Evidence-Based Emergency Management Of The Pediatric Airway

Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Prehospital Care
6. Anatomic And Physiologic Considerations
   1. Anatomic Differences
      1. Occiput
      2. Tongue
      3. Neck
      4. Airway Size
   2. Mechanics Of Ventilation
      1. Physiologic Response
7. Emergency Department Evaluation
   1. The Pediatric Assessment Triangle
      1. Overall Appearance
      2. Work Of Breathing
      3. Circulation To The Skin
   2. Complete Assessment
8. Emergency Department Treatment
   1. Preparation
      1. Laryngoscopy Blade Choice
      2. Cuffed Versus Uncuffed Endotracheal Tubes
      3. Endotracheal Tube Size
      4. Video-Assisted And Optical Laryngoscopy
      5. Gum Elastic Bougie
   2. Preoxygenation
      1. Preoxygenation Position
      2. Preoxygenation Duration
      3. Preoxygenation Using A Nonrebreather Mask
      4. Preoxygenation Using Nasal And/Or Oral Airways
      5. Preoxygenation Using Positive Pressure Ventilation
   3. Prevention Of Complications
      1. Critical Oxygen Desaturation
      2. Peri-intubation Hypotension
      3. Bradycardia
      4. Severe Acidosis
      5. Vomiting/Aspiration
   4. Pretreatment
      1. Lidocaine
      2. Opiates
      3. Atropine
      4. Defasciculating Dose Of A Paralytic
      5. Nontraditional Pretreatment Agents
   5. Paralysis With Induction
      1. Induction
         • Etomidate
      2. Ketamine
      3. Propofol
      4. Benzodiazepines (Diazepam, Lorazepam, Midazolam)
      5. Barbiturates (Methohexitol, Thiopental)
      6. Choice Of Induction Agent
      7. Paralytics
      8. Succinylcholine
      9. Rocuronium
      10. Others Paralytics (Vecuronium, Pancuronium, Mivacuronium)
   6. Protection And Positioning
   7. Placement With Confirmation
   8. Postintubation Management
9. Alternative Airway Techniques
   1. Supraglottic Airway Devices
   2. Fiberoptic Intubation
   3. Digital Intubation
   4. Cricothyrotomy
   5. Needle Cricothyrotomy
10. Special Circumstances
    1. The Obese Pediatric Patient
    2. The Difficult Airway
11. Disposition
12. Summary
13. Risk Management Pearls For Pediatric Airway Management
14. Time- And Cost-Effective Strategies
15. Case Conclusions
16. Clinical Pathway For Managing The Pediatric Airway
17. Clinical Pathway For The Difficult Airway
18. Tables and Figures
    1. Table 1. Anatomical Differences In The Airway Of The Young Child
    2. Table 2. Tone, Interactiveness, Consolability, Look-Gaze, Speech-Cry Assessment
    3. Table 3. Airway Features
    4. Table 4. Normal Respiratory Rates
    5. Table 5. Skin Circulation Characteristics
    6. Table 6. Normal Heart Rates
    7. Table 7. The 8 Ps of Rapid Sequence Intubation
    8. Table 8. Suggested Equipment For Successful Rapid Sequence Intubation
    9. Table 9. Prevention Strategies For Potential Complications
    10. Table 10. Recommendations For Pretreatment Agents For Rapid Sequence Intubation
    11. Table 11. Preferred And Alternate Sedative Agents
    12. Table 12. Sample Of Recommended Larygeal-Mask Airway Sizes Based On Size-Weight
19. References

Abstract

Pediatric airway emergencies are rare, yet they are anxiety-provoking events that can occur in both pediatric and general emergency departments. Several novel concepts regarding preoxygenation during rapid sequence intubation, anticipation and prevention of intubation-related complications, the utility of premedication agents, and the selection of induction and paralytic agents have been highlighted in recent clinical trials and review articles. In this review, we analyze the data behind these concepts, highlight current pediatric literature related to these issues, and present reasonable conclusions based on the best available evidence. We begin with an analysis of the anatomic and physiologic differences commonly encountered in the pediatric patient during rapid sequence intubation, and we then review a systematic approach to the assessment of the pediatric patient in respiratory distress (ie, the pediatric assessment triangle) and conclude with a simple approach to pediatric rapid sequence intubation, starting with the preparatory phase and ending with postintubation management. We additionally highlight several alternative airway devices and discuss special situations, including rapid sequence intubation in the obese pediatric patient and in the difficult airway patient.

