Emergency Intubation outside Operating Room/Intensive Care Unit Settings: Are We Following the Recommendations for Safe Practice?

CONTEXT: Although international guidelines have been developed for emergency tracheal intubation (ETI), there is little evidence of their applicability in developing countries. AIMS: The aim of this study was done to evaluate the different methods of ETI that are practiced among anesthetist and anesthesia trainees in India outside operating room (OR)/intensive care unit (ICU) settings. SETTINGS AND
DESIGN: This was prospective observational audit did among anesthesia personals managing ETI outside OR and ICU.
MATERIALS AND METHODS: The study was conducted through an online survey using electronic media. Certified anesthetists and anesthesia trainees were sent a questionnaire where they were asked to complete and submit it online.
RESULTS: Out of 145 respondents, 52% were certified anesthetists. Availability of equipment, technical staff, and visual monitors was a big constraint. About 28% of the participants do not examine the airway before ETI, 61% of participants invariably do not perform rapid sequence induction and intubation, and 89% of the participants have only the bougie at their disposal with the availability of videolaryngoscope (10%) and Fibreoptic bronchoscopy (FOB) (6%) being scarce. About 12% of the respondents use capnography for ETI confirmation. Only 48% of the participants accompany the patient during shifting.
CONCLUSIONS: Our survey has reported wide disparity during ETI with poor compliance to the international guidelines.

INTRODUCTION

Anesthetists are well versed in airway management in a controlled environment such as operation room (OR). However, airway management outside the OR in emergency settings tests there application and skill. Outside OR, the incidence of difficult intubation and other adverse events (e.g., hypoxemia, hypotension, esophageal intubation, aspiration, and cardiac arrest.) is significantly high.[123] Numerous countries have developed guidelines to minimize shortcomings and to improve patient care. However, data are lacking in India. Our study was planned to explore and to evaluate emergency tracheal intubation (ETI) practiced by anesthetist and anesthesia trainees, and find the difficulties faced by them. The information from this study may help in formulating a uniform directive to be followed by everybody who manages ETI.

MATERIALS AND METHODS

The study was conducted through an online survey using electronic media.[4] Anesthetists and anesthesia trainees were sent a questionnaire to their E-mail addresses and social media accounts which they were asked to complete and submit online. The questionnaire was made as a structured document with facility for in a tick-box format for the most appropriate answer(s). A provision was there for responding to more than a single option for a particular question. Figures 1 and 2 show the questionnaire for the survey.

Figure 1

The questionnaire for the survey

Figure 2

The questionnaire for the survey

There was also provision for expansion or comments if the anesthetist/trainee thought necessary. The certified anesthetist was defined as a person who was certified to practice anesthesia after completion of their training. A trainee was defined as the one who is currently undergoing training in anesthesia. These trainees were again divided by their years in anesthesia training into junior residents having <2 years training, and senior residents having more than 2 years training in anesthesia.

