Airway Management Article critique

American Journal of Emergency Medicine 72 (2023) 95–100

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

j ourna l homepage: www.e lsev ie r .com/ locate /a jem

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

Michael D. April, MD, DPhil, MSc a,b,⁎, Brian Driver, MDc, Steven G. Schauer, DO, MSb,d, Jestin N. Carlson, MD, MS, MHAe, Rachel E. Bridwell, MD f, Brit Long, MDb,g, Jamie Stang c, Subrina Farah h, Robert A. De Lorenzo, MD, MSM, MSCI i, Calvin A. Brown III, MD j

a 14th Field Hospital, Fort Stewart, GA, United States of America b Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America c Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America d US Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, United States of America e Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, United States of America f Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, United States of America g Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America h Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, United States of America i Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America j Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America

⁎ Corresponding author at: 14th Field Hospital, 2233 Stewart, GA 31314, United States of America.

E-mail address: [email protected] (M.

https://doi.org/10.1016/j.ajem.2023.07.024 0735-6757/Published by Elsevier Inc.

a b s t r a c t

a r t i c l e i n f o

Article history: Received 13 April 2023 Received in revised form 24 June 2023 Accepted 13 July 2023

Introduction:Airwaymanagement is a critical component of themanagement of emergency department (ED) pa- tients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. Methods: The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians en- tered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters inwhich EGD placement occurred.We used descriptive statistics to character- ize these encounters. Results: Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 partici- pating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1–2.5, range 1–31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one dif- ficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngealmask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA®de- vice. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experi- enced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. Conclusions: EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Published by Elsevier Inc.

Keywords: Emergency department Airway Extra-glottic device Supra-glottic device Laryngeal mask airway Difficult airway Oxygenation Ventilation

Gulick Ave Bldg 816-A, Fort

D. April).

1. Introduction

1.1. Airway management

Airway management is a crucial component of the resuscitation of many critically ill and injured emergency department (ED) patients

M.D. April, B. Driver, S.G. Schauer et al. American Journal of Emergency Medicine 72 (2023) 95–100

[1,2]. Definitive airway management entails the placement of a tube into a patient's trachea, typically by intubation through the mouth. Tube placement with inflation of a balloon cuff simultaneously allows delivery of positive pressure ventilation to the lungs while mitigating entry of esophageal and gastric contents into the pulmonary system.

Not all first intubation attempts, however, are successful; estimates of first-pass success in ED settings vary and depend on the initial device used, patient characteristics, and provider experience and range from 83% to 87.5% [1,3]. Observational data suggest an association between repeated attempts after initial intubation failure and adverse events such as dysrhythmias, hypoxia, and hypotension [4]. This association presumably exists in part due to delays in effective oxygenation and ventilation which in turn can predispose patients to adverse events including peri-intubation cardiac arrest [5]. Tools to achieve effective ventilation and oxygen delivery pending successful placement of a de- finitive airway are critical to optimize outcomes for patients undergoing emergency airway management.

1.2. Extraglottic devices

Extraglottic devices (EGD), the first being the Laryngeal Mask Airway invented in 1983, have sought to fill this capability gap [6,7]. While specific characteristics vary, most EGDs are placed superior or posterior to the glottis, inserted without direct visualization of airway structures with the exception of a few older devices [8]. EGDs are less technically challenging than intubation because they obviate the need for direct laryngoscopy. Available evidence demonstrates that EGDs re- liably provide oxygenation and ventilation after failed attempts [9-11]. These characteristics have prompted particular interest in study of this technique in prehospital settings with less experienced clinicians than ED-based physicians [12]. Prehospital data suggest that airwaymanage- ment by EGD yields better outcomes among prehospital patients than definitive airway management by endotracheal intubation [13]. This is not a consistent finding across the prehospital literature, [14] and the anesthesia literature suggests equipoise between these airwaymanage- ment options [15].

1.3. Goals of this investigation

Little research to date has examined EGD use in the ED setting, despite the fact that EGDs feature prominently in difficulty airwayman- agement algorithms [16-18]. The goal of this study was to describe the patient, operator, and procedural characteristics of EGD use during emergency airway management using a multi-center registry of ED intubations. Our intent was to characterize the current patterns of use of these airway adjuncts.

