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High-Flow Oxygen for Respiratory Support

Patricia Kritek, MD   Trial support using HFO in selected patients with acute hypoxemic respiratory failure and in patients with postoperative hypoxemia.   Multiple trials support using noninvasive positive pressure ventilation (NPPV) in patients with chronic obstructive pulmonary disease exacerbations and cardiogenic pulmonary edema. NPPV is most effective in rapidly reversible conditions where supporting... Read more..

Updated International Guidelines for Pediatric Resuscitation

Katherine Bakes, MD   Goals for emergency physicians include focusing on both respiratory and cardiac support, with consideration of targeted temperature management and extracorporeal membrane oxygenation when feasible.   Sponsoring Organization: International Liaison Committee on Resuscitation   Target Audience: Physician who care for critically ill children, including emergency physicians, family medicine physicians, pediatricians, and pediatric intensivists.   Background... Read more..

2015 Airway Article of the Year

Dr. Calvin A. Brown, III, presents four nominees for “Airway Article of the Year.” The nominated articles were chosen from among those featured in the 2015 Quarterly Airway Research Updates. Dr. Brown discusses the content and merits of each article and the audience votes to select the “Airway Article of... Read more..

December 2015 Quarterly Airway Management Research Update

Originally presented as a live webinar, Dr. Calvin A. Brown, III uses a case discussion to introduce the latest published airway research and discusses their impact on clinical practice. This month's case and discussion revolves around maximizing intubation safety. Read more..

Saline Flush After Bolus Rocuronium Shortens Onset of Neuromuscular Blockade

Calvin A. Brown, III, MD, FAAEM   In a randomized trial, patients receiving rocuronium followed by a saline flush had an earlier onset of neuromuscular blockade than those receiving rocuronium alone.   Reliable, rapid onset of neuromuscular blockade is critical for successful emergency rapid sequence intubation (RSI). Rocuronium has a slower onset than succinylcholine.... Read more..

Updated International Guidelines for Neonatal Resuscitation

Katherine Bakes, MD   Care goals include early ventilatory support and advanced resuscitative efforts when warming, drying and stimulation alone are ineffective.   Sponsoring Organization:International Liaison Committee on Resuscitation   Target Audience:Clinicians who care for newly born infants transitioning from intrauterine to extrauterine life and neonatal patients in the first weeks of life, including emergency physicians,... Read more..

Pediatric Out-of-Hospital Intubations: Experience of a Single EMS Agency

Katherine Bakes, MD   Success rates werehi gh, but this study leaves more questions than answers.   In a retrospective study of pediatric (<13 years) prehospital paramedic airway management in King County, Washington, investigators assessed the incidence and outcomes of intubation attempts during a 6-year period. Overall, 299 calls (0.05% of all calls) involved... Read more..

GlideScope Outperforms C-MAC D-Blade for Trainee Intubations of Predicted Difficult Airways

Calvin A. Brown, III, MD, FAAEM   In patients with predicted difficult airways intubated in the operating room, the GlideScope had a higher first-attempt intubation success rate than the C-MAC D-Blade.   Video laryngoscopy (VL) improves intubation success in patients with predicted difficult airways primarily by ensuring glottic visualization. While VL with acute-angled devices... Read more..

Just A Routine Operation

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Airway Article of the Year Winners

AirwayWorld Airway Article of the Year Nominees for the Airway Article of the Year are selected from among all of the articles covered during the Airway Management Research Update webinars held during the year. The content and merits of each article are... Read more..

Video Intubating Stylet for Nasotracheal Intubation in Patients with Reduced Mouth Opening

Calvin A. Brown, III, MD, FAAEM   Nasal intubation was quicker and easier with the new intubating stylet than with traditional flexible fiber-optic scopes.   Nasal intubation is required when oral access is limited or nonexistent. Flexible fiber-optic scopes have been the standard tool in this situation, but the technique is challenging and equipment... Read more..

Single-Dose Etomidate and Pediatric Cortisol Levels

Calvin A. Brown, III, MD, FAAEM   In a randomized, double-blink study, a single induction dose of etomidate suppressed postoperative cortisol levels in children, but this has no effect on clinical outcomes.   Etomidate transiently suppresses 11ß-hydroxylase, a key glucocorticoid synthetic enzyme, resulting in temporary reductions in circulating cortisol. A recent meta-analysis found no... Read more..

Digital Palpation of the Cricothyroid Membrane is Unreliable in Obese Laboring Patients

Calvin A. Brown, III, MD, FAAEM   In laboring at-term patients, palpation of the cricothyroid membrane was less accurate in obese than in nonobese patients, whereas ultrasound identified the cricothyroid membrane in all patients.   Obesity is a common marker of airway difficulty and may make a “can't intubate, can't oxygenate” scenario (and the... Read more..

No Clear Benefit of Early NPPV in Immunocmpromised Patients with Hypoxemic Respiratory Failure

Patricia Kritek, MD   Compared with oxygen therapy, noninvasive positive-pressure ventilation did not prevent subsequent intubation or lengthen survival.   In a small trial conducted in the late 1990s, early use of noninvasive positive-pressure ventilation (NPPV) conferred a mortality benefit in immunocompromised patients with hypoxemic respiratory failure (NEJM JW Emerg Med Jun... Read more..

Fiberoptic Tour of the Airway

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September 2015 Quarterly Airway Management Research Update

Originally presented as a live webinar, Dr. Calvin A. Brown, III uses a case discussion to introduce the latest published airway research and discusses their impact on clinical practice. Studies look at Conventional vs Video Laryngoscopy for tracheal tube exchange, Validation of the LEMON mnemonic in prediction of difficult intubation,... Read more..