Case Presentation

You are working a day shift that you traded with your colleague when your local EMS calls in about a 4-year-old boy who apparently went to sleep last night “fine” but is now febrile, significantly altered, and exhibiting a petechial rash. The paramedics report a respiratory rate of 40 breaths per minute, a heart rate of 180 beats per minutes, a blood pressure of 50/palp, and an oxygen saturation of 84% despite the use of high-flow oxygen via facemask. The child is weak, has increased work of breathing, and has a grayish skin color. As the child arrives in your resuscitation room, several questions come to mind: How am I going to preoxygenate this child prior to intubation? What if he begins to vomit and occlude his airway? What if I can’t intubate or ventilate this child? What steps can I take to reduce the risk of him coding during the intubation? Why did I agree to work this shift?

Introduction

Managing the pediatric patient who requires an advanced airway is a fundamental skill for physicians who work in the emergency department (ED). Although there are many pathways that lead to respiratory failure, there are only a handful of final common pathways that result in placing an endotracheal tube in the trachea of a sick child. Fortunately, complete respiratory failure in the pediatric patient is an uncommon event. Emergency clinicians should be prepared for the unique challenges posed by the anatomy and physiology of the pediatric airway, be familiar with the rapid assessment of the pediatric patient who requires intubation, be equipped with the standard and alternative sizes of pediatric airway devices, and have an organized approach to prepare for and execute successful pediatric rapid sequence intubation (RSI). This issue of Pediatric Emergency Medicine Practice presents an updated and systematic analysis of key principles regarding the pediatric airway, including newly recognized tips regarding preoxygenation and prevention of desaturation during airway management, the latest on the use of pretreatment, induction, and paralytic agents in pediatric RSI, and highlights the potential pitfalls of tracheal intubation with direct and video laryngoscopy.

Critical Appraisal Of The Literature

Unfortunately, there are few well-done prospective randomized controlled trials comparing intubation devices and techniques or pretreatment, induction, and paralytic medications in emergency pediatric intubation. The majority of data regarding these issues come from retrospective archives and chart reviews that report what was done and show an association between a particular device, technique, or medication and the overall outcome of the patient.

The nature of retrospective data limits the amount of information that can be abstracted from the medical record and ultimately cannot establish a cause-and-effect relationship between what is studied and the reported outcome. Prospective randomized trials that have been completed have had small sample sizes and may represent homogenous populations, thus limiting their external validity. Furthermore, the majority of data arise from the anesthesia literature, which pertains to elective pediatric intubations and not to the emergency or failing pediatric airway. Finally, there are areas within the airway literature where the best available evidence regarding pediatric techniques is extrapolated from the adult literature. These limitations should be kept in mind when reading this review.

Risk Management Pearls For Pediatric Airway Management

1. Be absolutely sure that your endotracheal tube is in the central trachea and not in the esophagus.

   Use a combination of clinical signs and CO₂ detectors or capnography, pulse oximetry, and chest radiography to verify proper placement.

2. Be familiar with pediatric anatomy and physiology and anticipate that the critically ill child that requires intubation will likely desaturate quickly. Hypoxia must be avoided.
3. Do everything you can to ensure proper preoxygenation prior to intubation. This includes airway positioning, use of oro/nasotracheal airway devices, positive pressure ventilation, and may even include placing an LMA prior to RSI.
4. If you believe your patient is at high risk for vomiting and aspiration during RSI, consider decompressing the stomach with a nasogastric tube prior to intubation, positioning the patient in a sitting position during intubation, and pretreating with an antiemetic or prokinetic agent.
5. Consider placing the pediatric patient in a cervical collar prior to interfacility transport. Some experts believe that the restricted head movement while in a cervical collar will prevent inadvertent tube dislodgement.
6. Anticipate complications (desaturation, hypotension, bradycardia, vomiting, and acidosis) and take steps to avoid these complications prior to the administration of induction and paralytic agents.
7. Have a difficult airway plan for patients with abnormal craniofacial anatomy and consider expert consultation, if time permits, for intubation of these patients.
8. Do not paralyze a patient who has difficult airway anatomy and who you anticipate would be difficult to ventilate. Instead, consider an awake intubation in these patients.
9. Disclose any difficulties with intubation and complications to the family. Let them know how difficult the situation was, what happened, and what steps you took to address the situation.
10. Document any difficulties with intubation and complications in the medical record. Describe the situation, what happened, and the steps you took to address the situation.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available.

