Airway Management


COCHRANE SYSTEMATIC REVIEW: Emergency intubation for acutely ill and injured patients
Implications for practice: Effectiveness unknown
Review Overview: The highest priority in an emergency is to enable a patient to breathe by securing their airway. Endotracheal intubation is one of various ways to secure the airway. However, this review reveals that the efficacy of emergency intubation as currently practiced has not been rigorously studied. Based on two trials on adults and one involving children, no difference was found between endotracheal intubation and other airway securing strategies for reducing deaths after non-traumatic cardiac arrest in adults or prehospital situations with children.
LINK to Cochrane Library: Issue 2 2008 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001429/frame.html


COCHRANE SYSTEMATIC REVIEW: Rocuronium versus succinylcholine for rapid sequence induction intubation
Implications for practice: Implications for practice: Succinylcholine creates superior intubation conditions
Review Overview: In emergency situations some patients need a general anaesthetic with an endotracheal tube. Succinylcholine is the most commonly used muscle relaxant because of its fast onset and short duration; unfortunately, it can have serious side effects. This updated meta-analysis compared one possible alternative, rocuronium, to succinylcholine to examine the quality of intubation conditions. This review of 37 studies with a total of 2690 patients found that rocuronium is less effective than succinylcholine for creating excellent intubation conditions. Contrary to the previous meta-analysis, the intubation conditions were superior with succinylcholine as compared to propofol.
LINK to Cochrane Library: Issue 2 2008 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002788/frame.html


COCHRANE SYSTEMATIC REVIEW: High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome
Implications for practice: Low vs. high levels of PEEP showed no difference between mortality, barotrauma or ventilator free days.
Review Overview: Available evidence indicates that high levels of PEEP, as compared with low levels, did not reduce mortality before hospital discharge. The data also show that high levels of PEEP produced no significant difference in the risk of barotrauma, but rather improved participants' oxygenation to the first, third, and seventh days. This review indicates that the included studies were characterized by clinical heterogeneity.
LINK to Cochrane Library: Issue 6, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009098.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Pharmacological agents for preventing morbidity associated with the haemodynamic response to tracheal intubation
Implications for practice: Local anesthetics may reduce the risk of cardiac ischemia during ETI.
Review Overview: During general anaesthesia, a tube may be inserted into the trachea (windpipe) using an instrument called a laryngoscope in order to safely deliver oxygen and anaesthetic gases and to remove carbon dioxide. This procedure is known as laryngoscopy and tracheal intubation. It initiates a reflex response (the haemodynamic response to intubation) of an increase in blood pressure and heart rate. Several drugs in varied doses and by different routes have been used to blunt or prevent this response in order to prevent serious complications for the heart and the brain, which may even be fatal. This is because the increase in blood pressure and heart rate may put undue stress on the heart and the brain circulation. In some patients it may lead to abnormal heart rhythm (arrhythmias) and lack of oxygen to the heart muscle (myocardial ischaemia) resulting in changes in recorded electrical activity of the heart (shown on the electrocardiogram (ECG)), heart failure, or stroke. In spite of several studies on the use of drugs to suppress this response, it remains unclear what the best drugs to use are and in what dosages. We included adult patients aged 18 years and above undergoing elective surgery in the operating room setting. We found that the effects of drugs on the stress response was the subject of 72 studies. The investigators used 32 drugs. Promising results were seen in the reduction of arrhythmias with intravenous injections of beta blockers (drugs that decrease the heart rate), narcotics (drug used to treat pain), local anaesthetics, and calcium channel blockers (drugs that block movement of calcium). Serious side effects were only reported with high doses of narcotics and an increase in airway pressure was seen in some patients with beta blockers. Only local anaesthetic drugs clearly reduced the risk of myocardial ischaemia but this evidence came from only one trial. There was some difficulty in comparing and interpreting the results of these different trials. Patients at a high risk of complications were investigated in 17 trials. A reduction in arrhythmias with treatment was seen in this high risk group but the number of studies was too small to reach a conclusion. Doctors need to further research the effects of drugs used for blunting the haemodynamic response and their effect on outcomes in terms of morbidity, in a standardized manner.
LINK to Cochrane Library: Issue 7, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004087.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Tracheal intubation with a flexible intubation scope versus other intubation techniques for obese patients requiring general anaesthesia
Implications for practice: More primary research is needed to investigate optimal intubation techniques in obese patients, and new studies should be powered to detect differences in complications and in success rates rather than process measures such as speed, which are of limited clinical importance.
Review Overview: : Guidelines suggest the use of flexible intubation scopes (FISs) for tracheal intubation in obese people. These scopes allow the intubator to see the airway via a camera, but no reviews have examined the use of an FIS in this situation. Intubation with an FIS is considered an advanced method, requiring training and experience; therefore it may be underused in clinical practice. We aimed to compare the safety and effectiveness of an FIS used for tracheal intubation in obese patients with direct laryngoscopy and other intubation methods that give the intubator an indirect view of the larynx. These other methods include videolaryngoscopes (VLSs)—metal laryngoscopes that contain a camera. We found three small studies, with a total of 131 patients, that compared an FIS with a VLS. The results for all patient safety outcomes were inconclusive, and no differences were noted between intubation with a flexible scope and intubation with a videolaryngoscope
LINK to Cochrane Library: Issue 1, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010320.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients
Implications for practice: Etomidate is known to suppress adrenal gland function, but it remains unclear whether or not this adrenal gland dysfunction affects mortality.
Review Overview: Although we have not found conclusive evidence that etomidate increases mortality or healthcare resource utilization in critically ill patients, it does seem to increase the risk of adrenal gland dysfunction and multi-organ system dysfunction by a small amount. The clinical significance of this finding is unknown. This evidence is judged to be of moderate quality, owing mainly to significant attrition bias in some of the smaller studies, and new research may influence the outcomes of our review. The applicability of these data may be limited by the fact that 42% of the patients in our review were intubated for "being comatose", a population less likely to benefit from the haemodynamic stability inherent in etomidate use, and less at risk from its potential negative downstream effects of adrenal suppression.
LINK to Cochrane Library: Issue 1, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010225.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants
Implications for practice: It is unclear whether deep or shallow ETT suction IN Neonates is ideal.
Review Overview: There is no evidence form randomized controlled trials concerning the benefits of deep versus shallow suctioning of endotracheal tubes in ventilated neonates and infants.
LINK to Cochrane Library: Issue 7, 2011 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003309.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Techniques to ascertain correct endotracheal tube placement in neonates
Implications for practice: To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography.
Review Overview: There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
LINK to Cochrane Library: Issue 9, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010221.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation
Implications for practice: Unknown: there is little high quality evidence in this area.
Review Overview: There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCT literature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure.
LINK to Cochrane Library: Issue 11, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011656.pub2/abstract