2. Materials and methods

2.1. Study design and setting

We conducted a secondary analysis of a prospective, multi-center registry of ED intubations: the National Emergency Airway Registry (NEAR) [3,19-21]. NEAR is an international network of community and academic hospitals. The iteration of the registry used for this study included 24 sites across the United States and a single interna- tional site (Singapore). Each participating site obtained approval from its local institutional review board to participate in this registry. Investi- gators prospectively collect data on all ED endotracheal intubation (ETI) attempts using a standardized data collection instrument. Each partici- pating center submits a study compliance plan, which the central coordinating center approves (Brigham and Women's Hospital, Boston MA). Compliance plans outline the local processes for identification of ED intubations and simultaneous surveillance to ensure data capture of at least 90% of ED intubations. Site investigators submit quarterly compliance reports that the NEAR coordinators review for quality

96

assurance. We report all data in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) state- ment [22]. Individual sites submitted and obtained regulatory approvals before collecting data for submission to the registry.

2.2. Selection of participants

We included all encounters with documentation of attempted EGD placement in the NEAR database from January 1, 2016 through Decem- ber 31, 2018. We did not include data from earlier iterations of NEAR as the data collection forms and participating centers varied from the cur- rent NEAR iteration. Periods of enrollment varied for individual sites since facilities joined NEAR on a rolling basis.

2.3. Data collection and definitions

Intubating providers entered data into NEAR using a centralized, web-based data collection instrument (StudyTRAX v.3.47.0011, ScienceTRAX, Macon, GA). Operators entered the data as soon as possi- ble upon completion of intubation, but delayed entry, up to 90days, was permissible if immediate entry was not possible. Site investigators then ensured data upload into a centralized web-based database. Investiga- tors reviewed these data using quality assurance algorithms to identify and correct data entry errors.

The data collection instrument included data fields for patient char- acteristics, clinical variables, procedural elements, and clinical out- comes. The standardized NEAR data instrument included entries for clinical context such as underlying medical and traumatic pathology but did not include detailed information regarding medical decision- making driving airway management strategy. Additional data fields in the instrument included patient characteristics, body habitus, and estimated weight. Additional clinical variables included subjective impression of airway difficulty, presence of reduced neck mobility (e.g., presence of cervical collar), specific difficult airway characteristics (e.g., mouth opening, Mallampati score, airway obstruction, etc.), intu- bation position and device, operator characteristics (e.g., post graduate year of training versus attending, and specialty), medications, andmed- ication doses. The instrument also solicited from providers whether the need for intubation was immediate, signifying that dire circumstances precluded proper preparation and pre‑oxygenation. The instrument col- lects data on whether an EGD was used, including which type of EGD, whether the placement and subsequent oxygenation was successful, whether intubation was attempted, and whether further intubation attempts were needed after EGD use.

2.4. Outcome measures

Descriptive outcomes of interest included successful EGD placement as reported by intubating providers, intubation success, oxygenation success, adverse events, and patient disposition. The registry defines hy- potension as systolic blood pressure (SBP) nadir <100 mmHg and hyp- oxia as oxygen saturation <90% [5,23]. Given the size of the registry and large numbers of personnel entering data, it was not feasible to obtain reliable date-time stamps for all events across all hospital systems in- cluded.We instructed site investigators to document only those adverse events occurring during or shortly after intubation to identify those eventsmost likely associatedwith the procedure rather than alternative causes.

2.5. Data analysis

Our primary analysis described encounters of EGD placement during ED airway management. We calculated the median number of EGD en- counters across the participating sites together with interquartile range (IQR) and complete range of values. Clinical characteristics described for individual encounters included patient features, numbers of airway

Table 1 Airwaymanagement characteristics for encounters based upon extra-glottic device (EGD) use.

