Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients

Year in Review 2024: Noteworthy Literature in Cardiothoracic Critical Care

This article reviews noteworthy additions to the literature for the management of critically ill cardiothoracic surgical patients published in 2024. We reviewed 8100 articles to identify 10 publications that provided new or updated information across a diverse range of topics including extracorporeal membrane oxygenation (ECMO), sepsis and shock, and acute hypoxemic respiratory failure (AHRF). Additional topics within these publications included prophylaxis guidelines and evidence for prevention of common complications in the intensive care unit, such as bleeding, thrombosis, and acute kidney injury (AKI).

Preoxygenation With and Without Positive End-Expiratory Pressure in Lung-Healthy Volunteers: A Randomized Clinical Trial

Importance

Optimal preoxygenation is critical in emergency medicine to prevent desaturation during airway management, especially in high-risk populations. Identifying the most effective preoxygenation device across diverse patient groups remains a clinical priority.

Objective

To compare the efficacy of 3 preoxygenation devices-nonrebreather mask (NRM), bag-valve mask (BVM), and BVM with positive end-expiratory pressure (BVM plus PEEP)-in lung-healthy volunteers.

Design, Setting, and Participants

This crossover randomized clinical trial was conducted from May 26 to 31, 2024, at Eurac Research, Bolzano, Italy. Volunteer participants included lung-healthy adults with normal weight (NM), adults with overweight or obesity (OW-OB), and children aged 6 to 12 years.

Exposures

Preoxygenation using each device (NRM, BVM, BVM plus PEEP) with 15 L/min of oxygen for a duration of 3 minutes in a randomized order.

Main Outcomes and Measures

The primary outcome was expiratory oxygen concentration (Feo2) at the end of preoxygenation. Secondary outcomes included ventilation in dependent lung regions assessed using electrical impedance tomography, noninvasive continuous monitoring of oxygenation status (oxygenation reserve index [ORI]) at the end of preoxygenation, and the time taken for ORI to return to baseline values.

Results

The study included 53 participants, 39 male (74%) and 14 female (26%), of whom 16 were adults with NW (mean [SD] age, 36 [11] years), 18 were adults with OW-OB (mean [SD] age, 45 [11] years), and 19 were children (mean [SD] age, 8 [3] years). Mean (SD) Feo2 at the end of preoxygenation was higher with BVM and BVM plus PEEP compared with NRM in adults with NW (72.1% [5.9%] and 75.6% [4.3%], respectively, vs 52.5% [6.1%]; P < .001), adults with OW-OB (65.8% [10.4%] and 73.0% [6.4%], respectively, vs 51.9% [6.1%]; P < .001), and children (64.6% [13.4%] and 67.5% [10.2%], respectively, vs 38.5% [7.5%]; P < .001). Ventilation in dependent lung regions was higher with BVM plus PEEP than NRM in adults with NW (BVM plus PEEP, 51.9 [9.3] vs NRM, 47.0 [5.7]; P = .03) and children (BVM plus PEEP, 53.0 [7.3] vs NRM, 47.7 [7.0]; P = .002). ORI at the end of preoxygenation was higher with BVM plus PEEP than with NRM in adults with OW-OB (BVM plus PEEP, 0.79 [0.13] vs NRM, 0.73 [0.13]; P < .001). Additionally, the mean (SE) time for ORI to return to baseline was longer with BVM plus PEEP compared with NRM in both adults with OW-OB (BVM plus PEEP, 196 [74] seconds vs NRM, 158 [53] seconds; P = .01) and children (BVM plus PEEP, 115 [59] seconds vs NRM, 62 [36] seconds; P < .001).

Conclusions and Relevance

In this crossover randomized clinical trial, preoxygenation with PEEP was more effective than preoxygenation without PEEP, resulting in higher Feo2 values and improved ventilation in dependent lung regions. These findings suggest that BVM plus PEEP should be prioritized for preoxygenation in emergency settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT06370689.

Non-invasive ventilation for preoxygenation during prehospital anaesthesia - a prospective observational study

BACKGROUND

Preoxygenation is used to prevent hypoxia during anaesthesia and intubation. In a prehospital setting, preoxygenation is usually performed using a non-rebreather mask or a bag-valve-mask. These methods are however not sufficient for some critically ill patients. Non-invasive ventilation (NIV) has been shown to be more effective than other methods for preoxygenation of these patients in a hospital setting. Despite this, the use of NIV for preoxygenation has not been reported in a prehospital setting. The purpose of this study is to describe the prehospital use of, and experience with, NIV as a preoxygenation technique in patients undergoing prehospital emergency anaesthesia (PHEA).

METHODS

In this prospective observational study, we included 42 patients preoxygenated with NIV for PHEA by one Finnish helicopter emergency medical services unit. We gathered data on, among other things, patient characteristics, vital signs, success of preoxygenation, post-intubation complications and mortality. In addition, we conducted a semi-structured survey on experiences of the use of NIV for preoxygenation among the prehospital physicians in the study unit. Descriptive analyses were performed as well as calculating confidence intervals.

