C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: A randomised clinical trial Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Preoxygenation Is More Effective in the 25° Head-up Position Than in the Supine Position in Severely Obese Patients: A Randomized Controlled Study Safety of Propofol as an Induction Agent for Urgent Endotracheal Intubation in the Medical Intensive Care Unit Comparison of Video Laryngoscopy Versus Direct Laryngoscopy During Urgent Endotracheal Intubation: A Randomized Controlled Trial* High-Flow Nasal Cannula Versus Bag-Valve-Mask for Preoxygenation Before Intubation in Subjects With Hypoxemic Respiratory Failure High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial Emergency Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial) Comparison Between the Effects of Alfentanil, Fentanyl and Sufentanil on Hemodynamic Indices During Rapid Sequence Intubation in the Emergency Department Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Complications of endotracheal intubation in the critically ill Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. 3,423 Emergency Tracheal Intubations at a University Hospital: Airway Outcomes and Complications Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults* Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review† Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: the single-centre, blinded, randomised controlled OPTINIV trial Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial
BACKGROUND Airway management in the emergency room can be challenging when patients suffer from life-threatening conditions . Mental stress , ignorance of the patient 's medical history , potential cervical injury or immobilisation and the presence of vomit and /or blood may also contribute to a difficult airway . Videolaryngoscopes have been introduced into clinical practice to visualise the airway and ultimately increase the success rate of airway management . OBJECTIVE The aim of this study was to test the hypothesis that the C-MAC videolaryngoscope improves first-attempt intubation success rate compared with direct laryngoscopy in patients undergoing emergency rapid sequence intubation in the emergency room setting . DESIGN A r and omised clinical trial . SETTING Emergency Department of the University Hospital , Zurich , Switzerl and . PATIENTS With approval of the local ethics committee , we prospect ively enrolled 150 patients between 18 and 99 years of age requiring emergency rapid sequence intubation in the emergency room of the University Hospital Zurich . Patients were r and omised ( 1 : 1 ) to undergo tracheal intubation using the C-MAC videolaryngoscope or by direct laryngoscopy . INTERVENTIONS Owing to ethical considerations , patients who had sustained maxillo-facial trauma , immobilised cervical spine , known difficult airway or ongoing cardiopulmonary resuscitation were excluded from our study . All intubations were performed by one of three very experienced anaesthesia consultants . MAIN OUTCOME MEASURES First-attempt success rate served as our primary outcome parameter . Secondary outcome parameters were time to intubation ; total number of intubation attempts ; Cormack and Lehane score ; inadvertent oesophageal intubation ; ease of intubation ; complications including violations of the teeth , injury/bleeding of the larynx/pharynx and aspiration/regurgitation of gastric contents ; necessity of using further alternative airway devices for successful intubation ; maximum decrease of oxygen saturation and technical problems with the device . RESULTS A total of 150 patients were enrolled , but three patients had to be excluded from the analysis , result ing in 74 patients in the C-MAC videolaryngoscopy group and 73 patients in the direct laryngoscopy group . Tracheal intubation was achieved successfully at the first attempt in 73 of 74 patients in the C-MAC group and all patients in the direct laryngoscopy group ( P = 1.0 ) . Time to intubation was similar ( 32 ± 11 vs. 31 ± 9 s , P = 0.51 ) in both groups . Visualisation of the vocal cords , represented as the Cormack and Lehane score , was significantly better using the C-MAC videolaryngoscope ( P < 0.001 ) . CONCLUSION Our study demonstrates that visualisation of the vocal cords was improved by using the C-MAC videolaryngoscope compared with direct laryngoscopy . Better visualisation did not improve first-attempt success rate , which in turn was probably based on the high level of experience of the participating anaesthesia consultants . TRIAL REGISTRATION Clinical trials.gov identifier NCT02297113 RATIONALE Hypoxemia is common during endotracheal intubation of critically ill patients and may predispose to cardiac arrest and death . Administration of supplemental oxygen during laryngoscopy ( apneic oxygenation ) may prevent hypoxemia . OBJECTIVES To determine if apneic oxygenation increases the lowest arterial oxygen saturation experienced by patients undergoing endotracheal intubation in the intensive care unit . METHODS This was a r and omized , open-label , pragmatic trial in which 150 adults undergoing endotracheal intubation in a medical intensive care unit were r and omized to receive 15 L/min of 100 % oxygen via high-flow nasal cannula during laryngoscopy ( apneic oxygenation ) or no supplemental oxygen during laryngoscopy ( usual care ) . The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after completion of endotracheal intubation . MEASUREMENTS AND MAIN RESULTS Median lowest arterial oxygen saturation was 92 % with apneic oxygenation versus 90 % with usual care ( 95 % confidence interval for the difference , -1.6 to 7.4 % ; P = 0.16 ) . There was no difference between apneic oxygenation and usual care in incidence of oxygen saturation less than 90 % ( 44.7 vs. 47.2 % ; P = 0.87 ) , oxygen saturation less than 80 % ( 15.8 vs. 25.0 % ; P = 0.22 ) , or decrease in oxygen saturation greater than 3 % ( 53.9 vs. 55.6 % ; P = 0.87 ) . Duration of mechanical ventilation , intensive care unit length of stay , and in-hospital mortality were similar between study groups . CONCLUSIONS Apneic oxygenation does not seem to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared with usual care . These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults . Clinical trial registered with www . clinical trials.gov ( NCT 02051816 ) Objective To determined whether the implementation of an intubation management protocol leads to the reduction of intubation-related complications in the intensive care unit ( ICU ) . Design Two-phase , prospect i ve , multicenter controlled study . Setting Three medical-surgical ICUs in two university hospitals . Patients Two hundred three consecutive ICU patients required 244 intubations . Interventions All intubations performed during two consecutive phases ( a 6-month quality control phase followed by a 6-month intervention phase based on the implementation of an ICU intubation bundle management protocol ) were evaluated . The ten bundle components were : preoxygenation with noninvasive positive pressure ventilation , presence of two operators , rapid sequence induction , cricoid pressure , capnography , protective ventilation , fluid loading , preparation and early administration of sedation and vasopressor use if needed . Measurements and main results The primary end points were the incidence of life-threatening complications occurring within 60 min after intubation ( cardiac arrest or death , severe cardiovascular collapse and hypoxemia ) . Other complications ( mild to moderate ) were also evaluated . Baseline characteristics , including demographic data and reason for intubation ( mainly acute respiratory failure ) , were similar in the two phases . The intubation procedure in the intervention phase ( n = 121 ) was associated with significant decreases in both life-threatening complications ( 21 vs. 34 % , p = 0.03 ) and other complications ( 9 vs. 21 % , p = 0.01 ) compared to the control phase ( n = 123 ) . Conclusions The implementation of an intubation management protocol can reduce immediate severe life-threatening complications associated with intubation of ICU patients BACKGROUND : Hypoxemia is the most common complication during endotracheal intubation of critically ill adults .  Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation , but has never been studied outside of the operating room . METHODS : Multicenter , r and omized trial comparing the ramped position ( head of the bed elevated to 25 ° ) with the sniffing position ( torso supine , neck flexed , and head extended ) among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four ICUs between July 22 , 2015 , and July 19 , 2016 . The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after intubation . Secondary outcomes included Cormack‐Lehane grade of glottic view , difficulty of intubation , and number of laryngoscopy attempts . RESULTS : The median lowest arterial oxygen saturation was 93 % ( interquartile range [ IQR ] , 84%‐99 % ) with the ramped position vs 92 % ( IQR , 79%‐98 % ) with the sniffing position ( P = .27 ) . The ramped position appeared to increase the incidence of grade III or IV view ( 25.4 % vs 11.5 % , P = .01 ) , increase the incidence of difficult intubation ( 12.3 % vs 4.6 % , P = .04 ) , and decrease the rate of intubation on the first attempt ( 76.2 % vs 85.4 % , P = .02 ) , respectively . CONCLUSIONS : In this multicenter trial , the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position . The ramped position may worsen glottic view and increase the number of laryngoscopy attempts required for successful intubation . TRIAL REGISTRY : Clinical Trials.gov ; No. : NCT02497729 ; URL : www . clinical BACKGROUND : Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults . Verbal performance of a written , preintubation checklist may prevent these complications . We compared a written , verbally performed , preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation . METHODS : A multicenter trial in which 262 adults undergoing endotracheal intubation were r and omized to a written , verbally performed , preintubation checklist ( checklist ) or no preintubation checklist ( usual care ) . The co primary outcomes were lowest arterial oxygen saturation and lowest systolic BP between the time of procedural medication administration and 2 min after endotracheal intubation . RESULTS : The median lowest arterial oxygen saturation was 92 % ( interquartile range [ IQR ] , 79‐98 ) in the checklist group vs 93 % ( IQR , 84‐100 ) with usual care ( P = .34 ) . The median lowest systolic BP was 112 mm Hg ( IQR , 94‐133 ) in the checklist group vs 108 mm Hg ( IQR , 90‐132 ) in the usual care group ( P = .61 ) . There was no difference between the checklist and usual care in procedure duration ( 120 vs 118 s ; P = .49 ) , number of laryngoscopy attempts ( one vs one attempt ; P = .42 ) , or severe life‐threatening procedural complications ( 40.8 % vs 32.6 % ; P = .20 ) . CONCLUSIONS : The verbal performance of a written , preprocedure checklist does not increase the lowest arterial oxygen saturation or lowest systolic BP during endotracheal intubation of critically ill adults compared with usual care . TRIAL REGISTRY : Clinical Trials.gov ; No. : NCT02497729 ; URL : www . clinical trials.gov AIM This study compared endotracheal intubation ( ETI ) performance during cardiopulmonary resuscitation ( CPR ) between  direct laryngoscopy ( DL ) and video laryngoscopy ( VL ) ( GlideScope ( ® ) ) by experienced intubators ( > 50 successful ETIs ) . METHODS This was a prospect i ve r and omized controlled study conducted in an emergency department between 2011 and 2013 . Intubators who used DL or VL were r and omly allocated to ETI during CPR . Data were collected from recorded video clips and rhythm sheets . The success , speed , complications , and chest compressions interruption were compared between the two devices . RESULTS Total 140 ETIs by experienced intubators using DL ( n=69 ) and VL ( n=71 ) were analysed . There were no significant differences between DL and VL in the ETI success rate ( 92.8 % vs. 95.8 % ; p=0.490 ) , first-attempt success rate ( 87.0 % vs. 94.4 % ; p=0.204 ) , and median time to complete ETI ( 51 [ 36 - 67 ] vs. 42 [34 - 62]s ; p=0.143 ) . In both groups , oesophageal intubation and dental injuries seldom occurred . However , longer chest compressions interruption occurred using DL ( 4.0 [1.0 - 11.0]s ) compared with VL ( 0.0 [0.0 - 1.0]s ) and frequent serious no-flow ( interruption>10s ) occurred with DL ( 18/69 [ 26.1 % ] ) compared with VL ( 0/71 ) ( p<0.001 ) . For highly experienced intubators ( > 80 successful ETIs ) , frequent serious no-flow occurred in DL ( 14/55 [ 25.5 % ] vs. 0/57 in VL ) . CONCLUSIONS The ETI success , speed and complications during CPR did not differ significantly between the two devices for experienced intubators . However , the VL was superior in terms of completion of ETI without chest compression interruptions . TRIAL REGISTRATION Clinical Research Information Service ( CRIS ) in South Korea KCT0000849 Background : Class III obese patients have altered respiratory mechanics , which are further impaired in the supine position . The authors explored the hypothesis that preoxygenation in the 25 ° head-up position allows a greater safety margin for induction of anesthesia than the supine position . Methods : A r and omized controlled trial measured oxygen saturation and the desaturation safety period after 3 min of preoxygenation in 42 consecutive ( male : female 13:29 ) severely obese ( body mass index > 40 kg/m2 ) patients who were undergoing laparoscopic adjustable gastric b and surgery and were r and omly assigned to the supine position or the 25 ° head-up position  . Serial arterial blood gases were taken before and after preoxygenation and 90 s after induction . After induction , ventilation was delayed until blood oxygen saturation reached 92 % , and this desaturation safety period was recorded . Results : The mean body mass indexes for the supine and 25 ° head-up groups were 47.3 and 44.9 kg/m2 , respectively ( P = 0.18 ) . The group r and omly assigned to the 25 ° head-up position achieved higher preinduction oxygen tensions ( 442 ± 104 vs. 360 ± 99 mmHg ; P = 0.012 ) and took longer to reach an oxygen saturation of 92 % ( 201 ± 55 vs. 155 ± 69 s ; P = 0.023 ) . There was a strong positive correlation between the induction oxygen tension achieved and the time to reach an oxygen saturation of 92 % ( r = 0.51 , P = 0.001 ) . There were no adverse events associated with the study . Conclusion : Preoxygenation in the 25 ° head-up position achieves 23 % higher oxygen tensions , allowing a clinical ly significant increase in the desaturation safety period — greater time for intubation and airway control . Induction in the 25 ° head-up position may provide a greater safety margin for airway control Purpose : Propofol is known to provide excellent intubation conditions without the use of neuromuscular blocking agents . However , propofol has adverse effects that may limit its use in the critically ill patients , particularly in the hemodynamically unstable patient . We report on the safety and efficacy of propofol for use as an agent for urgent endotracheal intubation ( UEI ) in the critically ill patients . Methods : We review ed the outcomes of 472 consecutive UEIs performed by a medical intensive care unit ( ICU ) team at a tertiary care hospital from November 2008 through November 2012 . Outcome data were collected prospect ively as part of an ongoing quality improvement project . Results : Propofol was used as the sole sedative agent in 409 ( 87 % ) of the 472 patients . In 18 ( 4 % ) of the 472 patients , other agents ( midazolam , lorazepam , or etomi date ) were used in addition to propofol . Of the 472 , 10 ( 2 % ) intubations were performed with a sedative agent other than propofol , and 35 ( 7 % ) of the 472 intubations were performed without any sedating agent . Endotracheal tube insertion was successful in all 472 patients . Complications of UEI in those patients who received propofol were as follows : desaturation ( Sao 2 < 80 % ) 30 ( 7 % ) of the 427 , hypotension ( systolic blood pressure < 70 mm Hg ) 19 ( 4 % ) of the 427 , difficult intubation ( > 2 attempts ) 44 ( 10 % ) of the 427 , esophageal intubation 24 ( 6 % ) of the 427 , aspiration 6 ( 1 % ) of the 427 , and oropharyngeal injury 4 ( 1 % ) of the 427 . There were no deaths . Average dose of propofol was 99 mg ( st and ard deviation 7.39 ) per person . Conclusions : Our results compare favorably with the complication rate of UEI reported in the critical care and anesthesiology literature and indicate that propofol is a useful agent for airway management in the ICU Objectives : In the critically ill undergoing urgent endotracheal intubation by direct laryngoscopy  , multiple attempts are often required with a higher complication rate due to the urgency , uncontrolled setting , comorbidities , and variability in expertise of operators . We hypothesized that Glidescope video laryngoscopy would be superior to direct laryngoscopy during urgent endotracheal intubation . Design : Single-center prospect i ve r and omized controlled trial . Setting : Beth Israel Medical Center , an 856-bed urban teaching hospital with a 16-bed closed medical ICU . Patients : Of 153 consecutive patients undergoing urgent endotracheal intubation by pulmonary and critical care medicine fellows , 117 met inclusion criteria . Interventions : Patients undergoing urgent endotracheal intubation  were r and omized to Glidescope video laryngoscopy or direct laryngoscopy as the primary intubation device . Measurements and Main Results : The primary outcome measure was the rate of first-attempt success . Acute Physiology and Chronic Health Evaluation II scores were similar between groups ( 20.9 ± 8.2 vs 19.9 ± 7.9 ) . First-attempt success was achieved in 74 % of the Glidescope video laryngoscopy group compared with 40 % in the direct laryngoscopy group ( p < 0.001 ) . All unsuccessful direct laryngoscopy patients were successfully intubated  with Glidescope video laryngoscopy , 82 % on the first attempt . There was no significant difference in rates of complications  between direct laryngoscopy and Glidescope video laryngoscopy :  esophageal intubations ( 7 % vs 0 % ; p = 0.05 ) , aspiration events ( 7 % vs 9 % ; p = 0.69 ) , desaturation ( 8 % vs 4 % ; p = 0.27 ) , and hypotension ( 13 % vs 11 % ; p = 0.64 ) . Conclusions : Glidescope video laryngoscopy improves the first-attempt success rate during urgent endotracheal intubation performed by pulmonary and critical care medicine fellows when compared with direct laryngoscopy BACKGROUND : Critically ill patients with