Rebellion in EM 2019: 3 Things That Have Changed the Way I Intubate

Background: Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In this talk at Rebellion in EM 2019, Rob J. Bryant, MD gave a 14 minute 12 second talk on 3 things that have changed the way he intubates (Back Up Head Elevated – BUHE, Bougie 1st Intubation, & Team Management).

Rebellion in EM 2019: 3 Things That Have Changed the Way I Intubate via Rob J Bryant, MD

[embedyt] https://www.youtube.com/watch?v=RgaboQrsddg[/embedyt]

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Head of Bed Elevated:

Elevating the head of the bed during pre-oxygenation, and during laryngoscopy has the potential to prolong the safe apnea duration and decrease peri-intubation complications.

• BUHE study:
  • >500 airways managed by anesthesiologists outside of the operating room. Randomized to Back up, Head elevated to 20 degrees vs supine.
  • Assessed for 1 or more airway complications: difficult intubation with >3 looks, or >10min tube placement, esophageal intubation, hypoxia <90%, or aspiration.
  • 1 or more complications: 9.3 vs 22.6%
• OR evidence:
  • 40 patients, 20 degrees HOB elevation vs supine, measured time to sats < 90%.
    • 386 vs 283 seconds.
  • 40 obese patients randomized to preoxygenation sitting upright (90 degrees) vs supine. Intubated supine, and measured time to desat <90%.
    • 214 vs 162 seconds.

Bougie First:

• Bougie use has traditionally been relegated to a poorly practiced rescue maneuver.
• Single center study with history of high bougie use: bougie vs ET tube with stylet.
• First pass success in patients with at least 1 difficult airway characteristic: 82% vs 96%
• First pass success in all patients: 87 vs 98%
• Be very good at your first choice of airway management device. Be facile with bougie use.

Team Management:

• No amount of airway skill / medical knowledge will prove successful in a resuscitation without good team management / leadership skills.
• Communication: The better it is, the safer for the patient
• Communication should be so good that anyone in the room can tell what is happening.
• Checklists can aid in, but not replace good team management skills

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References:

1. Khandelwal N et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016. PMID 26866753
2. Lane S et al. A prospective, randomized controlled trial comparing the efficacy of pre-oxygenation in the 20 degree head-up vs supine position. Anesthesia 2005. PMID: 16229689
3. Altermatt F. R. et al. Pre-oxygenation in the obese patient: effects of position on tolerance to apnea. Br J Anaesth. 2005. PMID: 16143575
4. Driver BE et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on first-Attempt Intubation Success Among Patients with Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA 2018. PMID: 29800096

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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