The Journal of Emergency Medicine, Vol. -, No. -, pp.

19, 2017
2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2017.04.003

Original
Contributions

MANAGEMENT OF PATIENTS WITH PREDICTED DIFFICULT AIRWAYS IN AN

ACADEMIC EMERGENCY DEPARTMENT

John C. Sakles, MD,* Matthew J. K. Douglas, MD,* Cameron D. Hypes, MD,* Asad E. Patanwala, PHARMD, and
Jarrod M. Mosier, MD*
*Department of Emergency Medicine, Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona
College of Medicine, Tucson, Arizona, and Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy,
Tucson, Arizona
Reprint Address: John C. Sakles, MD, Department of Emergency Medicine, University of Arizona College of Medicine, 1501 N. Campbell
Avenue, PO Box 245057, Tucson, AZ 85724

, AbstractBackground: Patients with difficult airways
are sometimes encountered in the emergency department
(ED), however, there is a little data available regarding their
management. Objectives: To determine the incidence, man-
agement, and outcomes of patients with predicted difficult
airways in the ED. Methods: Over the 1-year period from
July 1, 2015 to June 30, 2016, data were prospectively
collected on all patients intubated in an academic ED. After
each intubation, the operator completed an airway manage-
ment data form. Operators performed a pre-intubation
difficult airway assessment and classified patients into
routine, challenging, or difficult airways. All non-arrest pa-
tients were included in the study. Results: There were 456
patients that met inclusion criteria. Fifty (11%) had pre-
dicted difficult airways. In these 50 patients, neuromuscular
blocking agents (NMBAs) were used in 40 (80%), an awake
intubation technique with light sedation was used in 7
(14%), and no medications were used in 3 (6%). In the 40
difficult airway patients who underwent NMBA facilitated
intubation, a video laryngoscope (GlideScope 21, Verathon,
Bothell, WA and C-MAC 19, Karl Storz, Tuttlingen, Ger-
many) was used in each of these, with a first-pass success
of 90%. In the 7 patients who underwent awake intubation,
a video laryngoscope was used in 5, and a flexible fiberoptic
scope was used in 2. Ketamine was used in 6 of the awake in-
Disclosures: Dr. Sakles serves as an adviser to Verathon Med-
ical.
tubations. None of these difficult airway patients required
rescue with a surgical airway. Conclusions: Difficult airways
were predicted in 11% of non-arrest patients requiring intu-
bation in the ED, the majority of which were managed using
an NMBA and a video laryngoscope with a high first-pass
success. 2017 Elsevier Inc. All rights reserved.
, Keywordsdifficult airway; airway management;
tracheal intubation; intubation; video laryngoscopy; emer-
gency department
INTRODUCTION
Critically ill patients in the emergency department (ED)
frequently require tracheal intubation during their resus-
citation. Because all of these patients are presumed to
have a full stomach and are thus at high risk for aspira-
tion, neuromuscular blocking agents (NMBA) are
typically used, with a rapid sequence intubation (RSI)
technique (1). More recently, delayed sequence intuba-
tion (DSI) has been used to optimize preoxygenation in
patients at high risk of desaturation (2). Before intubation
is attempted, it is common practice to perform a difficult
airway assessment to determine if an NMBA can safely
be used (35). If a difficult airway is predicted, it is
generally recommended that an awake intubation be

RECEIVED: 29 March 2017;

