Objective
We aimed to compare the 72-hour survival of the endotracheal intubation (ETI) with video laryngoscope (VL), ETI with direct laryngoscope (DL), and supraglottic airway (SGA) in out-of-hospital cardiac arrest (OHCA) patients in Korea.
Methods
This study included adult OHCA patients who received advanced airway management by designated response teams for severe disease, using a nationwide OHCA registry in South Korea from July 2019 to December 2021. The primary outcome was 72-hour survival, and secondary outcomes were survival to hospital discharge and good neurological recovery. Multivariable logistic regression was used, adjusted for confounders, to compare the outcomes among the three airway management methods.
Results
Among 77,629 OHCA cases, 10,857 were included. SGA was attempted in 9,379 cases, ETI with DL in 493 cases, and ETI with VL in 985 cases. The rates of any prehospital ROSC and 72-hour survival were 13.3% and 11.0% for SGA, 16.0% and 11.4% for ETI with DL, and 18.2% and 11.9% for ETI with VL. Compared to SGA, ETI with VL was significantly associated with 72-hour survival: adjusted odds ratio (OR) [95% confidence interval (CI)] 1.34 (1.06-1.70) for ETI with VL and 1.13 (0.81-1.56) for ETI with DL). There was no significant association between the type of AAM and survival to discharge or good neurological recovery.
Conclusion
In an emergency medical service system staffed by advanced emergency medical technician-level providers, ETI with VL might be associated with improved 72-hour survival compared to SGA. However, this short-term benefit did not extend to survival to hospital discharge.
Objective The Korean National Fire Agency conducted a pilot project examining Advanced Life Support (ALS) protocols, including epinephrine administration, to improve survival among patients suffering out-of-hospital cardiac arrest (OHCA). In this study, we aimed to evaluate the effects of the Korean National Fire Agency ALS protocol on prehospital return of spontaneous circulation (ROSC) in patients with OHCA.
Methods This study included patients with adult-presumed cardiac arrest between January and December 2020. The main factor of interest was ambulance type according to ALS protocol, which was divided into dedicated ALS ambulance (DA), smartphone-based ALS ambulance (SALS), and non-DA, and the main analysis factor was prehospital ROSC. Multivariate logistic regression analysis was performed.
Results During the study period, a total of 18,031 adult patients with OHCA was treated by the emergency medical services, including 7,520 DAs (41.71%), 2,622 SALSs (14.54%), and 7,889 non-DAs (43.75%). The prehospital ROSC ratio was 13.19% for DA, 11.17% for SALS, and 7.91% for non-DA (P<0.01). Compared with that of the DA group, the odds ratios (95% confidence interval) for prehospital ROSC ratio were 0.97 (0.82–1.15) in the SALS group and 0.57 (0.50–0.65) in the non-DA group. The prehospital ROSC ratio of the DA group was higher than those of the non-DA group and the SALS group.
Conclusion ALS protocol intervention was associated with prehospital ROSC rates. Therefore, continuous efforts to promote systemic implementation of the ALS protocol to improve OHCA outcomes are necessary.
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Sangun Nah, Yonghee Lee, Sol Ji Choi, Jeongwoo Lee, Soyun Hwang, Seongmi Lim, Inhye Lee, Young Soon Cho, Hyun Soo Chung, on behalf of the Korean Emergency Airway Management Society
Clin Exp Emerg Med 2024;11(3):243-258. Published online March 15, 2024
Airway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical spaces. A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.
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Objective A new blind intubation device (BID) has been developed for endotracheal intubation. This study aimed to test the usability of the BID in comparison to direct laryngoscopy (DL) and video laryngoscopy (VL) with inexperienced healthcare providers for endotracheal intubation.
Methods This was a randomized crossover simulation study. Participants who had conducted fewer than five live intubation sessions were included in the study. The manikin simulation was conducted using a Laerdal trainer airway manikin. Participants performed intubation using all three devices, DL, VL, and BID. The primary outcome was intubation success rate in the first pass the secondary outcome was intubation time to first ventilation, and the tertiary outcome was dental injury.
Results A total of 45 healthcare workers who were novices in intubation participated in this study, including 13 physicians (interns), 14 emergency medical technicians, and 18 nurses. The intubation success rates in the first pass with BID, DL, and VL were 93.3%, 91.1%, and 97.8%, respectively (P=0.53). The intubation times to first ventilation with BID, DL, and VL were 13.15±6.16, 19.07±7.71, and 17.31±6.57 seconds, respectively (P<0.01). The proportions of dental injuries associated with BID, DL, and VL were 0% for physicians; 28.6%, 14.3%, and 0%, respectively for emergency medical technicians; and 27.8%, 11.1%, and 16.7%, respectively for nurses.