Variable EGD Encounters (n = 56)

Mean age, years (SD), n = 56 46 (16) % Female 17 (30%) Mean weight, kg (SD), n = 54 95 (30) % Indication Medical 47 (84%) Trauma 9 (16%)

% Pre-intubation hemodynamic status Hypertensive (>140 mmHg) 8 (14%) Normotensive (100–140 mmHg) 25 (45%) Hypotensive (no treatment provided) 1 (2%) Hypotensive (fluid or blood products provided) 9 (16%) Missing Data 13 (23%)

% Pre-intubation oxygenation 91–100% 38 (68%) 86–90% 2 (4%) <85% 5 (9%) Missing Data 11 (20%)

% Impression of difficult airway before intubation (n = 55) 31 (55%) % Any difficult airway characteristicsa 52 (93%) Reduced neck mobility 13 (23%) Reduced mouth opening 15 (27%) Airway obstruction 10 (18%) Facial trauma 7 (13%) Blood or vomit in airway 17 (30%)

% Intubation need emergentb 19 (34%) Intubator characteristics Emergency Medicine PGY1 1 (2%) Emergency Medicine PGY2 9 (16%) Emergency Medicine PGY3–4 39 (70%) Emergency Medicine Fellow 3 (5%) Emergency Medicine Attending 3 (5%) Other (non-Emergency Medicine) 1 (2%)

Abbreviations: ICP-intracranial pressure; PGY-post-graduate year, SD-standard deviation. a Difficult airway characteristics coded as yes if the patient had at least one of the

following: reduced neck mobility, Mallampati score >1, reduced mouth opening, airway obstruction, facial trauma, and blood or vomit in airway.

b Defined as determination by intubating clinician is that need for intubation was sufficiently immediate so as to preclude any pre‑oxygenation maneuvers.

M.D. April, B. Driver, S.G. Schauer et al. American Journal of Emergency Medicine 72 (2023) 95–100

management attempts, EGD device(s) used, operator prediction of air- way difficulty as judged subjectively by the intubating provider (yes vs. no), indication for intubation (medical vs. trauma), presence of diffi- cult airwaycharacteristics (reducedneckmobility,Mallampati score>1, reducedmouth opening, airway obstruction, facial trauma, and blood or vomit in the airway), medications administered, andwhether providers determined need for airway management to be immediate, precluding any preparation or pre‑oxygenation maneuvers. To show the size of the patient population that could potentially be a candidate for EGD use, we also present the number of patients who received a cricothyrotomy or required ≥3 intubation attempts.

3. Results

3.1. Cohort characteristics

During the study period, NEAR collected data on 19,071 encounters of patients undergoing airway management attempts across 25 institu- tions thatmet criteria for inclusion into the database. Of these, 56 (0.3%) underwent EGD placement. Thirteen sites reported no cases undergoing EGD placement during the data collection period. The median number of EGDs placed by participating sites was 2 (IQR 1–2, range 1–31). There were no instances of a single patient undergoing multiple EGD placement attempts. Most (84%) patients undergoing EGD placement had medical as opposed to trauma indications for airway management. Most (54%) patients had either hypotension or hypoxia prior to the start of airway management. Providers reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients (Table 1).

3.2. Extraglottic devices

LMA® devices accounted for 51 of the 56 EGD placements (91%). Forty-one encounters entailed placements of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative modalities. Use of a Fastrach™ without subsequent intuba- tion occurred in 1 encounter. Two patients received an Air-Q with subsequent intubations; one of these two patients subsequently under- went airway management by bronchoscopy. A non-intubating EGD was placed in the remaining 13 patients, none of whom underwent subsequent intubation. These included a standard LMA® placed in 10 encounters, a King laryngeal tube (LT) placed in 1 encounter, and a non-specified EGD placed in 2 encounters.

Clinicians placed 34 (61%) EGDs during the first intubation attempt. Clinicians placed the remaining 22 EGDs during subsequent attempts, accounting for 1% of 2223 patients in the dataset not intubated on the first attempt. Among 489 patients undergoing three or more intubation attempts, 5 (1%) underwent EGD placement (Table 2). To provide con- text for these results, there were 65 surgical airway procedures during the registry period (0.3% of intubation encounters). Of these patients undergoing surgical airways, only 2 had an EGD placed before or during the surgical procedure (1 medical airway obstruction not otherwise specified and 1 cardiac arrest secondary to penetrating trauma).