1. Pointer JE. Clinical characteristics of paramedics’ performance of pediatric endotracheal intubation. Am J Emerg Med. 1989;7(4):364-366. (Retrospective cohort; 36 pediatric patients)
2. Doran JV, Tortella BJ, Drivet WJ, et al. Factors influencing successful intubation in the prehospital setting. Prehosp Disaster Med. 1995;10(4):259-264. (Prospective cohort; 236 patients)
3. Aijian P, Tsai A, Knopp R, et al. Endotracheal intubation of pediatric patients by paramedics. Ann Emerg Med. 1989;18(5):489-494. (Retrospective cohort; 42 pediatric patients)
4. Losek JD, Hennes H, Glaeser P, et al. Prehospital care of the pulseless, nonbreathing pediatric patient. Am J Emerg Med. 1987;5(5):370-374. (Retrospective cohort; 114 pediatric cardiac arrest patients)
5. Losek JD, Bonadio WA, Walsh-Kelly C, et al. Prehospital pe2013diatric endotracheal intubation performance review. Pediatr Emerg Care. 1989;5(1):1-4. (Retrospective cohort; 63 pediatric patients)
6. Nakayama DK, Gardner MJ, Rowe MI. Emergency endotracheal intubation in pediatric trauma. Ann Surg. 1990;211(2):218-223. (Retrospective cohort; 6305 pediatric trauma patients)
7. Kumar VR, Bachman DT, Kiskaddon RT. Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital setting? Ann Emerg Med. 1997;29(6):743-747. (Retrospective cross-sectional study; 47 pediatric cardiac arrest patients)
8. Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med. 1995; 25(4):484-491. (Retrospective cohort; 157 pediatric cardiac arrest patients)
9. Brownstein D, Shugerman R, Cummings P, et al. Prehospital endotracheal intubation of children by paramedics. Ann Emerg Med. 1996;28(1):34-39. (Retrospective cohort; 355 pediatric patients)
10. Hubble MW, Brown L, Wilfong DA, et al. A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rate. Prehosp Emerg Care. 2010;14(3):377-401. (Meta-analysis; 140 studies, 57,132 prehospital patients)
11. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome: a controlled clinical trial. JAMA. 2000;283(6):783-790. (Prospective, quasi-randomized, clinical trial; 830 pediatric patients)
12. Cooper A, DiScala C, Foltin G, et al. Prehospital endotracheal intubation for severe head trauma in children: a reappraisal. Semin Pediatr Surg. 2001;10(1):3-6. (Retrospective trauma registry; 578 pediatric head trauma patients)
13. Murry JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients with severe head injury. J Trauma. 2000;49(6):1065-1070. (Retrospective trauma registry; 852 head trauma patients)
14. Stockinger ZT, McSwain Jr NE. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve mask ventilation. J Trauma. 2004;56(3):531-536. (Retrospective trauma registry; 533 trauma patients)
15. DiRusso SM, Sullivan T, Risucci D, et al. Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. J Trauma. 2005;59(1):84-91. (Retrospective trauma registry; 5460 pediatric trauma patients)
16. Youngquist ST, Gausche-Hill M, Squire BT, et al. Barriers to adoption of evidence-based prehospital airway management practices in California. Prehosp Emerg Care. 2010; 14(4):505-509. (Survey; 25 EMS medical directors)
17. Youngquist ST, Henderson DP, Gausche-Hill M, et al. Paramedic self-efficacy and skill retention in pediatric airway management. Acad Emerg Med. 2008;15(12):1295-1303. (Survey; 245 paramedics)
18. Gerritse BM, Draaisma JM, Schalkwijk A, et al. Should EMS-paramedics perform paediatric tracheal intubation in the field? Resus. 2008;79(2):225-229. (Prospective cohort; 155 pediatric patients)
19. Martinon C, Duracher C, Blanot S, et al. Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines. Pediatr Crit Care Med. 2011; 12(1):65-70. (Prospective cohort with retrospective control; 296 patients)
20. Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am. 2008;2(4):961-975. (Review article)