Conclusion We performed a pilot study to test the usability of the new BID. There was no significant difference in intubation success rate in the first pass among BID, DL, and VL. The intubation time to first ventilation was shorter with the BID compared to DL and VL.
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Objective We hypothesized that a multi-tier response (MTR) will provide high-quality cardiopulmonary resuscitation including airway management. However, the type of tier response system and airway management will have different interactive effects resulting in varying outcomes following out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether the advanced airway management method has an effect on OHCA outcomes and to compare the size of the effect across MTR types.
Methods This is a retrospective population-based observational study using the Korea OHCA Registry. Airway management methods were categorized into endotracheal intubation (ETI) and supraglottic airway (SGA) groups. The tier system was categorized into single-tier response (STR) or two types of MTR: ambulance-ambulance MTR or fire engine-ambulance MTR.
Results In total, 45,264 patients were analyzed among the 89,087 emergency medical service assessed OHCAs. The SGA group was significantly associated with a lower prehospital return of spontaneous circulation (ROSC) rate compared to the ETI group (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.72–0.88). Both MTR with an ambulance or fire engine were significantly associated with higher prehospital ROSC rates compared to STR (STR vs. MTR with an ambulance: aOR, 1.33; 95% CI, 1.21–1.47; STR vs. MTR with a fire engine: aOR, 1.43; 95% CI, 1.20–1.71). Prehospital SGA was significantly associated with poor neurological outcomes in MTR with fire engine (aOR, 0.71; 95% CI, 0.53–0.96).
Conclusion In this nationwide observational study, we observed that MTR was associated with higher prehospital ROSC than STR. Moreover, SGA is associated with a lower prehospital ROSC rate regardless of tier response type compared to ETI.
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Maxillofacial trauma occasionally presents a serious challenge for physicians, and an orofacial injury can be considered life-threatening. It is difficult to control the bleeding and prevent airway obstruction simultaneously with conventional treatment. Herein, we share two cases in which we managed massive orofacial bleeding using a King laryngeal tube, a supraglottic airway device equipped with an inflatable balloon. Both patients had uncontrolled orofacial bleeding. In one of the patients, endotracheal intubation was possible; however, bleeding continued, and vital signs became unstable. The second patient had failed endotracheal intubation due to uncontrolled bleeding. We deployed the King laryngeal tube in both patients and achieved bleeding control and airway maintenance. Both patients were discharged without complications after 3 to 4 weeks. The King laryngeal tube method can be considered a useful management option for addressing massive orofacial bleeding that is uncontrollable with conventional treatment.
Objective Most airway prediction tools only consider anatomical factors. The HEAVEN criteria incorporate both anatomical and physiological elements, but have never been studied in the emergency department. This study aimed to evaluate the association between HEAVEN criteria and intubation difficulty.
Methods We conducted a prospective cross-sectional study from April 1, 2020 to January 31, 2021 in the emergency department of a tertiary public hospital. All patients requiring rapid-sequence or delayed-sequence intubation were included. Patients intubated during cardiopulmonary resuscitation were excluded. We enrolled 174 patients. Study endpoints were first pass success and intubation complications.
Results The presence of any HEAVEN criteria was associated with a decrease in the first pass success rate (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.02–0.43; P < 0.01). The anatomical challenge was the only criterion associated with first pass sucess (OR, 0.13; 95% CI, 0.05– 0.29; P < 0.01), whilst other criteria (hypoxemia, extremes of size, vomit/blood/fluid, exsanguination, and neck mobility) were not (P > 0.05). All anatomical factor criteria were associated with difficult airway view (P < 0.05). Intubation complications occurred more in the presence of hypoxemia (OR, 7.44; 95% CI, 2.82–19.63; P < 0.01) and vomit/blood/fluid (OR, 5.55; 95% CI, 2.39–12.92; P < 0.01).
Conclusion Anatomical challenge in HEAVEN criteria can predict first pass success. All anatomical factors in HEAVEN criteria could predict difficult airway view and peri-intubation hypoxemia could be used to anticipate intubation complications. More validation studies are still needed to evaluate the use of HEAVEN criteria as a predictor tool for difficult airway.
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Methods We enrolled adult patients with EMS-treated OHCA of presumed cardiac origin between 2012 and 2014 from Osaka (Japan), Seoul (Republic of Korea), Singapore (Singapore), and Taipei (Taiwan). The main exposure variable was prehospital AAM. The primary endpoint was neurological recovery. We compared outcomes between the prehospital AAM and non-AAM groups using multivariable logistic regression with an interaction term between prehospital AAM and the four Asian cities.