3.3. Outcomes

Regarding short-term outcomes, 17 of EGD patients (30%) experi- enced peri-procedure adverse events. These events included hypoxia among 25% of patients undergoing EGD placement (Table 3). Disposi- tions for these patients included intensive care unit for 42 (75%), operating room for 4 (7%), and death in the ED not due to failed airway for 9 (16%). None of these patients expired due to failed airways.

97

4. Discussion

4.1. Significance

EGDs provide rescue oxygenation and ventilation with high success when the intubator is unable to secure a definitive airway. This study shows that EGD use is rare in ED settings, accounting for only 0.3% of all patients undergoing emergency airwaymanagement. Only 1% of pa- tients requiring three or more intubation attempts underwent EGD placement. The reasons for deployment of a rescue device are multifac- eted and our data are not capable of fully elucidating those reasons. Nevertheless, these findings suggest there is significant room for ex- panded use of EGDs. These devices deserve particular consideration in patients with difficult airways per the 2022 American Society of Anes- thesiologists (ASA) practice guidelines [16]. The fact that the number of patients undergoing surgical airways exceeds that undergoing EGD placement (65 versus 54) highlights the room for increased EGD use in ED airway management. The low usage of EGDs may reflect a lack of provider confidence in using the device. Despite its role as a backup airway tool, it can be difficult to place in patients with limited mouth openings or who are obese with large neck circumferences [24]. Also, these devices have important limitations in that they do not protect against aspiration, and air leaks can preclude ventilation performance [8]. In select circumstances, cricothyrotomy or alternative airway tech- niques may be preferrable. Surprisingly, fewer than 5% of patients

Table 2 Extra-glottic device (EGD) types used, stratified by airway management attempt number.

Success Attempt #1 (n = 18,413) Attempt #2 (n = 2223) Attempt #3 (n = 489) Attempt #4 (n = 107) Attempt #5 (n = 29)

LMA® Fastrach™ w/ intubation 27 12 0 1 0 LMA® Fastrach™ w/o intubation 0 1 0 0 0 Air-Q with intubation 0 1 0 1 0 LMA® 5 3 1 1 0 King LT 1 0 0 0 0 Other EGDa 1 0 1 0 0

Abbreviations: EGD-extraglottic device; I-intubating; LMA-laryngeal mask airway; LT-laryngeal tube. a Not specified in the dataset.

M.D. April, B. Driver, S.G. Schauer et al. American Journal of Emergency Medicine 72 (2023) 95–100

undergoing a cricothyrotomyhad anEGDplaced prior to surgical access, despite most (but not all) failed airway algorithms supporting place- ment of a rescue EGD in can't intubate: can't oxygenate scenarios [25]. It is possible that differences in the ED airway management population (as compared to patients typically cared for in anesthesiology settings) account for the increased use of surgical airway instead of EGD. Imme- diate escalation to a failed airway in which it is not possible to ventilate or oxygenate thepatientmay appropriately terminate in surgical airway management.

We observed an incidence of peri-procedure adverse events in patients undergoing EGDs higher than that reported among all ED intu- bations (30% versus 12%) [1]. This observation reflects the fact that this represents a challenging cohort to intubate. Indeed, most of these patients underwent multiple airway management attempts. A known association exists between repeated airway management attempts and adverse events [4]. The principal purpose of EGD use is to achieve rescue oxygenation so minimizing the incidence of hypoxia, mitigating risk of a peri-procedure adverse event shown to be associated with car- diac arrest [19]. Despite this, one-fourth of our cohort experienced peri- intubation hypoxia. We do not infer from this observational data that use of these devices places patients at higher risk of desaturation. Rather, webelieve thisfinding reflects the fact thatmanyof thesepatientsmaybe both anatomically and physiologically challenging airways with complex underlying pathology placing them at risk of peri-intubation hypoxia, re- gardless of airway management strategy. Nevertheless, incorporating these devices earlier in the management course of these patients may mitigate the risk of hypoxia and other adverse events.