RESULTS

Questionnaires were sent to 346 persons through electronic media (e.g., E-mail and messaging app) out of which 145 responded. About 52% of the respondents were certified anesthetist. Figures 3 and 4 show the responses to the questionnaires of the survey. About 98% of the respondents have on-call duties. Equipment necessary for performing ETI was available to 56% of the respondents on site whereas 47% carries them along and 20% have to arrange for it on reaching the place. A qualified technician accompanies 28% of the respondent to the site while 44% responded with the unavailability of such a helping hand. 28% sometimes gets such help. About 68% found patients in the supine position while attending ETI. Face mask/nasal prong was attached to the patients with oxygen supply in 54% of cases while 12% responded with the absence of such a care. About 68% of the respondents mentioned the presence of an intravenous (IV) line in situ with 56% finding them in working condition. Visual monitor at the site was available to 26% of the respondents while 55% was finding them occasionally. Even when available, only 29% found the monitors were always attached to the patient. The vital parameters that are displayed are SpO2 (92%), heart rate (81%), blood pressure (68%), electrocardiography (36%), and expired end-tidal carbon dioxide (EtCO2) in 2% monitors. On reaching the site for ETI, 66% of the respondents briefly examine the patient, 50% take history/find about the diagnosis, 41% attach the monitors if available, and 37% record the vitals. However, 28% of the participants directly do the intervention, certified anesthetist being most of them. 44% of the respondents examine the airway routinely before ETI whereas 45% was doing it occasionally. 10% replied of not examining the airway at all. About 60% of the respondents never examine the cricothyroid membrane (CTM) before ETI with 27% at times doing so. Only 12% of the respondents routinely practice it. Nearly 62% of the respondents preferred supine position for ETI while 40% performed ETI in head-up position as the situation demanded. 76% of the respondents preoxygenate before ETI with 21% doing it occasionally. 39% of the participants invariably perform rapid sequence induction and intubation (RSII) with 61% not doing it. About 63% of the respondents use an IV induction agent routinely while 34% using it occasionally. Their choice of agent includes thiopentone (47%), propofol (36%), midazolam (35%), ketamine (28%), and etomidate (7%). 33% of the respondents used a combination of IV agent most popular being that of propofol and ketamine (44%) followed by ketamine and thiopentone (37%). About 75% of the participants use muscle relaxant for ETI of whom 86% use succinylcholine and 14% use rocuronium. 68% of the respondents use AMBU bag for mask ventilation whereas 32% use the Bain circuit. About 89% of the respondents usually have a bougie at their disposal while managing difficult airway during ETI with 47% having additional laryngeal mask airway (LMA) to help them. Availability of videolaryngoscope (10%) and FOB (6%) was scarce. Postintubation, 97% of the participants confirm tube position by bilateral auscultation of the chest. Only 12% of respondents have availability of capnography to establish tube position. Tachycardia (51%) followed by hypertension (33%), hypotension (28%), and drop in saturation (24%) were the common complications after ETI. 59% of the respondents always have a health professional/worker to assist them during ETI. 64% of the respondents have a ventilator for ventilating the patient after ETI. 89% of the respondents usually document the procedure, 23% send a sample for arterial blood gas analysis, and 57% of the respondents discuss with other health professionals regarding the future plan of action. 4% of the respondents leave the site once ETI is over. 48% of the participants always accompany the patient during shifting with 40% doing it occasionally.

Figure 3

Responses to the questionnaires of the survey

Figure 4

Responses to the questionnaires of the survey

DISCUSSION

Our survey was sent to 346 doctors managing emergency airway. 145 doctors who responded included both certified anesthetists and anesthesia trainees. In our survey, 48% of the respondents were trainees who were not routinely using methods that augment successful intubation (e.g., examining airway, use of appropriate IV induction agent, muscle relaxant, and use of RSII). Schmidt et al.[1] reported that attending physicians used methods that add to successful intubation (e.g., using muscle relaxants) significantly more frequently than juniors, with fewer complications. In another study, it was identified that ETI performed by a junior supervised by a senior (i.e., two operators) as a protective factor for ETI complication occurrence.[5]

The American Society of Anesthesiologist (ASA) guidelines, 2013, have emphasized the presence of all necessary equipment in places where airway management takes place.[2] In our survey, only 56% of the respondents replied to its availability at the site. Furthermore, one additional trained individual should be there to serve as an assistant during ETI.[24] Our study participants usually found patients lying in the supine position. Supine position is a suboptimal position for preoxygenation as it is difficult to take deep breaths and also posterior regions of lungs are prone to atelectatic collapse. These will reduce the oxygen reservoir of the lung.[6] Patients should have oxygen supplementation titrated to their needs in the form of low-flow oxygen devices such as nasal prongs and venturi masks, and high-flow-like reservoir bags.[78] Recently, the use of high-flow nasal cannula oxygen therapy has been promising for preventing desaturation during ETI.[9]