RESULTS

During the study period from October 2022 to May 2023, a total of 115 PHEAs were performed and NIV preoxygenation was used in 42 (n = 42/115, 37%) of these. Preoxygenation using NIV was technically successful in 100% of cases (n = 42/42, 95% CI 92-100). The median (IQR) oxygen saturation at HEMS arrival was 98% (95-99) and preoxygenation with NIV achieved a median (IQR) oxygen saturation post-intubation of 99% (97-100). No complications of hypoxia were documented, and the rate of pneumonia and mortality did not exceed what was expected based on literature. In the survey, 40% (n = 4/10) of physicians reported using NIV routinely for all patients while 60% (n = 6/10) only used it for those considered susceptible to desaturation.

CONCLUSIONS

This study demonstrates that NIV for preoxygenation has been implemented and is frequently used in prehospital settings in Finland, and that the intervention seems technically successful without clear adverse events.

Practices of Rapid Sequence Induction for Prevention of Aspiration-An International Declarative Survey

Background/Objectives: Rapid sequence induction (RSI) for the prevention of aspiration is a frequent clinical situation during anesthesia. The lack of international guidelines on this topic may lead to differences in practices. The aim of this survey is to identify the clinical practices in RSI among practitioners at an international level. Methods: International declarative survey across the ESAIC network. Results: A total of 491 respondents in 61 countries, 74% of them were seniors and 42% with over 20 years of experience. Most of the practitioners (87%) performed preoxygenation under a high flow of oxygen (>10 L/min) with no PEEP and no pressure support and 69% use opioids in most cases of RSI. The Sellick maneuver was used by 42% of respondents. RSI was used in most situations at high risk of aspiration (bowel obstruction, trauma within 6 h after the last meal, caesarian section). RSI was used in 53% of cases of appendicectomy in the absence of vomiting. Conversely, 29% did not use RSI in cases of symptomatic esophageal reflux. A total of 11% encountered at least one episode of grade IV anaphylaxis to succinylcholine or rocuronium and 24% aspiration pneumonia. Conclusions: Our results support the need for international guidelines on RSI to limit differences between practitioners and countries.

Preoxygenation strategies for intubation of patients who are critically ill: a systematic review and network meta-analysis of randomised trials

BACKGROUND

Preoxygenation is a crucial preparatory step for intubation. Several strategies for preoxygenation exist, including facemask oxygen, high-flow nasal cannula (HFNC), and non-invasive positive pressure ventilation (NIPPV). However, the comparative efficacy of these strategies remains largely uncertain. We aimed to compare the efficacy and safety of HFNC, NIPPV, and facemask oxygen for preoxygenation of patients who are critically ill requiring tracheal intubation.

METHODS

In this systematic review and network meta-analysis, we searched Embase, MEDLINE, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials for randomised clinical trials published from database inception until Oct 31, 2024, with no language restrictions. We included randomised controlled trials that compared HFNC versus NIPPV, HFNC versus facemask oxygen, or NIPPV versus facemask oxygen in adult patients (age ≥18 years) who were critically ill requiring intubation in the intensive care or emergency department setting. We had no additional eligibility criteria for our network meta-analysis. We used Covidence software to screen eligible trials. Two reviewers independently screened trials for titles and abstracts, and then subsequently screened full-text reports. Discrepancies were resolved by discussion or a third party adjudicator. Summary-level data were extracted manually using a structured data collection form. Outcomes of interest were hypoxaemia during intubation, successful intubation on the first attempt, serious adverse events, and all-cause mortality. We performed a frequentist random-effects network meta-analysis. We assessed the risk of bias using the modified Cochrane tool (RoB 2.0) and the certainty of evidence using the GRADE approach. The protocol is registered on the Open Science Framework.

FINDINGS

We initially identified 6900 records, of which 48 were assessed via full-text screening, and 15 eligible studies with 3420 patients were included in our systematic review and network meta-analysis. Findings suggested that use of NIPPV for preoxygenation probably reduces the incidence of hypoxaemia during intubation versus HFNC (relative risk 0·73 [95% CI 0·55-0·98]; p=0·032; moderate certainty) and reduces the incidence of hypoxaemia versus facemask oxygen (0·51 [0·39-0·65]; p<0·0001; high certainty). HFNC for preoxygenation reduces the incidence of hypoxaemia during intubation versus facemask oxygen (0·69 [0·54-0·88]; p=0·0064; high certainty). None of the preoxygenation strategies affected the incidence of successful intubation on the first attempt (all low certainty). None of the preoxygenation strategies appeared to affect all-cause mortality (very low-to-moderate certainty). NIPPV probably reduces the risk of serious adverse events versus facemask oxygen (0·30 [0·12-0·77]; p=0·011; moderate certainty) and might reduce the risk of serious adverse events versus HFNC (0·32 [0·11-0·91]; p=0·035; low certainty). HFNC might not reduce the risk of serious adverse events versus facemask oxygen (0·95 [0·60-1·51]; p=0·83; low certainty).

