Advanced emergency airway management in adults
- Aaron E Bair, MD, MSc, FAAEM, FACEP
Aaron E Bair, MD, MSc, FAAEM, FACEP
- Professor of Emergency Medicine
- University of California, Davis
Airway management is an essential skill for clinicians caring for critically ill or injured patients and is fundamental to the practice of emergency medicine. In emergency medicine practice, rapid sequence intubation (RSI) is the most frequently used and successful means of intubating the trachea [1-7]. It is employed in approximately 70 to 85 percent of all patients requiring intubation in academic emergency departments, and about 82 percent of those without cardiac arrest. Cardiac arrest patients, who are intubated without medications, comprise the bulk of the remaining patients.
Although RSI is generally the preferred approach in the emergency department (ED), it may be poorly suited for some patients with difficult airway attributes. Thus, a careful assessment for airway difficulty must precede the decision to use RSI [1,3].
This topic review will discuss an algorithmic approach to advanced emergency airway management in adults. Other issues related to airway management, including basic airway management, difficult airway assessment, and rapid sequence intubation, are discussed in detail elsewhere. (See "Basic airway management in adults" and "The difficult airway in adults" and "Rapid sequence intubation in adults".)
RSI AND THE DIFFICULT AIRWAY
Clinicians should employ an approach to emergency airway management that accounts for the possibility of difficult intubation, difficult bag-mask ventilation (BMV), difficult extraglottic device ventilation (EGV), and difficult cricothyroidotomy. Methods for evaluating airway difficulty and management of difficult and failed airways are discussed in detail elsewhere. (See "The difficult airway in adults" and "The failed airway in adults" and "Emergency surgical cricothyrotomy (cricothyroidotomy)".)
In general, rapid sequence intubation (RSI) is used in patients for whom successful intubation and successful bag-mask ventilation are anticipated, despite any difficult airway attributes that may be identified. A significant number of emergency department (ED) patients in need of endotracheal intubation (ETI) have anatomic characteristics that can increase the procedure's difficulty. Nevertheless, the great majority of such patients can be managed using RSI.
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med 2002; 23:131.
- Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
- Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35:221.
- Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999; 17:141.
- Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med 2003; 10:612.
- Brown CA 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015; 65:363.
- Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005; 22:99.
- Mallampati SR. Clinical sign to predict difficult tracheal intubation (hypothesis). Can Anaesth Soc J 1983; 30:316.
- Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32:429.
- Eberhart LH, Arndt C, Cierpka T, et al. The reliability and validity of the upper lip bite test compared with the Mallampati classification to predict difficult laryngoscopy: an external prospective evaluation. Anesth Analg 2005; 101:284.
- Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42:487.
- Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia: a prospective blind study. Anesth Analg 1995; 81:254.
- Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 2004; 44:307.
- Bair AE, Caravelli R, Tyler K, Laurin EG. Feasibility of the preoperative Mallampati airway assessment in emergency department patients. J Emerg Med 2010; 38:677.
- Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999; 6:31.
- Bair AE, Panacek EA, Wisner DH, et al. Cricothyrotomy: a 5-year experience at one institution. J Emerg Med 2003; 24:151.
- Walls RM. The emergency airway algorithms. In: Manual of Emergency Airway Management, 3rd ed. Walls RM, Murphy MF. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.8.