Results A total of 16,510 patients were included in the final analyses. The rates of prehospital AAM varied among Osaka, Seoul, Singapore, and Taipei (65.0%, 19.2%, 84.9%, and 34.1%, respectively). The non-AAM group showed better outcomes than the AAM group (adjusted odds ratio [aOR] for neurological recovery 0.30; 95% confidence interval [CI], 0.24–0.38]). In the interaction model for neurological recovery, the aORs for AAM in Osaka and Singapore were 0.12 (95% CI, 0.06–0.26) and 0.21 (95% CI, 0.16–0.28), respectively. In Seoul and Taipei, the association between prehospital AAM and neurological recovery was not significant (aOR 0.58 [95% CI, 0.31–1.10] and 0.79 [95% CI, 0.52–1.20], respectively). The interaction between prehospital AAM and region was significant (P=0.01).
Conclusion The effects of prehospital AAM on outcomes of OHCA patients differed according to regional variability in the EMS systems.
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Objective The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database.
Methods We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome.
Results Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65–2.87 for SGAs; OR, 1.31; CI, 0.30–5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31–1.07 for SGAs; OR, 0.63; CI, 0.12–3.26 for ETI).
Conclusion Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.
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Objective The point-of-care ultrasound of the airway (POCUS-A) is a useful examination method but there are currently no educational programs for medical students regarding it. We designed a POCUS-A training curriculum for medical students to improve three cognitive and psychomotor learning domains: knowledge of POCUS-A, image acquisition, and image interpretation.
Methods Two hours of training were provided to 52 medical students in their emergency medicine (EM) rotation. Students were evaluated for cognitive and psychomotor skills before and immediately after the training. The validity measures were established with the help of six specialists and eight EM residents. A survey was administered following the curriculum.
Results Cognitive skill significantly improved after the training (38.7±12.4 vs. 91.2±7.7) and there was no significant difference between medical students and EM residents in posttest scores (91.2±7.7 vs. 90.8±4.6). The success rate of overall POCUS-A performance was 95.8%. The students were confident to perform POCUS-A on an actual patient and strongly agreed to incorporate POCUS-A training in their medical school curriculum.
Conclusion Cognitive and psychomotor skills of POCUS-A among medical students can be improved via a limited curriculum on EM rotation.
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Objective The head-tilt/chin-lift (HT/CL) is a simple, routinely used maneuver to open the upper airway. Changes in the peak expiratory flow rate (PEFR) before and after the HT/CL maneuver have not been evaluated among conscious volunteers who are regarded as a control cohort.
Methods Sixty healthy 20-year-old volunteers (30 males and 30 females) were enrolled. The supine position was defined as the position at which the ear-eye line was at a 10° angle to the horizontal. The HT/CL position was defined as the position at which the ear-eye line was at a 25° angle to the horizontal. PEFR was measured using a hand-held device with the subject in the supine position (pre-PEFR) and HT/CL position (post-PEFR), respectively. One set was defined as these two measurements. Five sets of measurements were performed on each subject (300 sets). The set with the maximal and minimal difference between pre-PEFR and post-PEFR were excluded from the analysis. We used a paired t-test to compare the mean pre-PEFR and post-PEFR values for the entire group and subgroups divided by sex, height, body weight, body mass index and response status.
Results Overall, 360 measurements (180 sets) were analyzed. The mean pre-PEFR and post-PEFR were 316.1±87.6 and 346.5±94.7 L/min, respectively. Further, significant differences were observed for sex, height, body weight, and body mass index. In 10 subjects, post-PEFR was lower than pre-PEFR.
Conclusion PEFR increased by 9.6% after the HT/CL maneuver in young conscious subjects, but some subjects showed decreased PEFR after the HT/CL maneuver.
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Objective This study aimed to evaluate the efficacy of i-gel blind intubation (IGI) as a rescue device for definitive airway management in ground intubation for pre-hospital trauma patients.
Methods A prospective randomized crossover study was conducted with 18 paramedics to examine intubation performance of two blind intubation techniques through a supraglottic airway devices (IGI and laryngeal mask airway Fastrach), compared with use of a Macintosh laryngoscope (MCL). Each intubation was conducted at two levels of patient positions (ground- and stretcher-level). Primary outcomes were the intubation time and the success rate for intubation.