respiratory failure undergoing intubation have an increased risk of hypoxemia-related complications . Delivering oxygen via a high-flow nasal cannula ( HFNC ) has theoretical advantages and is increasingly used . This study was conducted to compare HFNC with bag-valve-mask ( BVM ) for preoxygenation and to assess oxygenation during intubation in subjects with hypoxemic respiratory failure . METHODS : This study was a r and omized controlled trial including 40 critically ill subjects with hypoxemic respiratory failure who received either HFNC or BVM for preoxygenation before intubation in the ICU . The primary outcome was the mean lowest SpO2 during intubation . RESULTS : The mean lowest SpO2 during intubation was 89 ± 18 % in the HFNC group and 86 ± 11 % in the BVM group ( P = .56 ) . In subjects receiving HFNC , a significant increase in SpO2 after preoxygenation was only seen in those previously receiving low-flow oxygen ( P = .007 ) , whereas there was no significant difference in SpO2 in subjects previously receiving noninvasive ventilation or HFNC ( P = .73 ) . During the 1 min of apnea after the induction of anesthesia , SpO2 dropped significantly in the BVM group ( P = .001 ) , whereas there was no significant decrease in the HFNC group ( P = .17 ) . There were no significant differences between the 2 groups at any of the predefined time points before or after intubation concerning SpO2 , PaO2/FIO2 , and PaCO2 . CONCLUSIONS : Preoxygenation using HFNC before intubation was feasible and safe compared with BVM in critically ill subjects with acute , mild to moderate hypoxemic respiratory failure . There was no significant difference in the mean lowest SpO2 during intubation between the HFNC and the BVM group . There was also no significant difference in SpO2 between the 2 groups at any of the predefined time points . However , on continuous monitoring , there was a significant decrease in SpO2 during the apnea phase before intubation in the BVM group , which was not seen in the HFNC group . ( Clinical Trials.gov registration NCT01994928 . Purpose Intubation of hypoxemic patients is associated with life-threatening adverse events . High-flow therapy by nasal cannula ( HFNC ) for preoxygenation before intubation has never been assessed by r and omized study . Our objective was to evaluate the efficiency of HFNC for preoxygenation , compared to high fraction-inspired oxygen facial mask ( HFFM ) . Methods Multicenter , r and omized , open-labelled , controlled PREOXYFLOW trial ( NCT 01747109 ) in six French intensive care units . Acute hypoxemic adults requiring intubation were r and omly allocated to HFNC  or  HFFM . Patients were eligible if PaO2/FiO2 ratio was below 300 mmHg , respiratory rate at least 30/min and if they required FiO2 50 % or more to obtain at least 90 % oxygen saturation .  HFNC was maintained throughout the procedure , whereas HFFM was removed at the end of general anaesthesia induction . Primary outcome was the lowest saturation throughout intubation procedure . Secondary outcomes included adverse events related to intubation , duration of mechanical ventilation and death . Results A total of 124 patients were r and omized . In the intent-to-treat analysis , including 119 patients ( HFNC n = 62 ; HFFM n = 57 ) , the median ( interquartile range ) lowest saturation was 91.5 % ( 80–96 ) for HFNC and 89.5 % ( 81–95 ) for the HFFM group ( p = 0.44 ) . There was no difference for difficult intubation ( p = 0.18 ) , intubation difficulty scale , ventilation-free days ( p = 0.09 ) , intubation-related adverse events including desaturation < 80 % or mortality ( p = 0.46 ) . Conclusions Compared to HFFM , HFNC as a preoxygenation device did not reduce the lowest level of desaturation Objectives We aim ed to compare the performance of the C-MAC video laryngoscope ( C-MAC ) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED . Material and methods This was a prospect i ve r and omized study . The primary outcome measure is overall successful intubation . Secondary outcome measures are first attempt successful intubation , Cormack – Lehane ( CL ) grade , and indicators of the reasons for unsuccessful intubation at the first attempt with each device . Adult patients who suffered from blunt trauma and required intubation were r and omized to video laryngoscopy with C-MAC device or direct laryngoscopy ( DL ) . Results During a 17-month period , a total of 150 trauma intubations were performed using a C-MAC and DL . Baseline characteristics of patients were similar between the C-MAC and DL group . Overall success for the C-MAC was 69/75 ( 92 % , 95 % CI 0.83 to 0.96 ) while for the DL it was 72/75 ( 96 % , 95 % CI 0.88 to 0.98 ) . First attempt success for the C-MAC was 47/75 ( 62.7 % , 95 % CI 0.51 to 0.72 ) while for the DL it was 44/75 patients ( 58.7 % , 95 % CI 0.47 to 0.69 ) . The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL ( p = 0.93 ) . There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC ( p = 0.002 and p = 0.013 respectively ) . Discussion and conclusion The overall success rates were similar . The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate Introduction Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction ( RSI ) intubation in intensive care . Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium . So far , succinylcholine and rocuronium have not been compared in an adequately powered r and omized trial in intensive care . Accordingly , the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI . Methods This was a prospect i ve r and omized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel . Participants were 401 critically ill patients requiring emergent RSI . Patients were r and omized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade . The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5 % , assessed by continuous pulse oxymetry , at any time between the start of the induction sequence and two minutes after the completion of the intubation . A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5 % leading to a saturation value of ≤ 80 % . Results There was no difference between succinylcholine and rocuronium  regarding oxygen desaturations  ( succinylcholine 73/196 ; rocuronium 66/195 ; P = 0.67 ) ; severe oxygen desaturations  ( succinylcholine 20/196 ; rocuronium 20/195 ; P = 1.0 ) ; and extent of oxygen desaturations  ( succinylcholine -14 ± 12 % ; rocuronium -16 ± 13 % ; P = 0.77 ) . The duration of the intubation sequence was shorter after succinycholine than after rocuronium ( 81 ± 38 sec versus 95 ± 48 sec ; P = 0.002 ) . Intubation conditions  ( succinylcholine 8.3 ± 0.8 ; rocuronium 8.2 ± 0.9 ; P = 0.7 ) and failed first intubation attempts  ( succinylcholine 32/200 ; rocuronium 36/201 ; P = 1.0 ) did not differ between the groups . Conclusions In critically ill patients undergoing emergent RSI  , incidence and severity of oxygen desaturations , the quality of intubation conditions , and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium . Trial Registration Clinical Trials.gov , number NCT00355368 OBJECTIVES Desaturation leading to hypoxemia may occur during rapid sequence intubation  ( RSI ) . Apneic oxygenation ( AO ) was developed to prevent the occurrence of oxygen desaturation during the apnea period . The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care ( UC ) in the emergency setting . METHODS A r and omized controlled trial was conducted at an academic , urban , Level I trauma center . All patients requiring intubation were included . Exclusion criteria were patients in cardiac or traumatic arrest or if preoxygenation was not performed . An observer , blinded to study outcomes and who was not involved in the procedure , recorded all times , while all saturations were recorded in real time by monitors on a secured server . Two-hundred patients were allocated to receive AO ( n = 100 ) or UC ( n = 100 ) by predetermined r and omization in a 1:1 ratio . RESULTS A total of 206 patients were enrolled . There was no difference in lowest mean oxygen saturation between the two groups ( 92 , 95 % confidence interval [ CI ] = 91 to 93 in AO vs. 93 , 95 % CI = 92 to 94 in UC ; p = 0.11 ) . CONCLUSION There was no difference in lowest mean oxygen saturation between the two groups . The application of AO during RSI did not prevent desaturation of patients in this study population Background : Laryngoscopy and tracheal intubation lead to the alteration of hemodynamic parameters , including blood pressure and heart rate , in traumatic patients who sustain rapid sequence intubation ( RSI ) . Various drugs such as fentanyl , alfentanil and sufentanil have been used to modify these hemodynamic responses . Objectives : The aim of the present study is to compare the effects of fentanyl , sufentanil and alfentanil in trauma patients who require RSI in the emergency department ( ED ) . Patients and Methods : This was a r and omized double-blinded study conducted on 90 patients ( 18 - 65 years old , ASA I , II ) , who needed intubation following trauma . The patients were r and omly divided into three groups , Group I , Group II and Group III , who have received alfentanil , fentanyl and sufentanil , respectively . Heart rate , blood pressure , saturation of peripheral oxygen and end-tidal carbon dioxide were measured 5 minutes before and 3 , 5 and 10 minutes after intubation , respectively . The changes of the hemodynamic parameters were compared in between groups . Data were analyzed by One-way ANOVA , General Linear Model Repeated Measure and Mauchly ’s Sphericity Test . A P < 0.05 was considered statistically significant . Results : There was no significant statistical difference among groups with respect to hemodynamic parameters . Conclusions : Alfentanil , fentanyl and sufentanil can be used safely as premedication drugs for trauma patients who need intubation BACKGROUND Complications associated with  tracheal intubation may occur in up to 40 % of critically ill patients . Since practice in emergency airway management varies between intensive care units ( ICUs ) and countries , complication rates may also differ . We undertook a prospect i ve , observational study of  tracheal intubation performed by critical care doctors in Scotl and to identify practice , complications , and training . METHODS For 4 months , we collected data on any  intubation performed by doctors working in critical care throughout Scotl and except those in patients having elective surgery and those carried out before admission to hospital . We used a st and ardized data form to collect information on pre-induction physical state and organ support , the doctor carrying out the intubation , the techniques and drugs used , and complications noted . RESULTS Data from 794 intubations  were analysed . Seventy per cent occurred in ICU and 18 % occurred in emergency departments . The first-time intubation success rate was 91 % , no patient required more than three attempts at intubation , and one patient required surgical tracheostomy . Severe hypoxaemia ( < 80 % ) occurred in 22 % , severe hypotension ( systolic arterial pressure < 80 mm Hg ) in 20 % , and oesophageal intubation in 2 % . Three-quarters of intubations were performed by doctors with more than 24 months formal anaesthetic training and all but one doctor with < 6 months training had senior supervision . CONCLUSIONS  Tracheal intubation by critical care doctors in Scotl and has a higher first-time success rate than described in previous reports of critical care intubation , and technical complications are few . Doctors carrying out intubation had undergone longer formal training in anaesthesia than described previously , and junior trainees are routinely supervised . Despite these good results , further work is necessary to reduce physiological complications and patient morbidity Objective Assess the risk of complications during  endotracheal intubation ( ETI )  and their association with the skill level of the intubating physician . Design Prospect i ve cohort study of 136 patients intubated by the intensive care team during a 5-month period . St and ardized data forms were used to collect detailed information on the intubating physicians , supervisors , techniques , medications and complications . Setting Canadian academic intensive care unit . Measurements and results All intubations were successful and there were no deaths during intubation . Non-experts were supervised in 92 % of procedures . Expert operators were successful