INTERPRETATION

Preoxygenation with NIPPV or HFNC rather than facemask oxygen might prevent hypoxaemia during tracheal intubation of adults who are critically ill. Compared with HFNC, NIPPV probably decreases the incidence of hypoxaemia during intubation. Our findings will inform updated international guidelines on preoxygenation.

FUNDING

None.

Utilization of non-invasive ventilation before prehospital emergency anesthesia in trauma - a cohort analysis with machine learning

BACKGROUND

For preoxygenation, German guidelines consider non-invasive ventilation (NIV) as a possible method in prehospital trauma care in the absence of aspiration, severe head or face injuries, unconsciousness, or patient non-compliance. As data on the utilization and characteristics of patients receiving NIV are lacking, this study aims to identify predictors of NIV usage in trauma patients using machine learning and compare these findings with the current national guideline.

METHODS

A cross-regional registry of prehospital emergency services in southwestern Germany was searched for cases of emergency anesthesia in multiply injured patients in the period from 2018 to 2020. Initial vital signs, oxygen saturation, respiratory rate, heart rate, systolic blood pressure, Glasgow Coma Scale (GCS), injury pattern, shock index and age were examined using logistic regression. A decision tree algorithm was then applied in parallel to reduce the number of attributes, which were subsequently tested in several machine learning algorithms to predict the usage of NIV before the induction of anesthesia.

RESULTS

Of 992 patients with emergency anesthesia, 333 received NIV (34%). Attributes with a statistically significant influence (p < 0.05) in favour of NIV were bronchial spasm (odds ratio (OR) 119.75), dyspnea/cyanosis (OR 2.28), moderate and severe head injury (both OR 3.37) and the respiratory rate (OR 1.07). Main splitting points in the initial decision tree included auscultation (rhonchus and bronchial spasm), respiratory rate, heart rate, age, oxygen saturation and head injury with moderate head injury being more frequent in the NIV group (23% vs. 12%, p < 0.01). The rates of aspiration and the level of consciousness were equal in both groups (0.01% and median GCS 15, both p > 0.05). The prediction accuracy for NIV usage was high for all algorithms, except for multilayer perceptron and logistic regression. For instance, a Bayes Network yielded an AUC-ROC of 0.96 (95% CI, 0.95-0.96) and PRC-areas of 0.96 [0.96-0.96] for predicting and 0.95 [0.95-0.96] for excluding NIV usage.

CONCLUSIONS

Machine learning demonstrated an excellent categorizability of the cohort using only a few selected attributes. Injured patients without severe head injury who presented with dyspnea, cyanosis, or bronchial spasm were regularly preoxygenated with NIV, indicating a common prehospital practice. This usage appears to be in accordance with current German clinical guidelines. Further research should focus on other aspects of the decision making like airway anatomy and investigate the impact of preoxygenation with NIV in prehospital trauma care on relevant outcome parameters, as the current evidence level is limited.

Evaluation of MACOCHA Score for Predicting Difficult Intubation in Critically Ill Cancer Patients: A Prospective Observational Study

Introduction

Tracheal intubation (TI) is often needed in the intensive care unit (ICU) but can have disastrous consequences. The MACOCHA score was developed for prediction of difficult intubation (DI) in critically ill.

Material and methods

After Institutional Ethics Committee approval, we conducted this prospective, single-center observational study. Evaluated the ability of MACOCHA score to predict difficult intubation in our ICU. We included 500 adults undergoing TI in our ICU. We collected the demographic data, details of ICU admission, and intubation-related data for calculating MACOCHA score. We used Statistical Package for the Social Sciences (version 21) for analysis. The accuracy of MACOCHA score for predicting DI was determined by area under the receiver operating characteristic (AUROC) curve. The Hosmer-Lemeshow goodness-of-fit statistics was used to determine calibration.

Results

Since complete dataset was available for 449/500 patients, we analyzed their data. Acute renal failure and shock were the most frequent reasons for TI. Ketamine and rocuronium were most commonly used drugs for TI. The incidence of DI was 13.5% (60/449). There were 30 patients whose Mallampati score was either III and IV, while 84 and 45 patients had severe hypoxemia and coma before TI, respectively. The AUROC curve for the MACOCHA score was 0.659 (confidence interval, 0.574-0.743), suggesting a moderate discrimination. The Hosmer-Lemeshow goodness-of-fit test showed moderate calibration (χ2 = 3.142, with p = 0.208). One hundred and seventy-one (26.5%) complications occurred in the entire cohort. Some patients had multiple complications.

Conclusion

The MACOCHA score showed moderate discrimination and calibration in predicting DI in our study.

How to cite this article

Kulkarni AP, Bhosale SJ, Kalvit KR, Cherian S, Shrivastava AM, Gorade MR. Evaluation of MACOCHA Score for predicting Difficult Intubation in Critically Ill Cancer Patients: A Prospective Observational Study. Indian J Crit Care Med 2025;29(3):208-214.