ACCEPTED: 5 April 2017

1
2 J. C. Sakles et al.
performed in order to maintain spontaneous ventilation
and avoid a potentially catastrophic cant intubate- and the vast majority are performed by EM residents,
cant oxygenate scenario (47). Surprisingly, there is with an EM attending always at the bedside. In-house
little research on the management of the difficult
airway in the ED (8). The purpose of this investigation
is to determine the incidence, management and outcomes
of patients with predicted difficult airways in the ED.
MATERIALS AND METHODS
Study Design and Setting
This is a single-center prospective observational study of
ED intubations performed over the 1-year period from
July 1, 2015 to June 30, 2016, recorded in a continuous
quality-improvement database. The study design com-
plied with recommendations of the Strengthening the Re-
porting of Observational Studies in Epidemiology
statement (9). This project received an exemption from
the University of Arizona Institutional Review Board.
This study was conducted at a 61-bed tertiary care ac-
ademic ED certified by the American College of Sur-
geons as a Level I Trauma Center. There are 36 adult
beds, 18 pediatric beds, and 7 trauma resuscitation
bays. The annual census is approximately 78,000 visits.
The ED has standard airway equipment as well as a
wide array of difficult airway equipment available. There
are 12 portable airway rolls containing conventional
direct laryngoscopes with a variety of straight and curved
blades. There are three mobile GlideScope units (Vera-
thon, Bothell, WA) with an assortment of adult hyperan-
gulated blades (LoPro T3 and LoProT4), standard
geometry Macintosh blades (Mac T3 and Mac T4), and
pediatric blades (Cobalt video baton size 1-2 with Cobalt
Stat blades size 1 and 2). There are two mobile C-MAC
units (Karl Storz, Tuttlingen, Germany) with a variety of
standard geometry Macintosh blades (C-MAC Mac 2, 3
and 4) and straight blades (C-MAC Miller 0 and 1). A
portable flexible fiberoptic scope (Olympus MAF
GM; Olympus, Center Valley, PA) and rigid intubating
optical stylet (Karl Storz Bonfils) are also both avail-
able in the ED. There are three difficult airway carts in
the ED, which are stocked with tracheal tube introducers
(bougies), LMA Fastrachs (size 3, 4 and 5; Teleflex
Medical Europe, Ltd, Westmeath, Ireland) and a surgical
airway kit (Cook Universal Cricothyrotomy Catheter
Set; Cook Medical Europe Ltd, Limerick, Ireland).
The ED is staffed full time by 65 board-eligible/board-
certified emergency physicians who serve as faculty for a
university-based 3-year emergency medicine (EM) resi-
dency program, a community-based 3-year EM residency
program, and a university-based 5-year combined EM/
pediatrics residency program. There are a total of 78
residents in the combined EM training programs. All
ED intubations are the responsibility of the EM attending,
anesthesia back-up is available 24 h a day.
EM residents receive comprehensive airway training
throughout their residency. During intern orientation
there is a 1-day airway laboratory that includes both
didactics and hands-on experience in a simulation labora-
tory with a variety of airway devices. All interns in the
university-based residency programs rotate on the anes-
thesia service for 1 month. Regular didactics on airway
management continue throughout the residency program,
with ongoing training in both cadaver and simulation lab-
oratories. There is a yearly difficult/failed airway labora-
tory that all residents are expected to attend. Clinical
experience with airway management is obtained on rota-
tions in the ED, in the operating room and in the intensive
care unit.
Selection of Participants
This study included all non-arrest patients that underwent
intubation in the ED over the 1-year study period.
Methods and Measurements
After each ED intubation, a paper-based airway data form
is completed by the operator. Data collected on the airway
form include patient, operator, and intubation characteris-
tics. This includes data such as patient age, sex and diag-
nosis, operator postgraduate year (PGY) and specialty,
reason for intubation, method of intubation, drugs used
for intubation, device used on each attempt, number of
attempts, outcome of each attempt, the presence of
difficult airway characteristics, and the occurrence of
any adverse events. Adverse events that are tracked,
and their definitions, have been previously described
(10). Residents are taught to perform a rapid, focused,
difficult airway assessment that includes multiple predic-
tors of difficult intubation. Because an airway assessment
has been shown to be challenging to do on many patients
in the ED, a list of dichotomous variables is used to assess
anatomic airway difficulty (11,12). These include airway
edema, blood in the airway, cervical immobility, facial/
neck trauma, large tongue, obesity, restricted mouth
opening, short neck, small mandible, and vomit in the
airway. After the difficult airway evaluation is
completed, operators make a pre-intubation assessment
of airway difficulty and categorize the patient into one
of three categories: routine airway, challenging airway,
or difficult airway. We did not specify the definition of
each of these airway categories, as this is a subjective
evaluation by the operator and can vary with patient,
operator, and clinical circumstances.
Difficult Airway Management in the ED 3

