AIRWAY MATTERSJay Mekwan

DECLARATION

• No commercial bias or funding

OBJECTIVES

• Discuss some of the airway myths and look at the evidence behind them using scenarios (this is not a full literature review)

• Please feel free to ask questions as we move along

RESOURCES

• Up To Date• Dynamed search• Journal articles from searches• The Manual of Emergency Airway Management (aka the airway Bible)

• This is meant to be practical (ie can be done on the floor) NOT a Cochrane review)

CASE 1

• It’s 18:00 in the ED• 50M attends the ED feeling SOB and unwell• P120, BP90/50, RR32, Sats 80RA (92% with optiflow), GCS 15• Temp 39• Labs done, port CXR done, IV Abx done (you and your team are so good at

this!)

PORTABLE CXR

CASE 1: 1 HOUR LATER

• Lactate 5.0, BS 14, LKC 21• P120, BP 90/70, RR24, Pt getting tired (GCS E2 M5 V4 = 11)• You decide to intubate (finally something good to do!!)• The nurse asks you “what drugs do you want to use?”• You say “Ketamine & Roc”• She says “we’ve run out of Ketamine, Dr. Atkinson has been using Ketofol all

day!”“What about Etomidate?” she asks

• You start to ponder…..Etomidate in sepsis???

ANY INITIAL THOUGHTS?

LEVELS OF EVIDENCE• Level 1 (likely reliable) EvidenceRepresenting research results addressing clinical outcomes and meeting an extensive set of quality criteria which minimizes bias.There are two types of conclusions which can earn a Level 1 label: levels of evidence for conclusions derived from individual studies and levels of evidence for conclusions regarding a body of evidence• Level 2 (mid-level) EvidenceRepresenting research results addressing clinical outcomes, and using some method of scientific investigation, but not meeting the quality criteria to achieve Level 1 evidence labeling.• Level 3 (lacking direct) EvidenceRepresenting reports that are not based on scientific analysis of clinical outcomes. Examples include case series, case reports, expert opinion, and conclusions extrapolated indirectly from scientific studies

GRADES OF RECOMMENDATIONS

ETOMIDATE IN SEPSIS

• Theory: blockade of 11-β-hydroxylase, reduces serum cortisol & aldosterone levels

• Reversible blockade lasting 12-24hrs

INTENSIVE CARE MED. 2011 JUN;37(6):901-10. DOI: 10.1007/S00134-011-2160-1. EPUB 2011 MAR 4.

THE EFFECT OF ETOMIDATE ON ADRENAL FUNCTION IN CRITICAL ILLNESS: A SYSTEMATIC REVIEW.

ALBERT SG1, ARIYAN S, RATHER A

• Level 2 evidence• 7 RTs & 12 Observational studies (3715)• Increased mortality (RR 1.19; NNH 9-29) 14 studies• Increased adrenal insufficiency (RR 1.64; NNH 2-4) 14 studies• Subgroup Sepsis, mortality increased (RR 1.22)

• Limited by Heterogeneity

ANN EMERG MED. 2010 AUG;56(2):105-13.E5. DOI: 10.1016/J.ANNEMERGMED.2010.01.030. EPUB 2010 MAR 25.

THE EFFECT OF A BOLUS DOSE OF ETOMIDATE ON CORTISOL LEVELS, MORTALITY, AND HEALTH SERVICES UTILIZATION: A SYSTEMATIC REVIEW.