Non-Invasive Ventilation as a Pre-Oxygenation Strategy During In-Flight Rapid Sequence Intubation: A Case Report

Noninvasive ventilation has been used as a pre-oxygenation strategy for rapid sequence intubation in the emergency department and the intensive care unit, yet, limited research has examined its use in the transport setting. These case reports discuss the use of noninvasive ventilation via a Hamilton T1 ventilator (Hamilton Medical) during transport by an air medical crew for pre-oxygenation before intubation in two cases. In both cases, a noninvasive, bilevel-positive airway pressure mode with a backup rate was used to achieve adequate airway pressures while allowing for a two-handed seal by one emergency medical services clinician as the other prepared the equipment and medications. This method of pre-oxygenation in a space and resource-limited setting was associated with first-pass success without hypoxia in both cases. This adds another method of pre-oxygenation to facilitate safe intubation in similar settings.

Preoxygenation strategies before intubation in patients with acute hypoxic respiratory failure: a network meta-analysis

Background

Patients with acute hypoxic respiratory failure (AHRF) face life-threatening complications during tracheal intubation. Preoxygenation can enhance oxygen reserves and mitigate hypoxemia risk, but the optimal strategy remains unclear. This study aimed to identify the best preoxygenation strategy for these patients.

Methods

We conducted a network meta-analysis of studies published up to July 2024, evaluating conventional oxygen therapy (COT), high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), and their combinations prior to intubation. Data were extracted and analyzed using pairwise and network meta-analysis within a Bayesian framework. Model selection was based on the deviance information criterion (DIC).

Results

A total of 11 randomized controlled trials involving 2,874 patients were included. NIV preoxygenation significantly reduced the likelihood of SpO2 <80% during intubation compared to COT (RR 0.28, 95% CI 0.070-0.71). No significant differences were found in lowest SpO2, complications, ICU length of stay, or mortality across preoxygenation strategies. HFNC was the most effective for reducing complications, while HFNC combined with COT or NIV showed similar effects on the lowest SpO2 during intubation.

Conclusion

Preoxygenation with HFNC appears to be the safest and most effective approach prior to intubation in patients with AHRF compared to other strategies.

Systematic review registration

PROSPERO (CRD42024565053).

Oxygen reserve index vs. peripheral oxygen saturation for the prediction of hypoxemia in morbidly obese patients: a prospective observational study

BACKGROUND

Pulse oximetry is a standart of anesthesia for perioperative monitoring. Due to the principles of Hb oxygen dissociation curve, peripheral oxygen saturation has an approximate sensitivity and specificity of 90% for the detection of hypoxemia.

OBJECTIVES

The primary outcome of the study was to evaluate ORiⓇ as an early parameter to determine hypoxia in morbidly obese patients. The secondary outcome was to compare the effectiveness of ORiⓇ with SpO2 in non-obese patients.

DESIGN

Prospective, observational study.

SETTING

Department of elective operating room at tertiary hospital.

PATIENTS AND METHODS

Observational study included written informed consent from 51 patients with 19 < BMI < 25 kg/m2 and 51 patients with BMI > 40 kg/m2 undergoing an elective surgery requiring tracheal intubation. In addition to standard monitors, an ORi sensor was placed and baseline values were recorded. The patients were preoxygenated until end tidal expiratory oxygen concentration is reached to 90%. After anesthesia induction and tracheal intubation, the breathing circuit was not connected tracheal tube until the SpO2 decreased to 95%. Shapiro-Wilk, Pearson Chi-square, t-test, and Mann Whitney U test were used for the study.

MAIN OUTCOME MEASURES

Times of tolerable apnea, ORiⓇ and SpO2 values at the end of preoxygenation, beginning of intubation, beginning of the ORi alarm, when SpO2 reached 95%, and when ORi reaches a plateau.

SAMPLE SIZE

102 patients.

RESULTS

The alert period: time to reach ORiⓇ from 0.24 to a value of 95% SpO2 was observed as 32 s in morbidly obese patients and 94 s in patients with a normal body mass index. The SpO2 alert period was determined as time difference between 97% and 95% SpO2. The data were recorded as 15 s and 36 s, respectively. It was observed that tolerable apnea, ORiⓇ, SpO2 and added alert times were longer in patients with normal BMI compared to morbidly obese patients.

CONCLUSIONS

As a result, ORiⓇ can provide an early warning to prevent unexpected hypoxia before saturation begins to decrease in morbidly obese patients.

LIMITATIONS

Inability to perform arterial blood gas sampling in the time periods when we looked at the parameters to determine the relationship between ORiⓇ and PaO2.

CLINICAL TRIALS

GOV IDENTIFIER

NCT05480748 registered 2022-07-29.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Ventilator-assisted preoxygenation in an aeromedical retrieval setting

OBJECTIVE

Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting.

METHODS

Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2).

RESULTS

VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events.

CONCLUSION

VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.

Noninvasive Ventilation for Preoxygenation during Emergency Intubation

BACKGROUND

Among critically ill adults undergoing tracheal intubation, hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain.