For the purposes of this study, the following methods of Primary Data Analysis
intubation were defined. If an NMBA was used for intuba-
tion, this was considered an NMBA facilitated intubation All results are reported descriptively as proportions. The
(NMBA). This included both RSI and DSI (2,13). If no only continuous variable was age, which was reported as
NMBA was used, this was considered a non-NMBA the mean with standard deviation.
facilitated intubation (No NMBA). If only a sedative
agent was used for intubation, at a full induction dose, RESULTS
this was considered a deep sedation intubation (DEEP
Incidence and Assessment of Difficult Airways
SED). If a sub-induction dose of a sedative agent was
used in conjunction with a topical anesthetic agent for
A total of 526 intubations were performed in the ED over
intubation, this was considered an awake intubation
the 1-year study period. Seventy patients were excluded
(AWAKE). If patients were unresponsive and no drugs
because they were in cardiac arrest. This left 456 patients
were used, these patients were classified as no
in the study group. Of these, operators classified 237
medication intubations (NO MEDS).
(52.0%) as a routine airway, 169 (37.1%) as a challenging
The senior investigator reviewed all airway data
airway, and 50 (11.0%) as a difficult airway (Figure 1).
forms and cross-referenced them with a query of the
The baseline clinical characteristics of these three cohorts
electronic medical record. Any missing or incomplete
are summarized in Table 1.
forms were given to the operator for completion. This
resulted in 100% compliance with the airway
data forms. The data from the paper forms were Management of Difficult Airways
entered into Excel for Windows 2013 (Microsoft,
Redmond, WA) and then transferred and coded into Of the 50 patients in the difficult airway cohort, 80%
STATA 13 (StataCorp, College Station, TX) for (n = 40) underwent NMBA facilitated intubation. When
statistical analysis. an NMBA was used, an RSI technique was used in 85%

456
Non-arrest
ED Intuba ons

Rou ne Challenging Dicult

237/456 169/456 50/456
52.0% 37.1% 11.0%

NMBA No NMBA NMBA No NMBA NMBA No NMBA

234/237 3/237 160/169 9/169 40/50 10/50
98.7% 1.3% 94.7% 5.3% 80.0% 20.0%

2 Deep Sed 4 Deep Sed 0 Deep Sed

1 No Meds 5 No Meds 3 No Meds

RSI DSI Awake RSI DSI Awake RSI DSI Awake

233/234 1/234 0 158/160 2/160 0 34/40 6/40 7/10
99.6% 0.4% 0% 98.8% 1.2% 0% 85.0% 15.0% 70.0%
%
Figure 1. Flow diagram of patients in the study. ED = emergency department; RSI = rapid sequence intubation; DSI = delayed
sequence intubation; Awake = awake intubation; Deep Sed = deep sedation; No Meds = no medications used;
NMBA = neuromuscular blocking agent.
4 J. C. Sakles et al.

(34/40) and a DSI technique was used in 15% (6/40). A
video laryngoscope was used in all patients who under-
went RSI or DSI (GlideScope 21, C-MAC 19). Succinyl-
choline was the most common NMBA used (75%; 30/40),
and etomidate was the most common sedative used (78%;
31/40) (Table 2). In the 26 trauma patients in the difficult
airway cohort, 89% (n = 23) underwent NMBA
facilitated intubation (RSI 22 and DSI 1). Three patients
underwent intubation with no drugs. No patient under-
went awake intubation. In the 24 patients with medical
conditions in the difficult airway cohort, 71% (n = 17) un-
derwent NMBA facilitated intubation (RSI 12 and DSI 5)
and 29% (n = 7) underwent awake intubation.
An awake technique was used in 14% (7/50) of pa-
tients in the difficult airway cohort. A video laryngoscope
(GlideScope 1, C-MAC 4) was used in 5 and a flexible
fiberoptic scope was used in 2. The most common seda-
tive agent used for awake intubation in the difficult
airway cohort was ketamine (86%; 6/7) (Table 3).
Almost all the patients in the difficult airway cohort were
managed by an EM resident (94%; 47/50). Senior EM res-
idents at the PGY 3, 4, or 5 level managed roughly half of
the difficult airway patients (52%; 26/50) (Table 2).
Outcomes of Difficult Airways
The first-pass success in the entire difficult airway cohort
was 82% (41/50). When an RSI or DSI technique was
used, the first-pass success was 90% (36/40). When an
awake technique was used, the first-pass success was 57%
(4/7). Most patients (90%, 45/50) were intubated within
two attempts, all were intubated within 4 attempts and
none required a surgical airway. Adverse events occurred
in 40% (28/50) of patients in the difficult airway cohort,
with hypoxemia being the most commonly reported adverse
event (28%; 14/50) (Table 4). There were three difficult
airway patients that suffered a peri-intubation arrest, none
of which were due to a failed airway.
DISCUSSION
The difficult airway, though in principle understood by all
airway managers, is, in reality, a complex concept that is
based on the interplay of many different factors. The
American Society of Anesthesiologists cites the
following factors that can contribute to difficult airway
management: difficulty with patient cooperation, diffi-
culty with face mask ventilation, difficulty with supra-
glottic device placement, difficulty with laryngoscopy,
difficulty with intubation, and difficulty with surgical
airway access (4). Contextual aspects of difficult airway
management have also been described (14). Many guide-
lines suggest that when a difficult airway is anticipated,
an awake intubation should be performed (4,5,7).
Traditionally, this has been accomplished with a
flexible fiberoptic scope (15).