An easily accessible and functioning vascular access device should be in place during ETI.[10] Our study found only 68% of the respondents agreeing to its presence. Moreover, occlusion and dislodgement are a significant complication, which can lead to a reduced therapeutic effect of prescribed medicines.[11] Monitoring vital signs should be of paramount importance in patient care as they are susceptible to rapid changes in their physiological status. In our survey, very few respondents (26%) always found a visual monitor at the site and even when they were available, 29% of the respondents replied that they were routinely attached to the patient. Significant arrhythmias often develop during ETI further emphasizing the need for minimum mandatory monitoring.[12] Monitored patients have fewer and shorter episodes of hypoxemia during ETI than nonmonitored.[13] Continuous pulse oximeter monitoring is considered necessary during all phases of ETI.[14] Blood pressure monitoring helps to document the association of pressure abnormalities and occurrence of adverse events.[15] EtCO2 during ETI should be mandatory as per the ASA guidelines for successful tube placement irrespective of location.[116] Astin et al., in their survey, found capnography was routinely used by 56.3% of the respondents.[17] Our survey found only 2% of the respondents have excess to it. Combination of various monitors displaying vital parameters should be readily available and properly attached to the patient.

The assessment of airway, including demarcation of the cricothyroid membrane, is essential before establishing tracheal intubation.[18] In our survey, 60% of the participants have never identified the membrane. Marking the cricoid membrane is vital in cannot ventilate and cannot intubate conditions. During an emergency, intubation in head-up position improves glottic view along with the reduction in the risks of complications such as hypoxia, pulmonary aspiration, esophageal intubation, and prolonged time to intubation.[1920] In our survey, 40% of the respondents performed ETI in the head-up position as the situation demanded.

Patients requiring ETI are considered to be at high risk for aspiration pneumonitis, and hence, RSII should be the preferred method.[21] Our survey reported only 39% of the respondents performing it routinely with majority 61% not doing it at all. Jaber et al. also reported that rapid sequence induction was applied in only 36% of ETIs.[5] Cardiovascular collapse frequently occurs after RSII, and contributing factors include additive effects of drug-induced vasodilation. Reid et al. reported hypoxemia 19.2%, hypotension 17.8%, and arrhythmia 3.4% as the immediate complications following RSII.[22] Hence, there is a tendency to avoid RSII. However, literature has cited an increased incidence of complications of ETI when RSII is not applied.[2324] Moreover, preoxygenation during RSII prolongs the time to desaturation.[25] Morton et al. in his study on the effectiveness of preoxygenation of the critically ill patient for ETI found improvement in blood oxygen tensions.[26] Further, preoxygenation in head-up position augments the time to desaturation. In patients with unstable spine, Trendelenburg position can be an option to improve the preoxygenation.[2627]

Induction agents provide stable intubating condition during RSII.[28] Our study found the use of thiopentone (47%), propofol (36%), midazolam (35%), ketamine (28%), and etomidate (7%) for ETI. Helm et al., in their study, on ETI found that the choice of induction agents was etomidate (33%), thiopental (31%), fentanyl (21%), midazolam (19%), and ketamine (10%) and they often use it in combination.[29] Jaber et al., in his study, reported the use of etomidate as the most common hypnotic agent (50%).[5] Etomidate offers hemodynamic stability making it a first choice drug in the hypotensive patient.[3031] In this study, it was used by only 7% of the respondents. Midazolam is most commonly used for emergency intubation, however, it is frequently underdosed.[2232] The property of ketamine to preserve respiratory drive along with beneficial effects on the stunned myocardium can be used in the hemodynamically unstable patient.[33] Combination of ketamine and propofol (ketofol) is a popular combination with few studies reporting its efficacy.[3435] Our survey found the use of propofol and ketamine in 44% of the respondents. Choice of induction agent is not uniform among respondents that are quite understandable due to heterogeneity in the patient population.

