Airway lessons relearned

A UK study examined all out-of-operating room intubations over a one month period in nine hospitals1.
Patients whose indication for tracheal intubation was cardiac arrest and who were intubated without the use of drugs were excluded from analysis, as were neonatal intubations.
Disappointing – but not surprising – findings were the lack of universally applied capnography and the use of propofol as the most commonly used induction agent. However more senior intubators were less likely to use propofol than more junior ones (who used it in 93% of intubations!), and the seniors were also more likely to use non-depolarising neuromuscular blocking drugs (NMBDs) than juniors.
The authors report that in seven (4%) patients, pre-oxygenation “was felt to be impossible“. I find it hard to imagine this situation unless RSI is being done on combative patients without prior sedation, which if this is the case makes me shudder.
The authors express their understandable concern over the absence of an alternative airway such as a laryngeal mask in 12% of cases.
Although the adverse event rate seems high, they point out that they used the term ‘adverse events’ rather than ‘complications’ as the events may not be directly attributable to the intubation. In other words, some patients may have been hypoxaemic or hypotensive to start with due to their underlying clinical problem.
I find this study interesting because the results are similar to those reported in a study I and my colleagues conducted a decade ago2, in which ICU intubations were shown to be more hazardous that ED intubations. This can be explained by the higher proportion of patients on ICU with shock and/or respiratory failure. On the other hand, ED patients more commonly required intubation for neurological presentations, with relatively stable cardiorespiratory physiology.
Take a look at the breakdown of cases in the recent study:

and compare this with our findings:

…this is why I have to argue when I hear it occasionally stated that ‘all ED airways are difficult airways’ – some are actually easy, in patients with long stable apnoea times who make great teaching cases.
The authors “speculate that the low rate of hypoxaemia and airway complications may be related to the high proportion of intubations undertaken by those with anaesthesia as a base speciality, and to the almost universal use of NMBDs.” They do not provide strong data to support the first half of their statement. The supplementary data available online indeed show that the majority of intubators were anaesthesia-based, but how their adverse event rates compare with those of the emergency physicians and paediatricians who also undertook intubations is not available.
I don’t want to detract from the important message Dr Bowles and colleagues are conveying: that the lessons from the 4th National Audit Project on major complications of airway management in the UK still need to be applied.
This paper is one aspect of the potentially life-saving work done by this team, which includes the intubation checklist they created.

BACKGROUND: Tracheal intubation is commonly performed outside the operating theatre and is associated with higher risk than intubation in theatre. Recent guidelines and publications including the 4th National Audit Project of the Royal College of Anaesthetists have sought to improve the safety of out-of-theatre intubations.

METHODS: We performed a prospective observational study examining all tracheal intubations occurring outside the operating theatre in nine hospitals over a 1 month period. Data were collected on speciality and grade of intubator, presence of essential safety equipment and monitoring, and adverse events.

RESULTS: One hundred and sixty-four out-of-theatre intubations were identified (excluding those where intubation occurred as part of the management of cardiac arrest). The most common indication for intubation was respiratory failure [74 cases (45%)]. Doctors with at least 6 month’s experience in anaesthesia performed 136 intubations (83%); consultants were present for 68 cases (41%), and overall a second intubator was present for 94 procedures (57%). Propofol was the most common induction agent [124 cases (76%)] and 157 patients (96%) received neuromuscular blocking agents. An airway rescue device was available in 139 cases (87%). Capnography was not used in 52 cases (32%). Sixty-four patients suffered at least one adverse event (39%) around the time of tracheal intubation.

CONCLUSIONS: Out-of-theatre intubation frequently occurs in the absence of essential safety equipment, despite the existing guidelines. The associated adverse event rate is high.

1. Out-of-theatre tracheal intubation: prospective multicentre study of clinical practice and adverse events
Br J Anaesth. 2011 Nov;107(5):687-92

BACKGROUND: Emergency rapid sequence intubation (RSI) performed outside the operating room on emergency patients is the cornerstone of emergency airway management. Complication rates are unknown for this procedure in the United Kingdom and the factors contributing to immediate complications have not been identified.

AIMS: To quantify the immediate complications of RSI and to assess the contribution made by environmental, patient, and physician factors to overall complication rates.

METHODS: Prospective observational study of 208 consecutive adult and paediatric patients undergoing RSI over a six month period.

RESULTS: Patients were successfully intubated by RSI in all cases. There were no deaths during the procedure and no patient required a surgical airway. Patient diagnostic groups requiring RSI are described. Immediate complications were hypoxaemia 19.2%, hypotension 17.8%, and arrhythmia 3.4%. Hypoxaemia was more common in patients with pre-existing respiratory or cardiovascular conditions than in patients with other diagnoses (p<0.01). Emergency department intubations were associated with a significantly lower complication rate than other locations (16.9%; p = 0.004). This can be explained by the difference in diagnostic case mix. Intubating teams comprised anaesthetists, non-anaesthetists, or both. There were no significant differences in complication rates between these groups.
CONCLUSIONS: RSI has a significant immediate complication rate, although the clinical significance of transient events is unknown. The likelihood of immediate complications depends on the patient’s underlying condition, and relevant diagnoses should be emphasised in airway management training. Complication rates are comparable between anaesthetists and non-anaesthetists. The significantly lower complication rates in emergency department RSI can be explained by a larger proportion of patients with comparatively stable cardiorespiratory function.

2. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre
Emerg Med J. 2004 May;21(3):296-301 Free Full Text

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