The reasons for limited use of EGD use in the ED setting are unclear. EGD use appears more common in the prehospital setting [12,13].

Table 3 Outcomes for extra-glottic device (EGD) encounters.

Variable EGD Encounters (n = 56)

Median number of attempts until definitive airway placement (IQR) 1.0 (1,2)⁎⁎ % Glottic view grade 1–2 15 (27%) First-attempt Cormack-lehane glottic view during any intubation attempts preceding EGD placement (IQR)

2 (2, 4)

% Adverse events occurring during EGD placement attempt Hypoxemiaa 14 (25%) Vomiting 2 (4%) Dysrhythmiasb 1 (2%) Esophageal intubation during intubation attempt 2 (4%) Failed airway with cricothyrotomy 2 (4%) Otherc 1 (2%) Total 17 (30%)

Abbreviations: IQR-interquartile range. ⁎⁎ 1 patientwith no successful attempts. This patient died from cardiac arrest not related to airway management.

a Oxygen saturation ≤ 90% as observed and reported by the intubating provider. b Any dysrhythmia not itself consistent with cardiac arrest as observed and reported

by the intubating provider. We did not collect data regarding specific dysrhythmias diagnosed.

c Any adverse event includes airway trauma, dental trauma, epistaxis, lip laceration, laryngospasm,main-stem intubation, pneumothorax, endotracheal tube cuff failure, iatro- genic bleeding, and laryngoscope failure.

98

We suspect EMS medical directors may find EGD use more attractive given that these devices require relatively less initial and ongoing train- ing, less preparation, and less time to place than tracheal tubes [26]. Of course, in many instances, prehospital airway management protocols may dictate the use of EGDs given lack of access to rapid sequence intu- bation protocols. A common scenario for prehospital EGD placement is out of hospital cardiac arrest complicating comparison of outcomes between patients undergoing EGD placement versus intubation using observational data [27]. In the case of emergency physicians with greater clinical judgement andmore extensive training, there is perhaps hesitation to use these devices given the understanding that they do not represent a definitive airway. Conversely, it is possible that emergency physicians have less exposure to the use of EGDs during their training and thus have little desire to reach for these devices. The increased reli- ance on EGDs is a practice from the anesthesia literature that perhaps could be better incorporated into EM practices [16,18].

There is also limited data regarding the use of EGDs in the ED setting. The existing literature related to EGD use focuses on the prehospital [12-14,28] and operating room settings [29]. We are aware of only one prior study that has characterized the use of EGDs in the ED setting. This studywas a single-center descriptive analysis of I-LMAuse. The au- thors reported that over a 10-year period spanning 2007–2017, 218 pa- tients underwent I-LMA placement. They similarly reported favorable outcomes, with 98% of these patients experiencing successful oxygena- tion and ventilation [11]. The volume of I-LMA use for this single center appeared greater than that observed in our study. This may reflect the unique practice patterns at that particular tertiary care center which has an established track record as a location for interventional airway research [30]. The literaturewould benefit from further studies examin- ing the use of these devices in the ED setting. Ideally, future airway reg- istries will include data points to capture underlying medical decision making for airway management strategies.

4.2. Limitations

The principal limitation of this study is that as an observational and descriptive studywe cannot establish any correlations or causations be- tween EGD use and patient outcomes. We also report only short-term outcomes during the patients' ED stays and cannot speak to long-term complications or respiratory failure following hospital admission. Be- cause operators enter the data into the registry themselves, there is high potential for recall and recording bias. We attempted to minimize the potential for these biases by encouraging operators to enter data as quickly as possible after procedure completion and by requiring all NEAR sites to record at least 90% of the intubations performed at their locations. Thesemeasures help ensure accurate data, butwehave no ad- ditionalmeans to ensure quality control such as video recordings. Given the small number of EGDplacements, even small data entry errors could have an outsize impact on our results.