Table 1. Clinical Characteristics of Patients by Airway Classification

Airway Classification

Routine Airway Challenging Airway Difficult Airway

n = 237 n = 169 n = 50

Age
Years, mean (6SD) 47 (624) 44 (621) 49 (623)
Sex
Male 150 (63.3%) 110 (65.1%) 34 (68.0%)
Medical/trauma
Trauma 51 (21.5%) 68 (40.2%) 26 (52.0%)
Specific anatomic difficult airway
characteristics
Airway edema 2 (0.8%) 4 (2.4%) 7 (14.0%)
Blood in airway 17 (7.2%) 44 (26.0%) 16 (32.0%)
Cervical immobility 45 (19.0%) 62 (36.7%) 20 (40.0%)
Facial/neck trauma 11 (4.6%) 28 (16.6%) 20 (40.0%)
Large tongue 11 (4.6%) 31 (18.3%) 16 (32.0%)
Obesity 28 (11.8%) 46 (27.2%) 18 (36.0%)
Restricted mouth opening 7 (3.0%) 17 (10.1%) 8 (16.0%)
Short neck 16 (6.8%) 36 (21.3%) 11 (22.0%)
Small mandible 14 (5.9%) 26 (15.4%) 9 (18.0%)
Vomit in airway 14 (5.9%) 27 (16.0%) 12 (24.0%)
Other 1 (0.4%) 8 (4.7%) 11 (22.0%)
Number of anatomic difficult airway
characteristics
0 129 (54.4%) 24 (14.2%) 1 (2.0%)
1 68 (28.7%) 49 (29.0%) 11 (22.0%)
2 26 (11.0%) 39 (23.0%) 11 (22.0%)
$3 14 (5.9%) 57 (33.7%) 27 (54.0%)
Difficult Airway Management in the ED 5

Table 2. Method of Intubation, Drugs, Devices and Initial Operators by Airway Classification