21. Stewart C. Managing the pediatric airway in the ED. Pediatric Emergency Medicine Practice. 2006;3(1):1-24. (Review article)
22. Tucker JE, Coussa M. Pediatric rapid sequence intubation. Pediatr Emerg Med Reports. 2009;14(1):1-12. (Review article)
23. Luten RC, McAllister JD. Approach to the pediatric airway. In: Walls RM, Murphy MF, editors. Manual of Emergency Airway Management. 3rd edition. Phildadelphia: Lippincott, Williams & Wilkins; 2008:263–281. (Book chapter)
24. Sarnaik A, Heidemann SM. Respiratory pathophysiology and regulation. In: Kleigman RM, Rehrman RE, Jenson HB, eds. Nelson Textbook of Pediatrics. 18th edition. Philadelphia: Saunders; 2007:1719–1731. (Book chapter)
25. Moss IR. Physiologic considerations. In: McMillian JA, Feigin RD, DeAngelis CD, editors. Oski’s Pediatrics. 4th edition. Philadelphia: Lippincott, Williams & Wilkins; 2006:300-305. (Book chapter)
26. Dalal PG, Murray D, Messner AH, et al. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg. 2009;108(5):1475-1479. (Prospective cohort; 135 pediatric patients)
27. Litman RS, Weissend EE, Shibata D, et al. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesthesiology. 2003;98(1):41-45. (Prospective cohort; 99 pediatric patients)
28. Motoyama EK. The shape of the pediatric larynx: cylindrical or funnel shaped? Anesth Analg. 2009:108(5):1379-1781. (Editorial)
29. Keens TG, Bryan AC, Levison H, et al. Developmental pattern of muscle fiber types in human ventilatory muscles. J Appl Physiol. 1978;44(6):909-913. (Physiology study; 31 postmortum specimens)
30. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312-315. (Review article)
31. American Academy of Pediatrics. Pediatric Education for Prehospital Professionals: PEPP Textbook. 2nd ed. Sudbury, MA: Jones & Bartlett Publishers; 2006. (Book chapter)
32. Fine GF, Borland LM. The future of the cuffed endotracheal tube. Paediatr Anaesth. 2004;14(1):38-42. (Review article)
33. Newth CJ, Rachman B, Patel N, et al. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr. 2004;144(3):333-337. (Prospective cohort; 597 pediatric patients)
34. Browning DH, Graves SA. Incidence of aspiration with endotracheal tubes in children. J Pediatr. 1983;102(4):582-584. (Prospective; 27 pediatric patients)
35. King BR, Baker MD, Braitman LE, et al. Endotracheal tube selection in children: a comparison of four methods. Ann Emerg Med. 1993;22(3):530-534. (Prospective blinded; 237 pediatric patients)
36. White MC, Marsh CJ, Beringer RM, et al. A randomized, controlled trial of the Airtraq optical laryngoscope with conventional laryngoscopy in infants and children. Anaesth. 2012;67(3):226-231. (Prospective; 60 pediatric patients)
37. Armstrong J, John J, Karsli C. A comparison between GlideScope Video Laryngoscope and direct laryngoscope in paediatric patients with difficult airways – a pilot study. Anaesth. 2010;65(4):353-357. (Prospective pilot study; 18 pediatric patients)
38. Kim HJ, Kim JT, Kim HS, et al. A comparison of GlideScope Videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children. Paediatr Anaesth. 2011;21(4):417-421. (Prospective; 80 pediatric patients)
39. Redel A, Karademir F, Schlitterlau A, et al. Validation of the GlideScope Video Laryngoscope in pediatric patients. Paediatr Anaesth. 2009;19(7)667-671. (Prospective; 60 pediatric patients).
40. Serocki G, Bein B, Scholz J, et al. Management of the predicted difficult airway: a comparison of blade laryngoscopy with video-assisted blade laryngoscopy and the GlideScope. Eur J Anaesthesiol. 2010;27(1);24-30. (Prospective; 120 adult patients)
41. Kim JT, Na HS, Bae JY, et al. GlideScope Video Laryngoscope: a randomized clinical trial in 203 paediatric patients. Br J Anaesth. 2008;101(4):531-534. (Prospective; 203 pediatric patients)
42. Trevisanuto D, Fornaro E, Verghese C. The GlideScope video laryngoscope: initial experience in five neonates. Can J Anaesth. 2006;53(4):423-424. (Case series; 5 pediatric patients)
