMount Auburn Hospital Christiana Care Health SystemsSingapore General Hospital Massachusetts General HospitalNewport Hospital Emory PeachtreeUniversity of Alabama 6294 Intubations from the National Emergency Airway Registry

RESULTS 6294 Intubations from the National Emergency Airway Registry

Personnel Performing ED Intubations 6294 Intubations from the National Emergency Airway Registry

Demographics of Cases: IndicationCasesFemaleMaleUnknown Trauma1605 (22%)349 (22%)1059 (65%)97 (3%) Medical4286 (72%)1740 (40%)2194 (51%)352 (9%) Not Provided277 (6%)84 (2%)166 (3%)27 (1%) TOTAL6294 (100%)1642 (36%)2545 (55%)415 (9%) 6294 Intubations from the National Emergency Airway Registry

6294 Intubations from the National Emergency Airway Registry Oral RSI 4377 (69%) Oral no meds 1088 (17%) Oral induction without paralysis 427 (7 %) Nasal awake with topical 206 (3%) Nasal no meds 69 (1%) Nasal induction without paralysis 45 Surgical crico/tracheotomy 39 (0.6%) Other 16 Oral awake with topical 21 Unknown 5 TOTAL 6294

1st Course Success Rates: Medical Trauma Oral RSI99.8%97.7% Oral no meds94.7% 96.3% Oral induction without paralysis95.0%93.7% Nasal awake with topical97.2%98.1% Nasal no meds91.3%45.4% Nasal induction without paralysis97.0%100% Oral awake with topical93.7%N/A Other50.0%100% Surgical cricothyrotomy60.0%68.7% Unknown50.0%N/A TOTAL 94.7%96.2% 6294 Intubations from the National Emergency Airway Registry

6294 Intubations from the National Emergency Airway Registry Success Rates by Intubator: First pass Overall EM 84.7%98.5% Anesthesia93.5%93.5% Other64.9%97.4% Attending EM90.2%97.9% PGY 3 or 487.2% 98.4% PGY 1 or 277.5%98.7% Other81.1%98.5%

NEAR Other Studies: Analysis of failed intubations and rescue techniques - Bair, AE, et al. J Emerg Med. 2002;23: Sedative agents facilitate intubations with NMB - Sivilotti, MLA, et al. Acad Emerg Med. 2003;10: Underdosing of midazolam in 92% of adults, 56% of kids - Sagarin, MJ, et al. Acad Emerg Med. 2003;10: Benchmarking intubation data for North American EM residents - Sagarin, MJ, et al. Ann Emerg Med

Immediate Complications: Method IC Oral RSI 11.3% Oral no meds 9.2% Oral induction without paralysis 16.5% Nasal awake with topical 37.5% 6294 Intubations from the National Emergency Airway Registry

Airway Definitions What defines a complication? Unplanned event Negative consequences Not reversible Injury to the patient Unrelated to underlying disease What about corrected errors? Complications

Airway Definitions Technical Problems Mainstem Intubation Detected Esophageal Intubation Tube Obstruction Self Extubation Cuff Leak Other: Medication error Equipment failure

Cardiac Arrest Dysrhythmia Pneumomediastinum Other: Hypotension Hypoxemia Severe bleeding Seizure Subcutaneous emphysema Tension pneumothorax Physiologic Alterations Airway Definitions

True Complications Aspiration Laryngospasm Dental Trauma Epistaxis Vocal Cord Avulsion Malignant Hyperthermia Undetected Esophageal intubation Other: Lip laceration Emesis Trismus

Airway Events: MethodTPRPARTCR Oral RSI7.4%1.1%2.8% Oral no meds5.0%2.0%2.2% Oral induction 9.4%1.2%5.9% Nasal 25%4.2%8.3% Cricothyrotomy33%16.7%8.3% 6294 Intubations from the National Emergency Airway Registry

The Future: Standardize the jargon What is an intubation attempt? Immediate vs. long-term complications Difficult airway assessments Rapid and predictive Universally applied The “Science” of Airway Management

The Future: Unbiased reporting systems Large-scale data collection (web) Standardized reporting tools NEAR III and IV Data analysis Trends and outcomes New devices/technologies

Questions? Thank you!