HOHL CM1, KELLY-SMITH CH, YEUNG TC, SWEET DD, DOYLE-WATERS MM, SCHULZER M.• Level 3 Evidence• 20 studies looking at adrenal function and mortality post induction• Lower pooled mean cortisol at 4 hours (elective surgical patients)• No significant difference in mortality

• Not really looking exclusively at our pt population

LANCET. 2009 JUL 25;374(9686):293-300. DOI: 10.1016/S0140-6736(09)60949-1. EPUB 2009 JUL 1.ETOMIDATE VERSUS KETAMINE FOR RAPID SEQUENCE INTUBATION IN ACUTELY ILL PATIENTS: A

MULTICENTRE RANDOMISED CONTROLLED TRIAL.JABRE P1, COMBES X, LAPOSTOLLE F, DHAOUADI M, RICARD-HIBON A, VIVIEN B, BERTRAND

L, BELTRAMINI A, GAMAND P, ALBIZZATI S, PERDRIZET D, LEBAIL G, CHOLLET-XEMARD C, MAXIME V, BRUN-BUISSON C, LEFRANT JY, BOLLAERT PE, MEGARBANE B, RICARD JD, ANGUEL N, VICAUT

E, ADNET F; KETASED COLLABORATIVE STUDY GROUP

• Level 2 evidence• 28 day mortality after induction with Etomidate or Ketamine• Single blinded RT• 655 enrolled (234 vs 235 in each group)• No significant difference between the two

ANN EMERG MED. 2010 NOV;56(5):481-9. DOI: 10.1016/J.ANNEMERGMED.2010.05.034. EPUB 2010 SEP 15.

A COMPARISON OF THE EFFECTS OF ETOMIDATE AND MIDAZOLAM ON HOSPITAL LENGTH OF STAY IN PATIENTS WITH SUSPECTED SEPSIS: A PROSPECTIVE, RANDOMIZED STUDY.

TEKWANI KL1, WATTS HF, SWEIS RT, RZECHULA KH, KULSTAD EB

• Level 1 evidence• Double blinded RT for intubation in sepsis• 122 enrolled (59 Midaz; 63 Etomidate)• Mortality 36% vs 43% (M vs E)• No difference in length of stay

• Underpowered for mortality

CHEST. 2015 FEB;147(2):335-46. DOI: 10.1378/CHEST.14-1012.SINGLE-DOSE ETOMIDATE DOES NOT INCREASE MORTALITY IN PATIENTS WITH SEPSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS AND

OBSERVATIONAL STUDIES.GU WJ, WANG F, TANG L, LIU JC

• Systematic review and meta analysis• 2 RCTS and 16 observational studies (5552 pts)• No increase in mortality RR 1.2 for RCTs & 1.05 for observational

• Sepsis & adrenal insufficiency RR 1.42

IS SINGLE-DOSE ETOMIDATE INDUCTION SAFE IN EMERGENCY INTUBATION OF CRITICALLY ILL PATIENTS?

EBEM COMMENTATORS SUNEEL UPADHYE, MD, MSC MCMASTER UNIVERSITY HAMILTON, ONTARIO, CANADA OLGA CYGANIK, MD DEPARTMENT OF

FAMILY MEDICINE UNIVERSITY OF TORONTO , ONTARIO, CANADA

• March 2016• 7 studies in meta analysis• Mortality – 6 studies – 772 pts

OR 1.17

OPTIONS

• Avoid Etomidate• Give Steroids post Etomidate• Let ICU staff know that you used Etomidate and let them decide what to do

• The debate continues….

YOU ARE PROCEEDING WITH THE INTUBATION….

• The drugs are about to be given and the second nurse says “do you want cricoid pressure?”

• Everything stops again as you think….What’s the validity of cricoid pressure?

INITIAL THOUGHTS?

RSI & CRICOID PRESSURE

• Aim• Technique • Pressure 10 Newtons awake, 30N when unconscious

UP TO DATE

• Poor data, either observational or cadaveric• Studies have shown reduced gastric insufflation• Studies have show reduced reflux of saline in cadavers• 50% of subjects have a lateral esophagus• 90% of subjects had their esophagus displaced laterally

• Apply Cricoid pressure (Level 2C)

COCHRANE DATABASE SYST REV. 2015 NOV 18;11:CD011656. DOI: 10.1002/14651858.CD011656.PUB2.

EFFECTIVENESS AND RISKS OF CRICOID PRESSURE DURING RAPID SEQUENCE INDUCTION FOR ENDOTRACHEAL INTUBATION.