METHODS

In a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults (age, ≥18 years) undergoing tracheal intubation to receive preoxygenation with either noninvasive ventilation or an oxygen mask. The primary outcome was hypoxemia during intubation, defined by an oxygen saturation of less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation.

RESULTS

Among the 1301 patients enrolled, hypoxemia occurred in 57 of 624 patients (9.1%) in the noninvasive-ventilation group and in 118 of 637 patients (18.5%) in the oxygen-mask group (difference, -9.4 percentage points; 95% confidence interval [CI], -13.2 to -5.6; P<0.001). Cardiac arrest occurred in 1 patient (0.2%) in the noninvasive-ventilation group and in 7 patients (1.1%) in the oxygen-mask group (difference, -0.9 percentage points; 95% CI, -1.8 to -0.1). Aspiration occurred in 6 patients (0.9%) in the noninvasive-ventilation group and in 9 patients (1.4%) in the oxygen-mask group (difference, -0.4 percentage points; 95% CI, -1.6 to 0.7).

CONCLUSIONS

Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask. (Funded by the U.S. Department of Defense; PREOXI ClinicalTrials.gov number, NCT05267652.).

The comparison of preoxygenation methods before endotracheal intubation: a network meta-analysis of randomized trials

Background

Preoxygenation before endotracheal intubation (ETI) maintains asphyxiated oxygenation and reduces the risk of hypoxia-induced adverse events. Previous studies have compared various preoxygenation methods. However, network meta-analyses (NMAs) of the combined comparison of preoxygenation methods is still lacking.

Methods

We searched for studies published in PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Review Manager version 5.3 was used to evaluate the risk of bias. The primary outcome of this meta-analysis was low oxygen saturation (SpO2) during ETI. The secondary outcomes included SpO2 <80%, SpO2 <90%, and apnea time during ETI. NMA was performed using R 4.1.2 software gemtc packages in RStudio.

Results

A total of 15 randomized controlled trials were included in this study. Regarding the lowest SpO2, the noninvasive ventilation (NIV) with high-flow nasal cannula (HFNC) group performed better than the other groups. For SpO2 <80%, the NIV group (0.8603467) performed better than the HFNC (0.1373533) and conventional oxygen therapy (COT, 0.0023) groups, according to the surface under the cumulative ranking curve results. For SpO2 <90%, the NIV group (0.60932667) performed better than the HFNC (0.37888667) and COT (0.01178667) groups. With regard to apnea time, the HFNC group was superior to the COT group (mean difference: -50.05; 95% confidence interval: -90.01, -10.09; P = 0.01).

Conclusion

Network analysis revealed that NIV for preoxygenation achieved higher SpO2 levels than HFNC and COT and offered a more significant advantage in maintaining patient oxygenation during ETI. Patients experienced a longer apnea time after HFNC preoxygenation. The combination of NIV with HFNC proved to be significantly superior to other methods. Given the scarcity of such studies, further research is needed to evaluate its effectiveness.

Systematic review registration

identifier CRD42022346013.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

High-Flow Nasal Cannula versus Bag Valve Mask for Preoxygenation during Rapid Sequence Intubation in the Emergency Department: A Single-Center, Prospective, Randomized Controlled Trial

OBJECTIVE

Hypoxia is a frequently reported complication during the intubation procedure in the emergency department (ED) and may cause bad outcomes. Therefore, oxygenation plays an important role in emergency airway management. The efficacy of oxygenation with high-flow nasal cannula (HFNC) in the ED has been studied, though the evidence is limited. The study aim was to compare two methods of preoxygenation in patients undergoing rapid sequence intubation (RSI) in the ED: (1) HFNC and (2) bag-valve mask (BVM) oxygenation.

METHODS

This is a single-center, prospective, randomized controlled trial (RCT) in adult ED patients requiring RSI. Patients were randomized to receive preoxygenation with either HFNC or BVM. While HFNC therapy was continued during the intubation procedure, BVM oxygenation was interrupted for laryngoscopy. The primary outcome was the lowest peripheral oxygen saturation (SpO2) level during intubation. Secondary outcomes were incidence of desaturation (SpO2<90%) and severe hypoxemia (SpO2<80%) throughout the procedure, intubation time, rate of failed intubation, and 30-day survival rates.

RESULTS

A total of 135 patients were randomized into two groups (HFNC n = 68; BVM n = 67). The median lowest SpO2 value measured during intubation was 96% (88.8%-99.0%) in the HFNC group and 92% (86.0%-97.5%) in the BVM group (P = .161). During the intubation procedure, severe hypoxemia occurred in 13.2% (n = 9) of patients in the HFNC group and 8.9% (n = 6) in the BVM group, while mild hypoxemia was observed in 35.8% (n = 24) of the BVM group and 26.5% (n = 18) of the HFNC group. However, there was no statistically significant difference between the groups in terms of hypoxemia development (P = .429 and P = .241, respectively). No significant difference was reported in the rate of failed intubation between the groups. Thirty-day mortality was observed in 73.1% of the BVM group and 57.4% of the HFNC group, with a borderline statistically significant difference (difference 15.7; 95% CI of the difference: -0.4 to 30.7; P = .054).