Results The intubation time (sec) of each intubation technique was not significantly different between the two positions. In both patient positions, the intubation time of IGI was shortest among the three intubation techniques (17.9±5.2 at the ground-level and 16.9±3.8 at the stretcher-level). In the analysis of cumulative success rate and intubation time, IGI was the fastest to reach 100% success among the three intubation techniques regardless of patient position (all P<0.017). The success of intubation was only affected by the intubation technique, and IGI achieved more success than MCL (odds ratio, 3.6; 95% confidence interval, 1.1 to 11.6; P=0.03).
Conclusion The patient position did not affect intubation performance. Additionally, the intubation time with blind intubation through supraglottic airway devices, especially with IGI, was significantly shorter than that with MCL.
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Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D, Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial Mostafa Somri, Ibrahim Matter, Luis A. Gaitini, Anan Safadi, Nasir Hawash, Manuel Á. Gómez-Ríos The Journal of Emergency Medicine.2020; 58(1): 25. CrossRef
Transtracheal ultrasonographic confirmation of endotracheal intubation using I-gel and an endotracheal tube introducer Sin-Youl Park, Jong Kun Kim The American Journal of Emergency Medicine.2020; 38(12): 2629. CrossRef
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Translation of learning objectives in medical education using high-and low-fidelity simulation: Learners' perspectives Katarzyna A. Naylor, Kamil C. Torres Journal of Taibah University Medical Sciences.2019; 14(6): 481. CrossRef
Objective Endotracheal intubation is extremely difficult to perform in patients wearing a cervical collar for a head and neck injury. Therefore, we analyzed actual measurements using the look externally, evaluate 3-3-2, Mallampati score, obstruction, and neck mobility (LEMON) criteria before and after cervical collar application to investigate the causes of a difficult airway.
Methods This simulation study was performed in 76 healthy volunteers. We measured the mouth opening, modified Mallampati classification, and neck extension before and after cervical collar application.
Results The mean inter-incisor distance significantly decreased from 4.3 to 2.6 cm (P<0.001). Fifty-seven participants classified as I and II were newly classified as III and IV according to the modified Mallampati classification after cervical collar application (16% to 91%). The angles of neck extension significantly decreased from 44° to 22° after cervical collar application (P<0.001). Before cervical collar application, our simulations predicted that 14 of 76 participants (18%) would have a difficult airway, whereas after cervical collar application, 76 of 76 (100%) were predicted to have a difficult airway.
Conclusion All values for the LEMON criteria (mouth opening, modified Mallampati classification, and neck extension) worsened significantly after cervical collar application. Additionally, a difficult airway was predicted in all participants after cervical collar application.
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Objective This study aimed to compare intubation performance between blind intubation through supraglottic airway devices and direct laryngoscopy by novices under manikin simulation. We hypothesized that the intubation time by novices using supraglottic airway devices was superior to that with the Macintosh laryngoscope (MCL).
Methods A prospective, randomized crossover study was conducted with 95 participants, to evaluate i-gel, air-Q, LMA Fastrach, and MCL devices. Primary outcomes were the intubation time and the success rate for intubation.
Results The i-gel showed the shortest insertion and tube passing time among the four devices; the i-gel and air-Q also showed the shortest total intubation time (all P<0.0083; i-gel vs. air-Q, P=0.03). The i-gel and MCL showed the highest cumulative success rate (all P<0.0083; i-gel vs. MCL, P=0.12).
Conclusion Blind intubation through the i-gel showed almost equal intubation performance compared to direct laryngoscopy.
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Objective Airway management in patients with suspected cervical spine injury is classified as a “difficult airway.” The best device for managing difficult airways is not known. Therefore, we conducted an intubation study simulating patients with cervical spine injury using three devices: a conventional Macintosh laryngoscope, a video laryngoscope (GlideScope), and a fiberoptic bronchoscope (MAF-TM). Success rates, intubation time, and complication rates were compared.
Methods Nine physician experts in airway management participated in this study. Cervical immobilization was used to simulate a difficult airway. Each participant performed intubation using airway devices in a randomly chosen order. We measured the time to vocal cord visualization, time to endotracheal tube insertion, and total tracheal intubation time. Success rates and dental injury rates were compared between devices.
Results Total tracheal intubation time using the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope was 13.3 (range, 11.1 to 20.1), 14.9 (range, 12.7 to 22.3), and 19.4 seconds (range, 14.1 to 32.5), respectively. Total tracheal intubation time differed significantly among the devices (P=0.009). Success rates for the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope were 98%, 96%, and 100%, respectively, and dental injury rates were 5%, 19%, and 0%, respectively.
Conclusion The fiberoptic bronchoscope required longer intubation times than the other devices. However, this device had the best success rate with the least incidence of dental injury.
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