Airway Classification

Routine Airway Challenging Airway Difficult Airway

n = 237 n = 169 n = 50

Method of intubation
NMBA (RSI or DSI) 234 (98.7%) 160 (94.7%) 40 (80.0%)
Awake (Light Sedation) 0 0 7 (14.0%)
Sedative (Deep Sedation) 2 (0.8%) 4 (2.4%) 0
No meds (No drugs used) 1 (0.4%) 5 (3.0%) 3 (6.0%)
Drugs Used
NMBA
Succinylcholine 151 (63.7%) 100 (59.2%) 30 (60.0%)
Rocuronium 83 (35.0%) 60 (36.7%) 10 (20.0%)
None 3 (1.3%) 9 (5.3%) 10 (20.0%)
Sedative
Etomidate 205 (86.5%) 134 (79.3%) 31 (62.0%)
Ketamine 14 (5.9%) 19 (11.2%) 15 (30.0%)
Midazolam 9 (3.8%) 7 (4.1%) 1 (2.0%)
Propofol 7 (3.0%) 3 (1.8%) 0
None 2 (0.8%) 6 (3.6%) 3 (6.0%)
Initial device used
Direct laryngoscope 26 (11.0%) 12 (7.1%) 0
GlideScope video laryngoscope 87 (36.7%) 84 (49.7%) 23 (46.0%)
C-MAC video laryngoscope 124 (52.3%) 73 (43.2%) 25 (50.0%)
Flexible fiberoptic scope 0 0 2 (4.0%)
Initial operator specialty
Emergency medicine resident 223 (94.1%) 162 (95.9%) 47 (94.0%)
Emergency medicine attending 1 (0.4%) 0 1 (2.0%)
Anesthesia attending 0 0 1 (2.0%)
Other* 13 (5.5%) 7 (4.1%) 1 (2.0%)
Initial operator PGY
PGY-1 49 (20.7%) 30 (17.8%) 6 (12.0%)
PGY-2 98 (41.4%) 64 (37.9%) 16 (32.0%)
PGY-3, 4, 5 83 (35.0%) 73 (43.2%) 26 (52.0%)
Attending (0.4%) 0 2 (4.0%)
Other 6 (2.5%) 2 (1.2%) 0

NMBA = neuromuscular blocking agent; RSI = rapid sequence intubation; DSI = delayed sequence intubation; PGY = postgraduate year.
* Other = Non-EM/non-anesthesia physician.
Other = Medical student or paramedic student.

In this study we sought to determine the incidence of
the predicted difficult airway in the ED and how opera-
tors chose to manage these. We found that operators pre-
dicted a difficult airway in 11% of non-arrest patients
requiring intubation in the ED. Interestingly, the major-
ity of these patients underwent an NMBA facilitated
intubation using an RSI or DSI technique. While this
might seem somewhat surprising and contrary to recom-
mended guidelines, there are several explanations why
operators might have chosen to use a NMBA despite
the prediction of a difficult airway. First, the traditional
predictors for an anatomically difficult airway are based
on the use of the direct laryngoscope for intubation.
When using a video laryngoscope, many of
these anatomic predictors are probably not as relevant
(1620). Thus, if an operator has access to a video
laryngoscope and is skilled with its use, they might
think that intubation is likely to be successful despite
the presence of traditional anatomic predictors of
difficulty. Second, difficult anatomic characteristics
are only one component of the difficult airway
assessment (4). Other important considerations are the
assessment of the likelihood that rescue oxygenation
will be successful with face-mask ventilation, supra-
glottic device ventilation, or if necessary, by performing
a surgical airway. If an operator thinks that rescue
oxygenation is likely to be successful, they may have
feel that RSI/DSI is still the best approach to achieve
tracheal intubation, knowing that they have a safe
back-up plan for oxygenation. Third, although awake
intubation may be an appropriate technique in
controlled settings, in the ED it may not be practical
or safe due to a multitude of issues. For example, pa-
tients requiring intubation in the ED frequently have
altered mental status and may be agitated due to head
trauma, intoxicants, or hypoxemia. An awake intubation
in uncooperative patients is often not possible and may
be more dangerous than performing a NMBA facilitated
6 J. C. Sakles et al.

