Epidemiology |
Thakkar R, Wright SM, Alguire P, Wigton RS, Boonyasai RT. Procedures performed by hospitalists and non-hospitalist general internists. J Gen Intern Med. 2010;25:448–452. | Cross-sectional survey | 1059 respondents, 175 were classified as “hospitalists” and performed only 10 endotracheal intubations in the previous year with a range of 3–20. | - Older survey data from 2004.
- Small sample size.
- Low overall response rate (56%).
| The lack of clinical experience with airway management highlights the importance of a good educational program for the hospitalists. |
Airway complications: epidemiology |
Caplan RA, Posner KL. Adverse respiratory events in anesthesia—a closed claims analysis. Anesth. 1990;72:828–833. | Retrospective observational study of closed claims | 522 claims for adverse respiratory events. Three mechanisms accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196; 38%), esophageal intubation (94; 18%), and difficult tracheal intubation (87; 17%). Most adverse outcomes (72%) were considered preventable with better monitoring. | Inability to generate risk estimates due to the lack of denominator data, absence of a control group, bias toward adverse outcome, and reliance on self-reported data. | Most adverse outcomes were considered preventable with monitoring such as pulse oximetry and capnometry. |
Peterson GN, Domino KB. Management of the difficult airway—a closed claims analysis. Anesth. 2005;103:33–39. | Retrospective observational study of closed claims | 179 claims for difficult airway. Adverse outcomes: death (71; 46%), brain damage (19; 12%), airway injury including esophageal intubation (50; 32%), pneumothorax (7; 4%), aspiration pneumonitis (3; 2%), other (7; 5%). | Inability to generate risk estimates due to the lack of denominator data, absence of a control group, bias toward adverse outcome, and reliance on self-reported data. | Despite advances in anesthesia care several significant adverse outcomes can be attributed to the difficult airway. |
Bair AE, Filbin MR, Kulkarni RG. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med. 2002;23:131–140. | Prospective observational study of emergency department airway management in 30 hospitals participating in the National Emergency Airway Registry | 7712 patients identified who underwent emergency intubation; 207 patients required a rescue technique for intubation after an initial unsuccessful airway. Rescue techniques: RSI (102; 49%), cricothyrotomy (43; 21%). Adjuncts were used in 22 cases and included fiberoptics, oral endotrol, LMA, and retrograde intubation. | Self-reported data from individual study sites. Bias to underreport intubation with failed initial intubations. | A total of 2.7% of emergency intubations in the emergency department required rescue. |
Predicting a difficult airway |
Cattano D, Paniucci E, Paolicchi A, Forfori F, Giunta F, Hagberg C. Risk factors assessment of the difficult airway: an Italian survey of 1956 patients. Anesth Analg. 2004;99:1774–1779. | Prospective observational study of 1956 consecutive adult patients requiring endotracheal intubation | Mallampati score correlated with Cormack-Lehane scale but failed to reach high sensitivity (50%) or high positive predictive value (14%) for a difficult intubation. | Difficult airway was defined by the anesthesiologist. | Mallampati and other anatomical and clinical indexes had a low positive predictive value. |
Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesth. 2000;92:1229–1236. | Prospective observation study of 1502 patients requiring mask ventilation | Difficult mask ventilation was reported in 75 patients (5%; 95% CI, 3.9–6.1%). Five criteria were recognized as independent factors for difficult mask ventilation: age older than 55 years, body mass index > 26 kg/m2, beard, lack of teeth, and history of smoking). The presence of two indicated a high likelihood of difficult mask ventilation (sensitivity, 0.72; specificity, 0.73). | Subjective determination of difficult mask ventilation. Small number of patients defined as difficult. | Difficult mask ventilation was reported in 5% of cases. Five criteria were independent risk factors and the presence of two best indicate the potential for difficulty with mask ventilation. |
RSI and airway management competency |
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;31:325–332. | Observational, consecutive series of intubations in the emergency department over a 1-year period | A total of 610 patients required airway control and 569 (93%) were intubated by Emergency Medicine residents or attendants. Rapid sequence intubation was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated. Oral tracheal intubation without paralysis was attempted in 94 patients with a success rate of 91.5% (95% CI, 84% to 96%). | Compliance rate was 88.2% requiring the authors to obtain retrospective data on 72 intubations. Self-reported data. | High success rate in the emergency department when rapid sequence intubation was used for intubation. |
Reed M. Intubation training in Emergency Medicine: a review of one trainee's first 100 procedures. Emerg Med.J 2007;24:654–656. | Retrospective review study of the first 100 intubations by one Emergency Medicine trainee | Recorded 90 rapid sequence intubations and 10 intubations without drugs. Successful on 94 occasions with 8 complications. The complication rate improved after 30 intubations. | One trainee's experience. | Emergency Medicine residency review committee mandates 35 intubations for competency. This study supports a minimum of approximately 30 intubations to minimize complications. |