An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments.
Methods:
We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT).
Results:
Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event.
Conclusion:
An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.
SchwartzDEMatthayMACohenNH. Death and other complications of emergency airway management in critically ill patients: a prospective investigation of 297 tracheal intubations. Anaesthesiology. 1995;82(2):367–378.
PetersonGNDominoKBCaplanRAPosnerKLLeeLACheneyFW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33–59.
4.
JaberSAmraouiJLefrantJY. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34(9):2355–2361.
5.
MortTC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med. 2007;22(3):157–165.
6.
MortTC. Complications of emergency tracheal intubation: immediate airway-related consequences—part II. J Intensive Care Med. 2007;22(4):208–215.
7.
GriesdaleDEBosmaTLKurthTIsacGChittockDR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008;34(10):1835–1842.
8.
CookTMMacDougall-DavisSR. Complications and failure of airway management. Br J Anaesth. 2012;109(suppl 1): i68–i85.
9.
De JongAClavierasNConseilM. Implementation of a combo video laryngoscope for intubation in critically ill patients: a before-after comparative study. Intensive Care Med. 2013;39(12):2144–2152.
10.
KheterpalSMartinLShanksAMTremperKK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110(4):891–897.
11.
CookTMWoodallNFrerkC; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617–631.
12.
CookTMWoodallNHarperJBengerJ. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011;106(5):632–642.
13.
HeuerJFBarwingTABarwingJ. Incidence of difficult intubation in intensive care patients: analysis of contributing factors. Anaesth Intensive Care. 2012;40(1):120–127. Erratum in: Anaesth Intensive Care. 2012;40:351. Mörer, Onnen [corrected to Moerer, Onnen].
14.
SimpsonGDRossMJMcKeownDWRayDC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth. 2012;108(5):792–799.
15.
KheterpalSHealyDAzizMF; Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119(6):1360–1369.
16.
BrownCAIIIBairAEPallinDJWallsRM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65(4):363–370.
17.
DiggsLAYusufJEDe LeoG. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014;85(7):885–892.
18.
TachibanaNNiiyamaYYamakageM. Incidence of cannot intubate-cannot ventilate (CICV): results of a 3-year retrospective multicenter clinical study in a network of university hospitals. J Anesth. 2015;29(3):326–330.
19.
De JongAMolinariNPouzeratteY. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2015;114(2):297–306.
20.
PetriniFAccorsiAAdrarioE; Gruppo di Studio SIAARTI “Vie Aeree Difficili” IRC e SARNePI; Task Force. Recommendations for airway control and difficult airway management [In English, Italian]. Minerva Anestesiol. 2005;71(11):617–657.
21.
MayglothlingJDuaneTMGibbsM; Eastern Association for the Surgery of Trauma. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 suppl 4): S333–S340.
22.
ApfelbaumJLHagbergCACaplanRA; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–270.
23.
LawJABroemlingNCooperRM; Canadian Airway Focus Group. The difficult airway with recommendations for management—part 2—the anticipated difficult airway. Can J Anaesth. 2013;60(11):1119–1138.
24.
HuitinkJMBouwmanRA. The myth of the difficult airway: airway management revisited. Anaesthesia. 2015;70(3):244–249.
25.
CookTBehringerECBengerJ. Airway management outside the operating room: hazardous and incompletely studied. Curr Opin Anaesthesiol. 2012;25(4):461–469.
26.
MartinLDMhyreJMShanksAMTremperKKKheterpalS. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114(1):42–48.
27.
De JongAMolinariNTerziN; AzuRéa Network for the Frida-Réa Study Group. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med. 2013;187(8):832–839.
28.
KhandelwalNGalgonREAliMJoffeAM. Cardiac arrest is a predictor of difficult tracheal intubation independent of operator experience in hospitalized patients. BMC Anesthesiol. 2014;14:38.
29.