CONCLUSION

The use of HFNC for preoxygenation, when compared to standard care with BVM oxygenation, did not improve the lowest SpO2 levels during intubation. Also, the use of HFNC during intubation did not provide benefits in reducing the incidence of severe hypoxemia. However, the 30-day survival rates were slightly better in the HFNC group compared to the BVM group.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis

BACKGROUND

Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway.

METHODS

We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale.

RESULTS

We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse.

CONCLUSIONS

Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask

Background

Hypoxemia is a common and life-threatening complication during emergency tracheal intubation of critically ill adults. The administration of supplemental oxygen prior to the procedure ("preoxygenation") decreases the risk of hypoxemia during intubation.

Research Question

Whether preoxygenation with noninvasive ventilation prevents hypoxemia during tracheal intubation of critically ill adults, compared to preoxygenation with oxygen mask, remains uncertain.

Study Design and Methods

The PRagmatic trial Examining OXygenation prior to Intubation (PREOXI) is a prospective, multicenter, non-blinded randomized comparative effectiveness trial being conducted in 7 emergency departments and 17 intensive care units across the United States. The trial compares preoxygenation with noninvasive ventilation versus oxygen mask among 1300 critically ill adults undergoing emergency tracheal intubation. Eligible patients are randomized in a 1:1 ratio to receive either noninvasive ventilation or an oxygen mask prior to induction. The primary outcome is the incidence of hypoxemia, defined as a peripheral oxygen saturation <85% between induction and 2 minutes after intubation. The secondary outcome is the lowest oxygen saturation between induction and 2 minutes after intubation. Enrollment began on 10 March 2022 and is expected to conclude in 2023.

Interpretation

The PREOXI trial will provide important data on the effectiveness of noninvasive ventilation and oxygen mask preoxygenation for the prevention of hypoxemia during emergency tracheal intubation. Specifying the protocol and statistical analysis plan prior to the conclusion of enrollment increases the rigor, reproducibility, and interpretability of the trial.

Clinical trial registration number

NCT05267652.

Managing the Physiologically Difficult Airway in Critically Ill Adults

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from  https://link.springer.com/bookseries/8901 .

Evaluation of tracheal intubations in a paediatric intensive care unit

INTRODUCTION

Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality.

PATIENTS AND METHODS

Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events.

RESULTS

The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events.

CONCLUSIONS

In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.

A prospective randomized study to evaluate the efficacy of pressure support ventilation with and without positive end expiratory pressure for preoxygenation in adult patients

A primary concern for anesthesiologists is the maintenance of oxygenation during general anesthesia. Extending the safe apnea time, which is the time from the onset of apnea until the oxygen saturation concentration reaches 90% or less, increases the margin of safety with tracheal intubation. Preoxygenation before anesthetic induction has been a widely accepted manoeuver to increase oxygen reserves and hence delay the onset of arterial desaturation during apnea. This study aimed to evaluate the efficacy of pressure support ventilation with/without positive end-expiratory pressure (PEEP) for preoxygenation in adult patients. A total of 132 patients, aged 20 to 50 years, scheduled for elective surgery under general anesthesia, requiring endotracheal intubation, were included and randomly divided into three groups (n = 44 per group): spontaneous ventilation (SV), pressure support ventilation without PEEP (PS), and pressure support ventilation with PEEP (PEEP) groups. In the SV group, the patients breathed spontaneously without any support using a face mask; in the PS group, the patients breathed spontaneously with the inspiratory pressure support of 12 cm H₂O without PEEP; and in the PEEP group, the patients were subjected to preoxygenation (similar to the PS group) with PEEP at 6 cm H₂O. Preoxygenation was terminated when the fraction of expired oxygen reached 90% and the duration was recorded. Time from 90 seconds after administration of rocuronium bromide until oxygen saturation fell to 93% was recorded and taken as safe apnea time. The time taken for preoxygenation (the expired oxygen fraction reaches 90) was significantly shorter in patients of PEEP and PS groups when compared to the SV group. The safe apnea time was significantly longer in patients of PEEP and PS groups compared with the SV group. Application of inspiratory pressure support of 12 cm H₂O and PEEP of 6 cm H₂O during preoxygenation significantly reduces the preoxygenation time and prolongs the safe apnea time compared with conventional preoxygenation.