Fast-acting relaxants, such as succinylcholine and rocuronium, are recommended for RSII. The use of muscle relaxants minimizes complications.[2436] However, caution should be applied in subsets of patients with obstructed airways. Rocuronium is a convenient alternative to succinylcholine.[37] However, its availability is a big concern. Succinylcholine should be the first choice in RSII and rocuronium is the second choice.[38] For mask ventilation, 68% of the respondents use a bag valve mask, i.e. AMBU which may be the only type of ventilator in resource-limited settings.

Guidelines have recommended the use and availability of rescue devices such as bougie, LMA, and videolaryngoscope with a proper checklist in place.[538] The use of videolaryngoscope increases intubation success rate especially among nonexpert.[3940] Our survey reported only 10% of the respondents having accessibility to videolaryngoscope. The gold standard for confirming endotracheal intubation is through capnography.[16] There have been reports of delayed diagnosis of esophageal intubation in the absence of capnography.[41] Silvestri et al. found that failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.[42] In this study, only 12% of our respondents have access to EtCO2 monitoring during ETI. Auscultation of chest and epigastrium is not sufficiently reliable to confirm tube placement. Even, the use of ultrasound can be a promising tool to examine endotracheal tube placement during ETI.[43]

Alterations in hemodynamic parameters (tachycardia and hypotension) are often observed following ETI because of inadequate depth of anesthesia, hypovolemia, and use of induction agents. These rapid and profound fluctuations can have a negative impact on patients with head injury. Moreover, cardiac arrest during ETI in the remote is sharply higher than its OR/ICU counterpart.[44] Hence, during ETI use of drugs should be based on the circulatory status of the patient.

Modern EDs are stretched out from the availability of bed resources especially in developing countries. Intubated patients have to spend more time in ED that can affect the overall outcome.[45] An intubated patient should have excess to mechanical ventilators. The health professional attending ETI should document the procedure performed along with the problems faced. Samples for blood gas analysis should ideally be sent after intubation. Discussion with other healthcare professional regarding the future course of management must be followed. Transfers, whether inter- or intra-hospital, are also one of the high-risk procedures and it should be well backed with skilled staff, equipment, and a good assessment of patient condition before shifting.[3] Our survey found only 48% of the respondents accompany the patient during transfer. Szem et al., in their study, on intra-hospital transport, found the physician was present in all of their transport.[46] Edge et al., in his study, identified a 10-fold reduction in preventable morbidity when specialized staff undertook the transportation.[47]

Our survey brought to notice the limitation under which anesthetist is managing ETI and the need to have a proper system in place so that a uniform practice is followed. In this regard, emphasis on the following points should be there while performing safe ETI.

Experienced persons must perform all ETI, and if trainees do, that should be under the supervision

Every person performing ETI should be assisted by trained personnel who have experience and knowledge of the situation and equipment

Necessary drugs and equipment required for difficult airway management along with provisions of patient monitoring, especially capnography, should be in place in areas which are deemed to have situations for ETI

If situation permits, the proper assessment of airway, including CTM marking, should be made before doing ETI

Perform RSII if not contraindicated during all ETI and trainees should be thought and made accustomed to this practice

Facilities should be made to ventilate the patient with ventilators

Documentation of the procedure in all cases of ETI

A patient should be shifted in the company of a doctor(s) preferably the one who had performed the ETI.

Our study was carried out as a survey where the study samples were personal performing ETI responding to a set of questionnaires. The credibility of such a study sample is always subjected to scrutiny as they are not blinded. Furthermore, the sample size does not reflect the practices followed by all. Our study did not highlight the level of the health system where each participant work. This is important as healthcare provisions vary markedly from one level to another. However, it should be mentioned that all arrangements for managing ETI should be there irrespective of the standards of the healthcare system.

CONCLUSION

Our survey has reported a wide disparity in managing the airway during emergency settings by treating personnel with poor compliance with the international guidelines. Implementation of an intubation management protocol can reduce immediate complications associated with ETI.[48] Local institutional guidelines must be developed and stringently applied for improving the outcomes of patients in these high-risk areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.