within two attempts in 94 % , compared to only 82 % of non-experts ( P = 0.03 ) , with 13.2 % of all intubations requiring ≥3 attempts . Furthermore , 10.3 % of intubations required 10 or more minutes . Difficult intubation ( 3 or more attempts by an expert ) occurred in 6.6 % . Overall risk of complications was 39 % , including : severe hypoxemia ( 19.1 % ) , severe hypotension ( 9.6 % ) , esophageal intubation ( 7.4 % ) and frank aspiration ( 5.9 % ) . ICU and hospital mortality were 15.4 and 29.4 % , respectively . Compared with non-expert intubating physicians , propensity score-adjusted odds ratios ( 95 % confidence interval ) for expert physicians were 0.92 ( 95 % CI : 0.28 , 3.05 , P = 0.89 ) for any complication , 0.45 ( 95 % CI : 0.09 , 2.20 , P = 0.32 ) for ICU mortality and 0.47 ( 95 % CI : 0.13 , 1.70 , P = 0.25 ) for hospital mortality . Two or more attempts at ETI was independently associated with an increased risk of severe complications ( OR 3.31 , 95 % CI : 1.30 , 8.40 , P = 0.01 ) . Conclusions These prospect i ve data show a high risk of serious complications , and difficult intubations , that are associated with ETI of the critically ill . DescriptorArtificial airways and complications BACKGROUND Good visualization of the glottis is important for tracheal intubation . This study evaluated whether the 25 degrees back-up position improves the quality of the laryngeal view during laryngoscopy . METHODS Laryngoscopy with a curved blade was performed on 40 anaesthetized patients . The patients were r and omly assigned to two groups . Laryngeal views were captured with a rigid 0 degrees endoscope . Views were recorded for each patient in Group A ( n = 20 ) during laryngoscopies performed with the patient lying first in the supine position and then in the 25 degrees back-up position . Laryngeal views for patients in Group B ( n = 20 ) were first captured while the patient was in the 25 degrees back-up position and then while the patient was in the flat supine position . An anaesthetist blinded to the position grade d the quality of the images using the percentage of glottic opening ( POGO ) score . RESULTS Comparing the two positions , mean ( sd ) POGO scores increased significantly from 42.2 (27.4)% in supine position to 66.8 (27.6)% in 25 degrees back-up position ( P < 0.0001 ) . CONCLUSIONS During laryngoscopy , the laryngeal view , as assessed by POGO scores , improves significantly in the 25 degrees back-up position when compared with the flat supine position STUDY OBJECTIVE To determine whether shoulder and head elevation , such that the patient 's ear lies at or higher than the sternum ( " ramp " ) , improves laryngoscopic grade in adult patients of various body mass index ( BMI ) values . DESIGN Prospect i ve , unblinded study , with patients and laryngoscopists acting as their own controls . SETTING Operating room of a university-affiliated hospital . PATIENTS 189 adult ASA physical status 1 , 2 , and 3 patients . INTERVENTIONS After performing a st and ard preoperative airway evaluation and inducing general anesthesia , the anesthetist performed and grade d two laryngoscopies : one in the " ramp " position and one in the " sniff " position . MEASUREMENTS Patient BMI , Mallampati airway class , thyromental distance , neck circumference , cervical extension ability , Cormack and Lehane laryngoscopic grade for each laryngoscopy , subjective lifting force required , and need for external laryngeal pressure were recorded . MAIN RESULTS Use of the " ramp " provided significantly better or equal laryngoscopic views , relative to those with the " sniff " position , in the entire study population . CONCLUSIONS Shoulder and head elevation by any means that brings the patient 's sternum onto the horizontal plane of the external auditory meatus maintains or improves laryngoscopic view significantly RATIONALE Critically ill patients are predisposed to oxyhemoglobin desaturation during intubation . OBJECTIVES To find out whether noninvasive ventilation ( NIV ) , as a preoxygenation method , is more effective at reducing arterial oxyhemoglobin desaturation than usual preoxygenation during orotracheal intubation in hypoxemic , critically ill patients . METHODS Prospect i ve r and omized study performed in two surgical/medical intensive care units ( ICUs ) . Preoxygenation was performed , before a rapid sequence intubation , for a 3-min period using a nonrebreather bag-valve mask ( control group ) or pressure support ventilation delivered by an ICU ventilator through a face mask ( NIV group ) according to the r and omization . MEASUREMENTS AND MAIN RESULTS The control ( n = 26 ) and NIV ( n = 27 ) groups were similar in terms of age , disease severity , diagnosis at admission , and pulse oxymetry values ( Sp(O(2 ) ) ) before preoxygenation . At the end of preoxygenation , Sp(O(2 ) ) was higher in the NIV group as compared with the control group ( 98 + /- 2 vs. 93 + /- 6 % , p < 0.001 ) . During the intubation procedure , the lower Sp(O(2 ) ) values were observed in the control group ( 81 + /- 15 vs. 93 + /- 8 % , p < 0.001 ) . Twelve ( 46 % ) patients in the control group and two ( 7 % ) in the NIV group had an Sp(O(2 ) ) below 80 % ( p < 0.01 ) . Five minutes after intubation , Sp(O(2 ) ) values were still better in the NIV group as compared with the control group ( 98 + /- 2 vs. 94 + /- 6 % , p < 0.01 ) . Regurgitations ( n = 3 ; 6 % ) and new infiltrates on post-procedure chest X ray ( n = 4 ; 8 % ) were observed with no significant difference between groups . CONCLUSION For the intubation of hypoxemic patients , preoxygenation using NIV is more effective at reducing arterial oxyhemoglobin desaturation than the usual method STUDY OBJECTIVE To compare thiopental , fentanyl , and midazolam for rapid-sequence induction and intubation ( RSI ) . METHODS Eighty-six patients undergoing RSI in the emergency department were r and omly assigned in a double-blind fashion to receive either thiopental ( 5 mg/kg ) , fentanyl ( 5 microg/kg ) , or midazolam ( .1 mg/kg ) before paralysis was induced . Outcome measures were mortality , speed and ease of intubation , and hemodynamics . RESULTS Of the patients who received thiopental , 93 % were intubated within 2 minutes of paralysis ( P=.037 ) , but systolic blood pressure fell an average of 38 mm Hg in this group ( P=.045 ) . The midazolam group had a greater number of delayed intubations ( 31 % ) and an average heart rate increase of 17 beats/minute ( P=.008 ) . Mortality ( 24 % inhospital ) was unaffected by drug assignment . In all three groups , patients with pulmonary edema had the greatest decrease in blood pressure during RSI , and patients exposed to multiple attempts at intubation manifested pronounced hypertension . CONCLUSION Fentanyl provided the most neutral hemodynamic profile during RSI , although factors other than choice of sedative can play a more significant role in determining hemodynamic response . Depth of sedation may influence the speed of RSI Background : There are limited outcome data regarding emergent nonoperative intubation . The current study was undertaken with a large observational data set to evaluate the incidence of difficult intubation and complication rates and to determine predictors of complications in this setting . Methods :  Adult nonoperating room emergent intubations at our tertiary care institution from December 5 , 2001 to July 6 , 2009 were review ed . Prospect ively defined data points included time of day , location , attending physician presence , number of attempts , direct laryngoscopy view , adjuvant use , medications , and complications . At our institution , a senior resident with at least 24 months of anesthesia training is the first responder for all emergent airway requests . The primary outcome was a composite airway complication variable that included aspiration , esophageal intubation , dental injury , or pneumothorax . Results : A total of 3,423 emergent nonoperating room airway management cases were identified . The incidence of difficult intubation was 10.3 % . Complications occurred in 4.2 % : aspiration , 2.8 % ; esophageal intubation , 1.3 % ; dental injury , 0.2 % ; and pneumothorax , 0.1 % . A bougie introducer was used in 12.4 % of cases . Among 2,284 intubations performed by residents , independent predictors of the composite complication outcome were as follows : three or more intubation attempts ( odds ratio , 6.7 ; 95 % CI , 3.2–14.2 ) , grade III or IV view ( odds ratio , 1.9 ; 95 % CI , 1.1–3.5 ) , general care floor location ( odds ratio , 1.9 ; 95 % CI , 1.2–3.0 ) , and emergency department location ( odds ratio , 4.7 ; 95 % CI , 1.1–20.4 ) . Conclusions : During emergent nonoperative intubation , specific clinical situations are associated with an increased risk of airway complication and may provide a starting point for allocation of experienced first responders BACKGROUND Direct laryngoscopy ( DL ) has long been the most common approach for emergency endotracheal intubation , although the use of video laryngoscopy ( VL ) is becoming more widespread . Current observational data suggest that VL has higher first-pass success , although r and omized trials are lacking . OBJECTIVES The objective was to compare first-pass success in patients undergoing emergency intubation with DL or VL using a C-MAC device . METHODS This was an open-label , prospect i ve , r and omized , controlled trial in an academic emergency department of patients undergoing emergency intubation with a plan of DL for the first attempt . Patients were r and omly assigned in a 1:1 ratio to either DL or VL using a C-MAC device for the first intubation attempt . The primary outcome was first-pass success . Secondary outcomes included time to intubation , development of aspiration pneumonia , and hospital length of stay ( LOS ) . The study was registered at Clinical trials.gov , number NCT01710891 . RESULTS A total of 198 patients were enrolled and intubated with either DL ( n = 95 ) or VL ( n = 103 ) . First-attempt success was 86 and 92 % for the DL and VL groups , respectively ( difference = -5.9 % , 95 % confidence interval = -14.5 % to 2.7 % , p = 0.18 ) . Time to intubation , rates of aspiration pneumonia , and hospital LOS were not different between the two groups . CONCLUSIONS In patients undergoing emergency intubation in whom DL was planned for the first attempt , we did not detect a difference between VL or DL using the C-MAC device in first-pass success , duration of intubation attempt , aspiration pneumonia , or hospital LOS Objective : To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation  on first laryngoscopy attempt among critically ill adults . Design : A r and omized , parallel-group , pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows . Setting : Medical ICU in a tertiary , academic medical center . Patients : Critically ill patients 18 years old or older . Interventions : Patients were r and omized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation . Measurements and Main Results : Patients assigned to video ( n = 74 ) and direct ( n = 76 ) laryngoscopy were similar at baseline . Despite better glottic visualization with video laryngoscopy , there was no difference in the primary outcome of intubation on the first laryngoscopy attempt  ( video 68.9 % vs direct 65.8 % ; p = 0.68 ) in unadjusted analyses or after adjustment for the operator ’s previous experience with the assigned device ( odds ratio for video laryngoscopy on intubation on first attempt 2.02 ; 95 % CI , 0.82–5.02 , p = 0.12 ) . Secondary outcomes of time to intubation , lowest arterial oxygen saturation , complications , and in-hospital mortality were not different between video and direct laryngoscopy . Conclusions : In critically ill adults undergoing endotracheal intubation , video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications Difficulties with tracheal intubation commonly arise and impact patient safety . This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with  direct laryngoscopy in adults . We search ed CENTRAL , MEDLINE , Embase and clinical trials.gov up to February 2015 , and conducted forward and backward citation tracking . We included r and omized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy .  We did not primarily intend to compare individual videolaryngoscopes .  