Table 3. Outcomes by Airway Classification

Airway Classification

Routine Airway Challenging Airway Difficult Airway

n = 237 n = 169 n = 50

Success
First pass success 224 (94.5%) 143 (84.6%) 41 (82.0%)
Success within 2 attempts 232 (97.9%) 161 (95.3%) 45 (90.0%)
Success within 3 attempts 235 (99.2%) 166 (98.2%) 49 (98.0%)
Overall success 237 (100%) 169 (100%) 50 (100%)
Number of adverse events
0 210 (86.6%) 132 (78.1%) 30 (60.0%)
1 22 (9.3%) 32 (18.9%) 14 (28.0%)
2 5 (2.1%) 4 (2.4%) 4 (8.0%)
$3 0 1 (0.6%) 2 (4.0%)
Specific adverse events
Hypoxemia 13 (5.5%) 25 (14.8%) 14 (28.0%)
Hypotension 8 (3.4%) 7 (4.1%) 2 (4.0%)
Dysrhythmia 0 0 1 (2.0%)
Aspiration 3 (1.3%) 2 (1.2%) 0
Esophageal intubation 1 (0.4%) 2 (1.2%) 3 (6.0%)
Peri-intubation arrest 1 (0.4%) 1 (0.6%) 3 (6.0%)
Number of operators
1 232 (97.9%) 155 (91.7%) 42 (84.0%)
2 4 (1.7%) 13 (7.7%) 7 (14.0%)
3 0 1 (0.6%) 1 (2.0%)
4 1 (0.4%) 0 0
Rescue operators
Emergency medicine resident 2 (0.8%) 5 (3.0%) 3 (6.0%)
Emergency medicine attending 3 (1.3%) 8 (4.7%) 5 (10.0%)
Pulmonary fellow 0 0 1 (2.0%)
Number of devices used
1 232 (97.9%) 165 (97.6%) 46 (92.0%)
2 5 (2.1%) 3 (1.8%) 2 (4.0%)
3 0 0 2 (4.0%)
4 0 1 (0.6%) 0

intubation. Fourth, emergency physicians have consid- Limitations

erable experience with RSI, as it is the most common
technique to achieve airway control in the ED (1,21).
In contrast, most emergency physicians have limited
experience with awake intubation techniques,
particularly flexible fiberoptic intubation. Thus, when
faced with a difficult airway, operators may feel that
using a technique with which they are very familiar
and skilled at is the best option for safely achieving
intubation.
There is little research available on difficult airway
management in the ED with which to compare our re-
sults. Soyuncu et al. performed a 2-year prospective
observational study and found a 23.5% incidence of the
difficult airway, which was defined as a failed first intuba-
tion attempt (22). In a multicenter study of 4034 patients
by Hagiwara et al., a difficult airway was retrospectively
defined as two or more attempts (23). They found that us-
ing this definition, a difficult airway was encountered in
5.4% of patients intubated with a direct laryngoscope
and 7.4% of patients intubated with a video laryngoscope
(23). Though the methodology of these studies is not
directly comparable to our study, the incidence of diffi-
cult airways we observed was in this range.
There are several important limitations to this study. One
limitation is that all the data collected in the study were
documented on the airway form by the operator perform-
ing the intubation. Thus, the data are subject to operator
bias with potential for under- or over-reporting, which
has been well documented (24,25). Kerrey et al. used
video review of ED intubations and compared this
information with what was documented in the medical
record (24). They found that first-pass success was
over-reported by 612% in the medical record compared
with what was seen on video review. Additionally, oxy-
gen desaturation was observed to occur in 33% of patients
on video review, but in the medical record was docu-
mented to have occurred in only 19%. Cemalovic et al.
used trained observers to document various elements of
intubation in the ED and compared this information
with the perception of the operators (25). They found
that operators perceived desaturation to have occurred
in 13% of patients, but an observer recorded a desatura-
tion event in 23%. Therefore, our data probably suffers
from some degree of under- or over-reporting, with the
first-pass success likely higher and the adverse events
Difficult Airway Management in the ED 7