43. Hirabayashi Y, Otsuka Y. Early clinical experience with GlideScope video laryngoscope in 20 infants. Pediatr Anesth. 2009;19(8):800-814. (Case series; 20 pediatric patients)
44. Vlatten A, Aucoin S, Litz S et al. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the pediatric airway. Pediatr Anesth. 2009;19(11):1102-1107. (Prospective randomized clinical trial; 56 pediatric patients)
45. Hackell RS, Held LD, Stricker PA et al. Management of the difficult infant airway with the STORZ Video Laryngoscope: a case series. Anesth Analg. 2009;109(3):763-766. (Case series; 7 pediatric patients)
46. Singh R, Singh H, Vajifdar H. A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants. Pediatr Anesth. 2009;19(4):338-342. (Prospective randomized clinical trial; 60 pediatric patients)
47. Holm-Knudsen RJ, White J. The Airtraq may not be the solution for infants with difficult airways. Pediatr Anesth. 2010;20(4):374-375. (Editorial)
48. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007;54(1):154-157. (Case series; 2 patients)
49. Sime J, Bailitz J, Moskoff J. The bougie: an inexpensive lifesaving airway device. J Emerg Med. 2012;43(6):e393-e395. (Case series; 3 patients)
50. Shah KH, Kwong BM, Hazan A, et al. Success of the gum elastic bougie as a rescue airway in the emergency department. J Emerg Med. 2011;40(1):1-6. (Prospective; 26 patients)
51. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic bougie to facilitate blind nasotracheal intubation in children: a series of three cases. Anaesth. 2006;61(3):291-294. (Case series; 3 pediatric patients)
52. Lopez-Gil M, Brimacombe J, Barragan L, et al. Bougie-guided insertion of the ProSeal laryngeal mask airway has higher first attempt success rate than the digital technique in children. Br J Anaesth. 2006;96(2):238-241. (Prospective randomized clinical trial; 120 patients)
53. Shah KH, Kwong B, Hazan A, et al. Difficulties with gum elastic bougie intubation in an academic emergency department. J Emerg Med. 2011;41(4):429-434. (Prospective; 88 patients)
54. Kovacs G, Law JA, McCrossin C, et al. A comparison of fiberoptic stylet and a bougie as adjuncts to direct laryngoscopy in a manikin-simulated difficult airway. Ann Emerg Med. 2007;50(6):676-685. (Prospective; 103 inexperienced laryngoscopist participants)
55. Evans A, Morris S, Petterson J, et al. A comparison of the Seeing Optical Stylet and the gum elastic bougie in simulated difficult tracheal intubation: a manikin study. Anaesth. 2006;61(5):478-481. (Prospective; 44 anesthetist participants)
56. *Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;5993):165-175. (Review article)
57. Ramkumar V, Umesh G, Philip FA. Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011;25(2):189-194. (Prospective trial; 45 adult patients)
58. Lane S, Saunders D, Schofield A, et al. A prospective, randomised controlled trial comparing the efficacy of pre-oxygenation in the 20 degrees head-up vs supine position. Anaesthesia. 2005;60(11):1064-1067. (Prospective trial; 35 adult patients) 59.
59. Baraka AS, Hanna MT, Jabbour SI, et al. Preoxygenation of pregnant and nonpregnant women in the head-up versus supine position. Anesth Analg. 1992;75(5):757-759. (Prospective trial; 20 adult patients)
60. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25° head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102(6):1110-1115. (Prospective randomized clinical trial; 42 obese adult patients)
61. Altermatt FR, Muñoz HR, Delfino AE, et al. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. Br J Anaesth. 2005;95(5):706-709. (Prospective randomized clinical trial; 40 obese adult patients)
62. Boyce JR, Ness T, Castroman P, et al. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13(1):4-9. (Prospective randomized trial; 26 obese adult patients)
