title: Prehospital management of the difficult airway: a prospective cohort study.
abstract: The role of prehospital endotracheal intubation (ETI) remains controversial, with significant national variability in practice. The purpose of this project was to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a "difficult airway." Data were collected prospectively for all ETIs performed by the fire department over a 4-year period (2001-2005), and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes. Of 80,501 ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts. The difficult airway cohort included 130 patients (3.2%), whose airway management consisted of oral ETI after more than four attempts (46%), bag-valve-mask ventilation (33%), cricothyroidotomy (8%), retrograde ETI (5%), and digital ETI (1%). Procedural success rates ranged from 14% (digital ETI) to 91% (cricothyroidotomy). Nine patients (7%) had failed airway management, of whom 5 were found in cardiac arrest. The two most common reasons subjectively reported by ALS providers for airway difficulty were anterior trachea (39%) and small mouth (30%). Overall mortality for the difficult airway cohort was 44%. Prehospital ETI can be performed with a high success rate by experienced ALS providers, but may still require advanced airway techniques in a small subset of patients. Patient anatomy is a primary factor in failed ETI. Among the advanced procedures, cricothyroidotomy had the highest success rate and should not be delayed by other interventions.
authors.affiliation: Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA.
authors.forename: Keir J
authors.initials: KJ
authors.lastname: Warner
authors.forename: Sam R
authors.initials: SR
authors.lastname: Sharar
authors.forename: Michael K
authors.initials: MK
authors.lastname: Copass
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
mesh_terms: D000402:Airway Obstruction / Q000601:surgery / Q000628:therapy*; D000465:Algorithms; D015331:Cohort Studies; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D007821:Laryngeal Muscles / Q000601:surgery; D008021:Life Support Systems; D008297:Male; D008875:Middle Aged; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage; D011446:Prospective Studies; D013390:Succinylcholine / Q000008:administration & dosage
chemical_list: D009466:Neuromuscular Blocking Agents; D013390:Succinylcholine