Another limitation is missing data. We lack data on pre-intubation hemodynamics for 23% of the patients in our cohort. We lack data on pre-intubation oxygen saturation for 20% of the included patients. Both of these data points are important given the known association between these variables and intubation outcomes [5].

M.D. April, B. Driver, S.G. Schauer et al. American Journal of Emergency Medicine 72 (2023) 95–100

The other limitation is lack of data to clarify clinician decision mak- ing and EGD function. Our data lack any detailed information regarding medical decision making to explain clinician choices for airway man- agement strategy. For example, among the 7 patients who underwent I-LMA placement with subsequent documentation of definitive airway management by methods other than intubation through the I-LMA, it is unclear if those cases experienced unsuccessful EGD placement ver- sus clinician determination of a need to establish a definitive airway for reasons other than unsuccessful EGD placement. The only other in- stance in our dataset of a patient undergoing EGD placement who sub- sequently underwent alternative definitive airway management was a patient intubated via an Air-Q device who then underwent intubation via bronchoscopy. We infer that the remaining cases of EGD placement in our dataset represent successful placement given no documentation of subsequent airway management, failed airway, or patient death.

4.3. Conclusions

In conclusion, EGD use was uncommon in this multi-center ED reg- istry. EGD use occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. EGDs placement prior to cricothyrotomy was rare. ED physicians should consider early integration of EGDs into a comprehensive difficult emergency airway management plan.

Funding

None.

Disclaimer

The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army Medical Department, Department of the Army, Department of Defense, or the U.S. Government.

CRediT authorship contribution statement

Michael D. April: Writing – review & editing, Writing – original draft, Visualization, Validation, Project administration, Methodology, Investigation, Formal analysis, Conceptualization. Brian Driver:Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Steven G. Schauer: Writing – review & editing, Resources, Investigation, Funding acquisi- tion, Conceptualization. Jestin N. Carlson:Writing – review & editing, Methodology, Formal analysis, Conceptualization. Rachel E. Bridwell: Formal analysis, Writing – review & editing. Brit Long: Formal analy- sis, Supervision, Writing – review & editing. Jamie Stang: Conceptual- ization, Formal analysis, Writing – review & editing. Subrina Farah: Data curation, Formal analysis, Writing – review & editing. Robert A. De Lorenzo: Conceptualization, Supervision, Writing – review & editing. Calvin A. Brown: Conceptualization, Formal analysis, Investi- gation, Methodology, Project administration, Resources, Supervision, Writing – review & editing.

Declaration of Competing Interest

None to report; no financial relationships with any organizations that might have an interest in the submitted work, no other relation- ships or activities that could appear to have influenced the submitted work.

Acknowledgements

The authors thank Andrea Fantegrossi for management of the data- bases and systems that support theNational Emergency Airway Registry.

99

References

[1] Brown 3rd CA, Bair AE, Pallin DJ, Walls RM, Near III Investigators. Techniques, suc- cess, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65(4):363–370.e1.

[2] Pallin DJ, Dwyer RC,Walls RM, Brown 3rd CA, NEAR III Investigators. Techniques and trends, success rates, and adverse events in emergency department pediatric intuba- tions: a report from the national emergency airway registry. Ann Emerg Med. 2016; 67(5):610–615.e1.

[3] April MD, Schauer SG, Brown Rd CA, et al. A 12-month descriptive analysis of emer- gency intubations at brooke army medical center: a national emergency airway reg- istry study. US Army Med Dep J. 2017;3–17(3–17):98–104.

[4] Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated in- tubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6): 749–754.e2.

[5] April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the emergency department: a national emergency airway registry (NEAR) study. Resuscitation. 2021;162:403–11.

[6] Brain AI. The laryngeal mask–a new concept in airway management. Br J Anaesth. 1983;55(8):801–5.

[7] Copeland GB, Zilevicius DJ, Bedolla CN, et al. Review of commercially available supraglottic airway devices for prehospital combat casualty care. Mil Med. 2022; 187(7–8):e862–76.