63. Videira RL, Neto PP, do Amaral RV, et al. Preoxygenation in children: for how long? Acta Anaesthesiol Scand. 1992;36(2):109-111. (Randomized trial; 11 healthy children)
64. Xue, FS, Tong SY, Wang XL, et al. Study of the optimal duration of preoxygenation in children. J Clin Anesth. 1995;7(2):93-96. (Randomized trial; 40 healthy children)
65. Dupeyrat A, Dubreuil M, Ecoffey C. Preoxygenation in children. Anesth Analg. 1994;79(5):1027. (Editorial)
66. Morrison JE, Collier E, Friesen RH, et al. Preoxygenation before laryngoscopy in children: how long is enough? Pediatr Anaesth. 1998;8(4):293-298. (Prospective; 58 healthy children)
67. Chiron B, Mas C, Ferrandiere M, et al. Standard preoxygenation vs two techniques in children. Pediatric Anesthesia. 2007;17(10):963-967. (Prospective; 20 healthy children)
68. Patel R, Lenczyk M, Hannallah R, et al. Age and the onset of desaturation in apnoeic children. Can J Anesth. 1994;41(9):771-774. (Prospective; 50 healthy children)
69. Xue FS, Luo LK, Tong SY, et al. Study of the safe threshold of apneic period in children during anesthesia induction. J Clin Anesth. 2006; 8(7):568-574. (Prospective; 152 healthy children)
70. Dels J, Estrada CM, Abramo T. Noninvasive ventilation techniques in the emergency department – applications in pediatric patients. Pediatr Emerg Med Pract. 2009;6(6);1-18. (Review article)
71. Calderini E, Chidini G, Pelosi P. What are the current indications for noninvasive ventilation in children? 2010. Curr Opinion Anaesth. 23(3);368-374. (Review article)
72. Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled study. Anesth Analg. 2008;107(5):1707-1713. (Randomized controlled trial; 28 obese operative patients)
73. Futier E, Constantin JM, Pelosi P, et al. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Anesthesiology. 2011;114(6):1354-1363. (Randomized controlled trial; 66 obese operative patients)
74. Cressey DM, Berthoud MC, Reilly CS. Effectiveness of continuous positive airway pressure to enhance pre-oxygenation in morbidly obese women. Anaesthesia. 2001;56(7):680-684. (Randomized controlled trial; 20 obese operative patients)
75. Gander S, Frascarolo P, Suter M, et al. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg. 2005;100(2):580-584. (Randomized controlled trial; 30 obese operative patients)
76. Herriger A, Frascarolo P, Spahn DR, et al. The effect of positive airway pressure during pre-oxygenation and induction of anaesthesia upon duration of non-hypoxic apnoea. Anaesthesia. 2004;59(3):243-247. (Randomized controlled trial; 40 operative patients)
77. Antonelli M, Conti G, Rocco M, et al. Noninvasive positive pressure ventilation versus conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy. Chest. 2002;121(4):1149-1154. (Randomized controlled trial; 26 intensive care unit patients)
78. Baraka AS, Taha SK, Siddik-Sawwid SM, et al. Supplementation of pre-oxygenation in morbidly obese patients using nasopharyngeal oxygen insufflation. Anaesth. 2007;62(8):769-773. (Randomized controlled trial; 34 obese operative patients)
79. Ramachandran SK, Cosnowski A, Shanks A, et al. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010;22:164-168. (Randomized controlled trial; 30 obese operative patients)
80. Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia. 2006;61(5):427-430. (Randomized controlled trial; 30 patients)
81. Comroe JH Jr, Dripps RD. Artificial respiration. JAMA. 1946;130:381-383. (Case series; 2 patients)
82. Enghoff H, Holmdahl MH, Risholm L. Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation. Acta Chir Scand. 1952;103(4):293-301. (Case series; 7 patients)
83. Holmdahl MH. Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea. Acta Chir Scand Suppl 1956;212:1-128.
84. Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation in man. Anesthesiology 1959;20:789-798. (Observational; 8 patients)