[The role of HFNC oxygen in pre-oxygenation prior to intubation and the practice of invasive procedures]

Over recent years, High Flow Nasal Cannula (HFNC) oxygen therapy has been more and more extensively applied in numerous medical settings, and it is now carried out in invasive procedures such as pre-oxygenation before orotracheal intubation, often leading to complications. More generally, pre-oxygenation is aimed at maintaining the highest possible oxygen saturation for extended periods of time. With this in mind, HFNC seems as effective as standard oxygen delivery with regard to hematosis in patients with mild or moderate hypoxemia, and it presents the advantage of reducing the adverse events associated with intubation. That said, during pre-oxygenation of patients with severe hypoxemia, non-invasive ventilation (NIV) is probably more effective than HFNC, especially in the prevention of respiratory events. However, in patients with little or no hypoxemia undergoing risky procedures such as bronchial endoscopy, HFNC allows better oxygen saturation than standard methods. To summarize, even though NIV remains useful in unstable patients, especially in decreasing desaturation episodes, HFNC could represent a reasonable alternative in case of poor tolerance, allowing continuous oxygenation of patients requiring digestive endoscopy or trans-esophageal ultrasound.

[The perioperative role of high-flow cannula oxygen (HFNO)]

High-flow nasal cannula oxygen (HFNO) is commonly used during the perioperative period. Its numerous physiological benefits, satisfactory tolerance and ease of use have led to its widespread application in intensive care and post-anesthesia care units. HFNO is also used in the operating theater in multiple indications: as oxygen supplementation (associated with pressurization) prior to orotracheal intubation; in digestive and bronchial endoscopies, especially in patients at risk of hypoxemia; and in intraoperative surgery requiring spontaneous ventilation (ENT, thoracic surgery…). During the postoperative period, HFNO can be used in a curative strategy for respiratory failure or in a prophylactic strategy to prevent reintubation. In a curative approach, HFNO seems of interest following cardiac or thoracic surgery but has not been evaluated in respiratory failure subsequent to abdominal surgery, in which case noninvasive ventilation remains the gold standard. The risk of respiratory complications depends on type of surgery and on patient comorbidities. As prophylaxis, HFNO is currently preferred to conventional oxygen therapy after cardiac or thoracic surgery, especially in patients at high risk of respiratory complications. For the clinician, it is important to acknowledge the limits of HFNO and to closely monitor patients receiving HFNO, the objective being to avoid delays in intubation that could lead to increased mortality.

Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project

Introduction

The feasibility of implementing a revised Montpellier intubation bundle incorporating recent evidences was tested in a quality-improvement project. It was hypothesized that this "Care Bundle" implementation would reduce intubation-related complications.

Materials and methods

The project was conducted in an 18-bedded multidisciplinary intensive care unit (ICU). Baseline data for intubations were collected over 3-month "Control Period". During the 2-month "Interphase", a revised intubation bundle was developed, and staff members involved in the intubation process were extensively trained on different aspects of intubation with emphasis on bundle components. Various components of the bundle were pre-intubation fluid loading, pre-oxygenation with NIV plus PS, positive-pressure ventilation post-induction, succinylcholine as a first-line induction agent, routine use of stylet, and lung recruitment within 2 minutes of intubation. Intubation data were collected again in the 3-month "Intervention Period".

Results

Data were collected for 61 and 64 intubations, respectively, during control and intervention periods. There was significant improvement in compliance to five of six-bundle components; improvement in pre-intubation fluid loading during the intervention period did not reach statistical significance. Overall, at least 3 components of the bundle were complied within over 92% of intubations in the intervention period. However, whole-bundle compliance was limited to 14.3%. Incidences of major complications were reduced significantly in the intervention period (23.8% vs 45.9%, p = 0.01). There was significant reduction in profound hypotension (21.77% vs 29.51%, p = 0.04) and a nonsignificant 11.89% reduction in profound hypoxemia. There were no differences in minor complications.

Conclusion

Implementation of an evidence-based revised Montpellier intubation bundle is feasible and it reduces major complications related to endotracheal intubation.

How to cite this article

Ghosh S, Salhotra R, Arora G, Lyall A, Singh A, Kumar N, et al. Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project. Indian J Crit Care Med 2022;26(10):1106-1114.

How to improve intubation in the intensive care unit. Update on knowledge and devices

Tracheal intubation in the critically ill is associated with serious complications, mainly cardiovascular collapse and severe hypoxemia. In this narrative review, we present an update of interventions aiming to decrease these complications. MACOCHA is a simple score that helps to identify patients at risk of difficult intubation in the intensive care unit (ICU). Preoxygenation combining the use of inspiratory support and positive end-expiratory pressure should remain the standard method for preoxygenation of hypoxemic patients. Apneic oxygenation using high-flow nasal oxygen may be supplemented, to prevent further hypoxemia during tracheal intubation. Face mask ventilation after rapid sequence induction may also be used to prevent hypoxemia, in selected patients without high-risk of aspiration. Hemodynamic optimization and management are essential before, during and after the intubation procedure. All these elements can be integrated in a bundle. An airway management algorithm should be adopted in each ICU and adapted to the needs, situation and expertise of each operator. Videolaryngoscopes should be used by experienced operators.

Non-invasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials

Background and objectives

Preoxygenation is crucial for providing sufficient oxygen reservoir to a patient before intubation and enables the extension of the period between breathing termination and critical desaturation (safe apnoea time). Conventionally, face mask ventilation is used for preoxygenation. Non-invasive ventilation is a new preoxygenation method. The study objective was to compare the outcomes of non-invasive ventilation and face mask ventilation for preoxygenation.