Table 4. Assessment, Management and Outcomes in difficulties and did not collect information on other as-
Difficult Airway Cohort by Method of Intubation
pects of difficult airway management such as potential
NMBA Awake difficulty with rescue oxygenation, including difficult
Group Group face-mask ventilation, difficult supraglottic device venti-
n = 40 n=7 lation, and difficult surgical airway access. These assess-
Assessment ments are likely to contribute to airway management
Specific anatomic difficult decisions, in particular, if an NMBA can be safely used
airway characteristics to facilitate intubation. For example, even if an anatomi-
Airway edema 6 (15.0%) 1 (14.3%)
Blood in airway 14 (35.0%) 0 cally difficult airway is predicted, the operator might feel
Cervical immobility 18 (45.0%) 1 (14.3%) that RSI/DSI is still a safe choice if rescue oxygenation
Facial/neck trauma 19 (47.5%) 0 with face-mask ventilation is predicted not to be difficult.
Large tongue 11 (27.5%) 5 (71.4%)
Obesity 13 (32.5%) 5 (71.4%) Another limitation is that we did not provide specific def-
Restricted mouth opening 6 (15.0%) 1 (14.3%) initions of the three different airway classifications on the
Short neck 7 (17.5%) 4 (57.1%) airway data form. Instead we relied solely on the opera-
Small mandible 7 (17.5%) 2 (28.6%)
Vomit in airway 10 (25.0%) 0 tors assessment after their airway evaluation. A final lim-
Other* 7 (17.5%) 3 (42.9%) itation is that the vast majority of intubations in this study
Number of anatomic difficult were managed by residents in EM and thus might not
airway characteristics
0 1 (2.5%) 0 reflect actual clinical practice by seasoned clinicians in
1 9 (22.5%) 1 (14.3%) non-academic medical centers. Additionally, the EM res-
2 9 (22.5%) 2 (28.6%) idents in this program receive extensive training and have
$3 21 (52.5%) 4 (57.1%)
Management a great deal of clinical experience with both hyperangu-
Drugs used lated and standard geometry video laryngoscopes, and
NMBA thus, the results might be applicable to operators with
Succinylcholine 30 (75.0%) NA
Rocuronium 10 (25.0%) NA less video laryngoscopy experience.
Sedative
Etomidate 31 (77.5%) 0 CONCLUSION
Ketamine 8 (20.0%) 6 (85.7%)
Midazolam 0 1 (14.3%)
None 1 (2.5%) 0 In this study we found that a difficult airway was pre-
Initial device used dicted in 11% of non-arrest patients requiring intubation
Direct laryngoscope 0 0
GlideScope video laryngoscope 21 (52.5%) 1 (14.3%) in a large urban academic ED. The majority of these pa-
C-MAC video laryngoscope 19 (47.5%) 4 (57.1%) tients were managed with an RSI or DSI technique and a
Flexible fiberoptic laryngoscope 0 2 (28.6%) video laryngoscope, with a high first-pass success.
Outcomes
Success A small number underwent an awake intubation, which
First pass success 36 (90.0%) 4 (57.1%) was most commonly performed with a video laryngo-
Success within 2 attempts 39 (97.5%) 5 (71.4%) scope and ketamine. A flexible fiberoptic scope was
Success within 3 attempts 39 (97.5%) 7 (100%)
Success within 4 attempts 40 (100%) - rarely used. There were no failed airways requiring
Specific adverse events rescue with a surgical airway. Further research is
Hypoxemia 12 (30.0%) 2 (28.6%) warranted on the optimal management of patients with
Hypotension 2 (5.0%) 0
Dysrhythmia 0 1 (14.3%) difficult airways requiring intubation in the ED.
Aspiration 0 0
Esophageal intubation 2 (5.0%) 0
Peri-intubation arrest 2 (5.0%) 1 (14.3%) REFERENCES
NMBA = neuromuscular blocking agent.
* Other = previous tracheostomy, subglottic stenosis, retrophar- 1. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM. Techniques, success,
yngeal hematoma, ankylosing spondylitis, failed prehospital intu- and adverse events of emergency department adult intubations. Ann
bation, neck radiation, oropharyngeal trauma. Emerg Med 2015;65:3633701.
2. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS.
Delayed sequence intubation: a prospective observational study.
lower than their true values. Another limitation is that Ann Emerg Med 2015;65:34955.
although the difficult airway assessment was performed 3. Baker P. Assessment before airway management. Anesthesiol Clin
prior to the intubation, it was not documented on the 2015;33:25778.
4. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines
airway form until after the procedure was completed. It for management of the difficult airway: an updated report by the
is possible that difficulty encountered during the intuba- American Society of Anesthesiologists Task Force on Management
tion might have affected the classification decision of the Difficult Airway. Anesthesiology 2013;118:25170.
5. Law JA, Broemling N, Cooper RM, et al. The difficult airway with
made by the operator after the fact. Another limitation recommendations for managementpart 2the anticipated diffi-