Difficult Airway Society Extubation Guidelines Group, PopatMMitchellVDravidRPatelASwampillaiCHiggsA. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318–340.
30.
McGillJClintonJERuizE. Cricothyrotomy in the emergency department. Ann Emerg Med. 1982;11(7):361–364.
31.
SpaiteDWJosephM. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg Med. 1990;19(3):279–285.
32.
GillespieMBEiseleDW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. Laryngoscope. 1999;109(11):1766–1769.
33.
BairAEPanacekEAWisnerDHBalesRSaklesJC. Cricothyrotomy: a 5-year experience at one institution. J Emerg Med. 2003;24(2):151–156.
34.
McIntoshSESwansonERBartonED. Cricothyrotomy in air medical transport. J Trauma. 2008;64(6):1543–1547.
35.
WarnerKJShararSRCopassMKBulgerEM. Prehospital management of the difficult airway: a prospective cohort study. J Emerg Med. 2009;36(3):257–265.
36.
PaixBRGriggsWM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Emerg Med Australas. 2012;24(1):23–30.
37.
HessertMJBennettBL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness Environ Med. 2013;24(1):53–66.
38.
HillCReardonRJoingSFalveyDMinerJ. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med. 2010;17(6):666–669.
39.
NakstadARBredmosePPSandbergM. Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scand J Trauma Resusc Emerg Med. 2013;21:59.
40.
BrownCAIIICoxKHurwitzSWallsRM. 4,871 emergency airway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: “A-TEAM”) project. West J Emerg Med. 2014;15(2):188–193.
41.
DillonJKChristensenBFairbanksTJurkovichGMoeKS. The emergent surgical airway: cricothyrotomy vs. tracheotomy. Int J Oral Maxillofac Surg. 2013;42(2):204–208.
42.
GrahamDBEastmanALAldyKN. Outcomes and long term follow-up after emergent cricothyroidotomy: is routine conversion to tracheostomy necessary?Am Surg. 2011;77(12):1707–1711.
43.
WrightMJGreenbergDEHuntJPMadanAKMcSwainNEJr. Surgical cricothyroidotomy in trauma patients. South Med J. 2003;96(5):465–467.
44.
AltmanKWWaltonenJDKernRC. Urgent surgical airway intervention: a 3 year county hospital experience. Laryngoscope. 2005;115(12):2101–2104.
45.
PetersJBruijstensLvan der PloegJTanEHoogerwerfNEdwardsM. Indications and results of emergency surgical airways performed by a physician-staffed helicopter emergency service. Injury. 2015;46(5):787–790.
46.
XeropotamosNSCoatsTJWilsonAW. Prehospital surgical airway management: 1 year’s experience from the Helicopter Emergency Medical Service. Injury. 1993;24(4):222–224.
47.
BerkowLCGreenbergRSKanKH. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg. 2009;109(6):1860–1869.
48.
HillelATPandianVMarkLJ. A novel role for otolaryngologists in the multidisciplinary Difficult Airway Response Team. Laryngoscope. 2015;125(3):640–644.
49.
HendersonSOMcClungCDSintuuCSwadronSP. The presence of an Emergency Airway Response Team and its effects on in-hospital Code Blue. J Emerg Med. 2009;36(2):116–120.
50.
LongLVanderhoffBSmykeNShafferLESolomonJSteuerJD. Management of difficult airways using a hospital-wide “Alpha Team” approach. Am J Med Qual. 2010;25(4):297–304.
51.
AdamsMCSchmidtUHessDRStelfoxHTBittnerEA. Examination of patterns in intubation by an emergency airway team at a large academic center: higher frequency during daytime hours. Respir Care. 2014;59(5):743–748.
52.
GonzalezMNWestonBYuceTK. One-year experience with the Institution of a Critical Airway Team at an Academic Medical Center. J Emerg Med. 2016;50(1):194–197.
53.
MarkLJHerzerKRCoverR. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg. 2015;121(1):127–139.