Method

PubMed, Embase, Cochrane Library, and the ClinicalTrials.gov registry were searched for eligible studies published from database inception to September 2021. Individual effect sizes were standardized, and a meta-analysis was conducted using random effects models to calculate the pooled effect size. Inclusion criteria were randomised controlled trials of comparing the outcomes of non-invasive ventilation or face mask ventilation for preoxygenation in patients scheduled for surgeries. The primary outcome was safe apnea time, and the secondary outcomes were post-operative complications, number of patients who achieved the expired O₂ fraction (FeO₂) after 3 min of preoxygenation, minimal SpO₂ during tracheal intubation, partial pressure of oxygen in the arterial blood (PaO₂) and partial pressure of carbon dioxide (PaCO₂) after preoxygenation, and PaO₂ and PaCO₂ after tracheal intubation.

Results

13 trials were eligible for inclusion in this study. Significant differences were observed in safe apnoea time, number of patients who achieved FeO₂ 90% after preoxygenation for 3 min, and PaO₂ and PaCO₂ after preoxygenation and tracheal intubation. Only in the non-obese subgroup, no significant difference was observed in safe apnoea time (mean difference: 125.38, 95% confidence interval: − 12.26 to 263.03).

Conclusion

Non-invasive ventilation appeared to be more effective than conventional methods for preoxygenation. We recommend non-invasive ventilation based on our results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01842-y.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study

Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/Fi_O2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).

Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials

Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.

Tracheal intubation in the critically ill patient

Tracheal intubation is among the most commonly performed and high-risk procedures in critical care. Indeed, 45% of patients undergoing intubation experience at least one major peri-intubation adverse event, with cardiovascular instability being the most common event reported in 43%, followed by severe hypoxemia in 9% and cardiac arrest in 3% of cases. These peri-intubation adverse events may expose patients to a higher risk of 28-day mortality, and they are more frequently observed with an increasing number of attempts to secure the airway. The higher risk of peri-intubation complications in critically ill patients, compared with the anaesthesia setting, is the consequence of their deranged physiology (e.g. underlying respiratory failure, shock and/or acidosis) and, in this regard, airway management in critical care has been defined as "physiologically difficult". In recent years, several randomised studies have investigated the most effective preoxy-genation strategies, and evidence for the use of positive pressure ventilation in moderate-to-severe hypoxemic patients is established. On the other hand, evidence on interventions to mitigate haemodynamic collapse after intubation has been elusive. Airway management in COVID-19 patients is even more challenging because of the additional risk of infection for healthcare workers, which has influenced clinical choices in this patient group. The aim of this review is to provide an update of the evidence for intubation in critically ill patients with a focus on understanding peri-intubation risks and evaluating interventions to prevent or mitigate adverse events.

Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.

Recommendations for developing clinical care protocols during pandemics: From theory and practice

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services – including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

BACKGROUND

Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.

METHODS

Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m^-2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO₂/FiO₂ < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.

RESULTS

Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m^-2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI - 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77-93] with noninvasive ventilation and 86% [78-92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.

CONCLUSIONS

Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen. Trial registration Clinical trial number: NCT02668458 ( http://www.clinicaltrials.gov ).

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients With Severe Acute Respiratory Failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analog classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Impact of Videolaryngoscopy Expertise on First-Attempt Intubation Success in Critically Ill Patients

OBJECTIVES

The use of a videolaryngoscope in the ICU on the first endotracheal intubation attempt and intubation-related complications is controversial. The objective of this study was to evaluate the first intubation attempt success rate in the ICU with the McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN) according to the operators' videolaryngoscope expertise and to describe its association with the occurrence of intubation-related complications.

DESIGN

Observational study.

SETTING

Medical ICU.

SUBJECTS

Consecutive endotracheal intubations in critically ill patients.

INTERVENTIONS

Systematic use of the videolaryngoscope.

MEASUREMENTS AND MAIN OUTCOMES

We enrolled 202 consecutive endotracheal intubations. Overall first-attempt success rate was 126 of 202 (62%). Comorbidities, junior operator, cardiac arrest upon admission, and coma were associated with a lower first-attempt success rate. The first-attempt success rate was less than 50% in novice operators (1-5 previous experiences with videolaryngoscope, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (> 15 previous experiences with videolaryngoscope). Multivariate analysis confirmed the association between specific skill training with videolaryngoscope and the first-attempt success rate. Severe hypoxemia and overall immediate intubation-related complications occurred more frequently in first-attempt failure intubations (24/76, 32%) than in first-attempt success intubations (14/126, 11%) (p < 0.001).

CONCLUSIONS

We report for the first time in the critically ill that specific videolaryngoscopy skill training, assessed by the number of previous videolaryngoscopies performed, is an independent factor of first-attempt intubation success. Furthermore, we observed that specific skill training with the McGrath MAC videolaryngoscope was fast. Therefore, future trials evaluating videolaryngoscopy in ICUs should consider the specific skill training of operators in videolaryngoscopy.