is that we only collected information on anatomic cult airway. Can J Anaesth 2013;60:111938.
8 J. C. Sakles et al.
6. Enterlein G, Byhahn C. [Practice guidelines for management of the
difficult airway: update by the American Society of Anesthesiolo-
gists task force]. Der Anaesthesist 2013;62:8325. [in German].
7. Benumof JL. Management of the difficult adult airway. With special
emphasis on awake tracheal intubation. Anesthesiology 1991;75:
1087110.
8. Cook T, Behringer EC, Benger J. Airway management outside the
operating room: hazardous and incompletely studied. Curr Opin
Anaesthesiol 2012;25:4619.
9. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC,
Vandenbroucke JP. The Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) statement: guidelines for report-
ing observational studies. Ann Intern Med 2007;147:5737.
10. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of
first pass success when performing orotracheal intubation in the
emergency department. Acad Emerg Med 2013;20:718.
11. Bair AE, Caravelli R, Tyler K, Laurin EG. Feasibility of the preop-
erative Mallampati airway assessment in emergency department pa-
tients. J Emerg Med 2010;38:67780.
12. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult
airway prediction in patients intubated in the emergency depart-
ment. Ann Emerg Med 2004;44:30713.
13. El-Orbany M, Connolly LA. Rapid sequence induction and intuba-
tion: current controversy. Anesth Analg 2010;110:131825.
14. Hung O, Murphy M. Context-sensitive airway management. Anesth
Analg 2010;110:9823.
15. Law JA, Morris IR, Brousseau PA, de la Ronde S, Milne AD. The
incidence, success rate, and complications of awake tracheal intuba-
tion in 1,554 patients over 12 years: an historical cohort study. Can J
Anaesth 2015;62:73644.
16. Mosier JM, Stolz U, Chiu S, Sakles JC. Difficult airway manage-
ment in the emergency department: GlideScope videolaryngoscopy
compared to direct laryngoscopy. J Emerg Med 2012;42:62934.
17. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of
video laryngoscopy to direct laryngoscopy for intubation of patients
with difficult airway characteristics in the emergency department.
Intern Emerg Med 2014;9:938.
18. Paolini JB, Donati F, Drolet P. Review article: video-laryngoscopy:
another tool for difficult intubation or a new paradigm in airway
management? Can J Anaesth 2013;60:18491.
19. Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualiza-
tion during direct laryngoscopy and high upper lip bite test score
are predictors of difficult intubation with the GlideScope videolar-
yngoscope. Anesth Analg 2008;106:1495500. table of contents.
20. Joshi R, Hypes CD, Greenberg J, et al. Difficult airway characteris-
tics associated with first-attempt failure at intubation using video
laryngoscopy in the intensive care unit. Ann Am Thorac Soc
2017;14:36875.
21. Sagarin MJ, Barton ED, Chng YM, Walls RM. Airway management
by US and Canadian emergency medicine residents: a multicenter
analysis of more than 6,000 endotracheal intubation attempts.
Ann Emerg Med 2005;46:32836.
22. Soyuncu S, Eken C, Cete Y, Bektas F, Akcimen M. Determina-
tion of difficult intubation in the ED. Am J Emerg Med 2009;
27:90510.
23. Hagiwara Y, Watase H, Okamoto H, Goto T, Hasegawa K. Prospec-
tive validation of the modified LEMON criteria to predict difficult
intubation in the ED. Am J Emerg Med 2015;33:14926.
24. Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Rapid sequence intubation for pediatric emergency patients: higher
frequency of failed attempts and adverse effects found by video re-
view. Ann Emerg Med 2012;60:2519.
25. Cemalovic N, Scoccimarro A, Arslan A, Fraser R, Kanter M,
Caputo N. Human factors in the emergency department: is physi-
cian perception of time to intubation and desaturation rate accurate?
Emerg Med Australas 2016;28:2959.
Difficult Airway Management in the ED 9

ARTICLE SUMMARY
1. Why is this topic important?
Patients requiring airway management in the emer-
gency department (ED) occasionally may have difficult
airways, and the current management of these patients
is unknown.
2. What does this study attempt to show?
This study attempts to determine the incidence of pre-
dicted difficult airways in the ED and to describe how
they were managed.
3. What are the key findings?
One in 10 patients were predicted to have a difficult
airway in the ED. The majority of them were intubated us-
ing a neuromuscular blocking agent and a video laryngo-
scope with a high first-pass success.
4. How is patient care impacted?
Rapid sequence intubation with a video laryngoscope
may be a reasonable management option for patients
with difficult airways in the ED if rescue oxygenation is
predicted to be successful.