ALGIE CM1, MAHAR RK, TAN HB, WILSON G, MAHAR PD, WASIAK J.• Systematic review• 493 records, 1 study met inclusion criteria• RCT 40 participants but outcome measures did not look at efficacy of

cricoid pressure.

• Conclusion: no current information on RCTs on this subject

EMERG MED J. 2013 FEB;30(2):163-5. DOI: 10.1136/EMERMED-2012-202190.2.TOWARDS EVIDENCE-BASED EMERGENCY MEDICINE: BEST BETS FROM THE MANCHESTER ROYAL

INFIRMARY. BET 1: CRICOID PRESSURE IN EMERGENCY RAPID SEQUENCE INDUCTION.BUTLER J1, SEN A

• Search revealed only 6 relevant papers• Observational studies or review

OPTIONS

• Doesn’t cause harm, but doesn’t conclusively help• May actually make the view worse• In ATLS• Being dropped from Airway courses

• Starting to fall out of favor

JUST AS YOU WAVE GOODBYE TO THE SEPTIC PT AS THEY GO TO ICU,

• A 26 M arrives having been assaulted. Was bought in by EMS with Police in attendance as he has been combative

• He was found in the street, with head wounds.• P80, BP 160/70, Resps 22, pupils +4, gluc 6, acting aggressively. Fortunately

EMS had gained IV access.• You decide it is safest to intubate this pt (great decision !)• The nurse says “I found some more Ketamine – do you want to use it?”• Damn – now you have to think again….Ketamine in Head injuries???

INITIAL THOUGHTS?

KETAMINE & HEAD INJURIES

• Causes catecholamine release• Stimulates sympathetic system• Augment heart rate & BP in those that are not catecholamine depleted

(secondary to disease process)

• Concern is raising ICP in head injured patients

ANN EMERG MED. 2015 JAN;65(1):43-51.E2. DOI: 10.1016/J.ANNEMERGMED.2014.06.018. EPUB 2014 JUL 23.

THE EFFECT OF KETAMINE ON INTRACRANIAL AND CEREBRAL PERFUSION PRESSURE AND HEALTH OUTCOMES: A SYSTEMATIC REVIEW.

COHEN L1, ATHAIDE V1, WICKHAM ME2, DOYLE-WATERS MM3, ROSE NG4, HOHL CM5

• 4900 titles searched, 10 met criteria = 953 pts• 2 studies reported rise in ICP• 8 studies reported a small, transient drop in ICP• No difference in CPP, outcome, LOS, mortality

• No evidence that Ketamine adversely affects outcome

ANESTH ANALG. 2005 AUG;101(2):524-34, TABLE OF CONTENTS.REVISING A DOGMA: KETAMINE FOR PATIENTS WITH NEUROLOGICAL INJURY?

HIMMELSEHER S1, DURIEUX ME

• Systematic review• Largely dealing with NICU patients and sedation• Included 76 articles• 16 patient trials (>500 pts)

• Ketamine does not affect ICP

• Limited use to us because of patient population

UP TO DATE

• In the patient with a head injury or potentially elevated intracranial pressure (ICP), adequate cerebral perfusion pressure must be maintained to prevent secondary brain injury. We suggest etomidate for induction of these patients. For hypotensive patients, etomidate or ketamine may be used. Ketamine should be avoided in patients with hypertension or if elevated ICP is caused by spontaneous cerebral hemorrhage

• Level 2C

FROM THE AIRWAY MANUAL

OPTIONS

• Little data is from RSI in the ED• Not enough data to suggest to use it as the induction agent for all brain

injured patients (but the trend is going that way)• If brain injured patient is also hypotensive than Ketamine is the drug of

choice

REMINDERS

• Please use the C-Mac to intubate and record your intubations.• The C-mac can be used for DL (just don’t look at the screen)• Please try and complete an airway audit/RSI form after each advanced

airway