The i-gel vs. the PRO-Breathe Laryngeal Mask Airway in Children

Calvin A. Brown, III, MD, FAAEM   In anesthetized spontaneously breathing children, leakage volume was greater, device dislodgement was more common, and first-attempt insertion success was lower with the i-gel.   The i-gel is an extraglottic device with a noninflatable cuff made of a flexible gelatinous material. The PRO-Breathe is a silicone-based standard laryngeal... Read more..

McGrath MAC Video Laryngoscope Does Not Provide Adequate Direct Views of the Airway

Calvin A. Brown, III, MD, FAAEM   When used to obtain a direct view — for which it was not designed — the McGrath was associated with more difficult intubation and worse glottic views than a conventional Macintosh laryngoscope.   Video laryngoscopes improve glottic view and first-attempt intubation success compared with direct laryngoscopes. Curved... Read more..

The Jaw Thrust Finds a Purpose During Flexible Fiberoptic Intubation

Calvin A. Brown, III, MD, FAAEM   During oral flexible fiberoptic intubation, the jaw-thrust maneuver was more effective when patients were in a semi-erect position than a supine position.   An unobstructed path through the airway makes fiberoptic intubation easier to perform. Patient positioning, airway adjuncts, and jaw or tongue manipulation have all been... Read more..

Time to Adopt High-Flow Oxygen Delivery Systems for Emergency Airway Procedures

Calvin A. Brown, III, MD   High-flow oxygen delivery via nasal cannula improved oxygen saturations and prevented desaturation in patients with difficult airways undergoing flexible bronchoscopic intubation.   Flexible bronchoscopic intubation, although not a common procedure in the emergency department, is usually performed in the setting of an airway difficulty. Maintaining adequate oxygenation during... Read more..

Be Ready to Extend the Incision Beyond Landmarks When Performing a Crich!

Ali S. Raja, MD, MBA, MPH, FACEP   Compared with ultrasound, three classic landmark techniques were inaccurate for identification of the cricothyroid membrane.   Cricothyrotomy is a rare procedure, and it is becoming more so given the increasing adoption of video laryngoscopy. However, it remains an essential skill, not only as a rescue procedure... Read more..

“Protective” Ventilation During Surgery Lowers Risk for Postoperative Complications

Patricia Kritek, MD   Ventilation in the operating room probably should resemble ventilation in the intensive care unit.   Low tidal volume ventilation (6 mL/kg predicted body weight; plateau pressure, <30 cm H2O) has become the standard of care for patients with acute respiratory distress syndrome (ARDS). Because of concern about ventilator-induced lung injury,... Read more..

Physician-Led Prehospital Airway Management in Trauma

R. Eleanor Anderson, MD; Ron M. Walls, MD, FRCPC, FAAEM   Intubation was successful in 99% of patients, and all surgical airways were successful in this large retrospective series.   To assess airway management of trauma patients in a physician-led prehospital system in England, researchers conducted a retrospective database review of 7256 prehospital trauma... Read more..

Rise in Video Laryngoscopy Has Not Affected Rates of Awake Intubation

Calvin A. Brown, III, MD   In this retrospective review at a single center, use of video laryngoscopy increased significantly over time, but the rate of awake intubation remained constant.   Awake intubation is used when glottic visualization with a laryngoscope and rescue mask ventilation are anticipated to be significantly difficult. It involves the... Read more..

Can the Modified LEMON Score Predict Difficult Intubation?

Daniel J. Pallin, MD, MPH   A Japanese registry study suggests the score has fair sensitivity and specificity.   The LEMON score is a mnemonic for predicting difficult intubation. It stands for Look, Evaluate the 3-3-2 rule, Mallampati score, Obstruction, and Neck mobility (NEJM JW Emerg Med Mar 2005 and Emerg Med... Read more..

Strategies to Prevent Ventilator-Associated Pneumonia

Neil M. Ampel, MD   In a decision model, use of the Institute for Healthcare Improvement VAP prevention bundle plus subglottic endotracheal suction and probiotics had the best cost‐benefit ratio.   Mortality from ventilator‐associated pneumonia (VAP) exceeds 10%. Many strategies to prevent this infection have been evaluated, but little is known about their comparative effectiveness. Such... Read more..

Need to Exchange a Tracheal Tube? Use Video Laryngoscopy

Calvin A. Brown, III, MD   Video laryngoscopy improved first‐attempt success and lowered rates of complications compared with direct laryngoscopy in a single‐center registry study of endotracheal tube exchanges using airway exchange catheters.   Endotracheal tube (ETT) exchange is required when ventilation is ineffective because of either cuff failure or tube size. The procedure... Read more..

Predictors of Swallowing Dysfunction During Deep Sedation with Propofol

Calvin A. Brown, III, MD   Increasing body‐mass index, age, and propofol dose were predictors of swallowing impairment and aspiration in this single‐center observational study.   Deep sedation is becoming increasingly popular in a variety of clinical settings to facilitate medical and surgical procedures. Sedatives have the potential to affect swallowing function and protective airway reflexes. During... Read more..

Markers of Difficult Ventilation with a Supraglottic Airway Device

Calvin A. Brown, III, MD   In large study of Southeast Asian patients, risk factors for difficult or failed ventilation with an SGA were short thyromental distance, cervical spine immobility, male sex, and age over 45.   Risk factors for difficult bag‐and‐mask ventilation have been well validated, but less is known about risk factors for difficult... Read more..

June 2015 Quarterly Airway Management Research Update

Originally presented as a live webinar, Dr. Calvin A. Brown, III uses case discussions to introduce the latest published airway research and discusses their impact on clinical practice. Read more.. 1 2