[8] Hernandez MR, Klock Jr PA, Ovassapian A. Evolution of the extraglottic airway: a re- view of its history, applications, and practical tips for success. Anesth Analg. 2012; 114(2):349–68.

[9] Amathieu R, Combes X, AbdiW, et al. An algorithm for difficult airway management, modified for modern optical devices (airtraq laryngoscope; LMA CTrach): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology. 2011;114(1):25–33.

[10] Combes X, Le Roux B, Suen P, et al. Unanticipated difficult airway in anesthetized pa- tients: prospective validation of amanagement algorithm. Anesthesiology. 2004;100 (5):1146–50.

[11] Driver BE, Martel M, Lai T, Marko TA, Reardon RF. Use of the intubating laryngeal mask airway in the emergency department: a ten-year retrospective review. Am J Emerg Med. 2020;38(7):1367–72.

[12] Schauer SG, Naylor JF, Chow AL, et al. Survival of casualties undergoing prehospital supraglottic airway placement versus cricothyrotomy. J Spec Oper Med. 2019;19 (3):86–9.

[13] Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2018;320(8): 769–78.

[14] Benger JR, Kirby K, Black S, et al. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. JAMA. 2018;320(8):779–91.

[15] Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013(9):CD010105 doi(9): CD010105.

[16] Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 american society of anesthesiolo- gists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31–81.

[17] Butler KH, Clyne B. Management of the difficult airway: alternative airway tech- niques and adjuncts. Emerg Med Clin North Am. 2003;21(2):259–89.

[18] Frerk C, Mitchell VS, McNarry AF, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115 (6):827–48.

[19] April MD, Arana A, Pallin DJ, et al. Emergency department intubation success with succinylcholine versus rocuronium: a national emergency airway registry study. Ann Emerg Med. 2018;72(6):645–53.

[20] Kaji AH, Shover C, Lee J, et al. Video versus direct and augmented direct laryngos- copy in pediatric tracheal intubations. Acad Emerg Med. 2020;27(5):394–402.

[21] Brown 3rd CA, Kaji AH, Fantegrossi A, et al. Video laryngoscopy compared to aug- mented direct laryngoscopy in adult emergency department tracheal intubations: a national emergency airway registry (NEAR) study. Acad Emerg Med. 2020;27 (2):100–8.

[22] von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observa- tional studies in epidemiology (STROBE) statement: guidelines for reporting obser- vational studies. Ann Intern Med. 2007;147(8):573–7.

[23] April MD, Arana A, Schauer SG, et al. Ketamine versus etomidate and peri-intubation hypotension: a national emergency airway registry study. Acad Emerg Med. 2020; 27(11):1106–15.

[24] Katsiampoura AD, Killoran PV, Corso RM, Cai C, Hagberg CA, Cattano D. Laryngeal mask placement in a teaching institution: analysis of difficult placements. F1000Res. 2015;4:102.

[25] Hagberg CA, Connis RT. Difficult airway society 2015 guidelines for themanagement of unanticipated difficult intubation in adults: not just another algorithm. Br J Anaesth. 2015;115(6):812–4.

[26] Schauer SG, Tapia AD, Hudson IL, et al. A mixedmethods end-user assessment to de- termine the ideal supraglottic airway device for inclusion into the medic’s aid bag. J Trauma Acute Care Surg. 2022;93(2S Suppl 1):S64–70.

[27] Smida T, Menegazzi J, Scheidler J, et al. A retrospective comparison of the king laryn- geal tube and iGel supraglottic airway devices: a study for the CARES surveillance group. Resuscitation. 2023.;109812.

M.D. April, B. Driver, S.G. Schauer et al. American Journal of Emergency Medicine 72 (2023) 95–100

[28] Association of prehospital intubation with decreased survival among pediatric trauma patients in Iraq and Afghanistan. Am J Emerg Med. 2018;36(4):657–9.

[29] Matioc AA, Wells JA. Positive pressure ventilation with the laryngeal mask airway in the operating room and prehospital: a practical review. J Trauma. 2006;60(6): 1371–6.

100

[30] Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA. 2018;319(21): 2179–89.