Sixty-four studies ( 7044 participants ) were included . Moderate quality evidence showed that videolaryngoscopy reduced failed intubations ( Odds Ratio ( OR ) 0.35 , 95 % Confidence Interval ( CI ) 0.19 - 0.65 ) including in participants with anticipated difficult airways ( OR 0.28 , 95 % CI 0.15 - 0.55 ) . There was no evidence of reduction in hypoxia or mortality , but few studies reported these outcomes . Videolaryngoscopes reduced laryngeal/airway trauma ( OR 0.68 , 95 % CI 0.48 - 0.96 ) and hoarseness ( OR 0.57 , 95 % CI 0.36 - 0.88 ) . Videolaryngoscopy increased easy laryngeal views ( OR 6.77 , 95 % CI 4.17 - 10.98 ) and reduced difficult views ( OR 0.18 , 95 % CI 0.13 - 0.27 ) and intubation difficulty , typically using an ' intubation difficulty score ' ( OR 7.13 , 95 % CI 3.12 - 16.31 ) . Failed intubations were reduced with experienced operators ( OR 0.32 , 95 % CI 0.13 - 0.75 ) but not with inexperienced users . We identified no difference in number of first attempts and incidence of sore throat . Heterogeneity around time for intubation data prevented meta- analysis . We found evidence of differential performance between different videolaryngoscope design s. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates .  Videolaryngoscopes may reduce the number of failed intubations , particularly among patients presenting with a difficult airway . They improve the glottic view and may reduce laryngeal/airway trauma . Currently , no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications , and no evidence indicates that use of a videolaryngoscope affects time required for intubation Purpose High-flow nasal cannula oxygen ( HFNC ) has the potential to provide apnoeic oxygenation . We decided to assess in a proof-of-concept study whether the addition of HFNC to non-invasive ventilation ( NIV ) could reduce oxygen desaturation during intubation , compared with NIV alone for preoxygenation , in severely hypoxaemic intensive care unit ( ICU ) patients with respiratory failure . Methods We conducted a r and omised , controlled , single-centre trial with assessor-blinded outcome assessment in patients admitted to the ICU . Hypoxaemic patients requiring orotracheal intubation for respiratory failure were r and omised to receive preoxygenation using HFNC [ flow = 60 L/min , fraction of inspired oxygen ( FiO2 ) = 100 % ] combined with NIV ( pressure support = 10 cmH2O , positive end-expiratory pressure = 5 cmH2O , FiO2 = 100 % ) in the intervention group or NIV alone in the reference group prior to intubation . The primary outcome was the lowest oxygen saturation ( SpO2 ) during the intubation procedure . Secondary outcomes were intubation-related complications and ICU mortality . Results Between July 2015 and February 2016 , we r and omly assigned 25 and 24 patients to the intervention and reference groups , respectively . In both groups the main reasons for respiratory failure were pneumonia and ARDS . During the intubation procedure , the lowest SpO2 values were significantly higher in the intervention group than in the reference group [ 100 ( 95–100 ) % vs. 96 ( 92–99 ) % , p = 0.029 ] . After exclusion of two patients from analysis for protocol violation , no ( 0 % ) patients in the intervention group and five ( 21 % ) patients in the reference group had SpO2 below 80 % ( p = 0.050 ) . We recorded no significant difference between the groups in intubation-related complications or ICU mortality . Conclusions A novel strategy for preoxygenation in hypoxaemic patients , adding HFNC for apnoeic oxygenation to NIV prior to orotracheal intubation , may be more effective in reducing the severity of oxygen desaturation than the reference method using NIV alone Importance In the intensive care unit ( ICU ) , orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable , requiring prompt intervention , often by a practitioner with nonexpert skills . Video laryngoscopy may decrease this risk by improving glottis visualization . Objective To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients . Design , Setting , and Participants R and omized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016 ; there was 28 days of follow-up . Interventions Intubation using a video laryngoscope ( n = 186 ) or direct laryngoscopy ( n = 185 ) . All patients received general anesthesia . Main Outcomes and Measures The primary outcome was the proportion of patients with successful first-pass intubation . The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications . Results Among 371 r and omized patients ( mean [ SD ] age , 62.8 [ 15.8 ] years ; 136 [ 36.7 % ] women ) , 371 completed the trial . The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups ( 67.7 % vs 70.3 % ; absolute difference , −2.5 % [ 95 % CI , −11.9 % to 6.9 % ] ; P = .60 ) . The proportion of first-attempt intubations performed by nonexperts ( primarily residents , n = 290 ) did not differ between the groups ( 84.4 % with video laryngoscopy vs 83.2 % with direct laryngoscopy ; absolute difference 1.2 % [ 95 % CI , −6.3 % to 8.6 % ] ; P = .76 ) . The median time to successful intubation was 3 minutes ( range , 2 to 4 minutes ) for both video laryngoscopy and direct laryngoscopy ( absolute difference , 0 [ 95 % CI , 0 to 0 ] ; P = .95 ) . Video laryngoscopy was not associated with life-threatening complications ( 24/180 [ 13.3 % ] vs 17/179 [ 9.5 % ] for direct laryngoscopy ; absolute difference , 3.8 % [ 95 % CI , −2.7 % to 10.4 % ] ; P = .25 ) . In post hoc analysis , video laryngoscopy was associated with severe life-threatening complications ( 17/179 [ 9.5 % ] vs 5/179 [ 2.8 % ] for direct laryngoscopy ; absolute difference , 6.7 % [ 95 % CI , 1.8 % to 11.6 % ] ; P = .01 ) but not with mild to moderate life-threatening complications ( 10/181 [ 5.4 % ] vs 14/181 [ 7.7 % ] ; absolute difference , −2.3 % [ 95 % CI , −7.4 % to 2.8 % ] ; P = .37 ) . Conclusions and Relevance Among patients in the ICU requiring intubation , video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications . Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical setting s and among operators with diverse skill levels . Trial Registration clinical trials.gov Identifier :
Background We performed a systematic review of r and omized controlled studies evaluating any drug , technique or device aim ed at improving the success rate or safety of  tracheal intubation in the critically ill .