85. Babinski MF, Sierra OG, Smith RB, et al. Clinical application of continuous flow apneic ventilation. Acta Anaesthesiol Scand. 1985;29(7):750-752. (Observational; 5 patients)
86. Teller LE, Alexander CM, Frumin MJ, et al. Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea. Anesthesiology. 1998;69(6):980-982. (Randomized controlled trial; 12 patients)
87. Baraka A, Salem MR, Joseph NJ. Critical hemoglobin desaturation can be delayed by apneic diffusion oxygenation. Anesthesiology. 1999;90(1):332-333. (Commentary)
88. Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations. J Intensive Care Med. 2007;22(3):157-165. (Review article)
89. Franklin C, Jacob S, Hu T. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Emerg Med. 1994;12(4):425-428. (Retrospective; 84 patients)
90. Qadir S, Raju P, Smina M, et al. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Respir Crit Care Med. 2001;163:A128. (Abstract)
91. Stowe DF, Bosnjak ZK, Kampine JP. Comparison of etomidate, ketamine, midazolam, propofol, and thiopental on function and metabolism of isolated hearts. Anesth Analg. 1992;74(4):547-558. (Animal study)
92. Griesdale DEG, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008;34(10):1835-1842. (Prospective cohort; 136 patients)
93. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA guidelines in the remote location. J Clin Anesth. 2004;16(7):508-516. (Retrospective chart review; 60 patients)
94. *Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. J Emerg Med. 2010;38(5):622-631. (Review article)
95. Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance, and atropine. Arch Dis Child. 2012;97(2):139-144. (Review article)
96. McAuliffe G. Bissonnette B. Boutin C. Should the routine use of atropine before succinylcholine in children be reconsidered? Can J Anaesth. 1995;42(8):724-729. (Randomized controlled trial; 41 patients)
97. Fastle RK. Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004;20(10):651-655. (Retrospective cohort; 163 patients)
98. Bean A, Jones J. Atropine: re-evaluating its use during paediatric RSI. EMJ. 2007;24(5):361-362. (Systematic review)
99. *Fleming B, McCollough M, Henderson HO. Myth: atropine should be administered before succinylcholine for neonatal and pediatric intubation. CJEM. 2005;7(2):114-117. (Systematic review)
100. Tibodeau LG, Verdile VP, Bartfield JM. Incidence of aspiration after urgent intubation. Am J Emerg Med. 1997;15(6):562-565. (Retrospective chart review; 87 patients)
101. Sackles JC, Laurin EG, Rantapaa AA, et al. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med. 1998;31(3):325-332. (Prospective; 10 patients)
102. Donegan MF. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology. 1980;52(8):516-518. (Prospective; 10 patients)
103. White PF, Schlobohm RM, Pitts LH, et al. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology. 1982;57(3):242-244. (Prospective; 15 patients)
104. Yano M, Nishiyama H, Yokota H, et al. Effect of lidocaine on ICP response to endotracheal suctioning. Anesthesiology. 1986;64(5):651-653. (Prospective; 9 patients)
105. Bedford RF, Winn HR, Tyson G. Lidocaine prevents increased ICP after endotracheal intubation. In: Shulman K, Mamorou, Miller JD, eds. Intracranial Pressure IV. Berlin, Germany: Springer; 1980:595-598. (Book chapter)
106. Hamill JF, Bedford RF, Weaver DC, et al Lidocaine before endotracheal intubation: intravenous or laryngotracheal? Anesthesiology. 1981;55(5):578-581. (Prospective; 22 patients)
107. Grover VK, Reddy GM, Kak VK, et al. Intracranial pressure changes with different doses of lignocaine under general anesthesia. Neurol India. 1999;47(2):118-121. (Prospective; 30 patients)
108. Asfar SN, Abdulla WY. The effect of various administration routes of lidocaine on hemodynamics and ECG rhythm during endotracheal intubation. Acta Anaesthesiol Belg. 1990;41(1):17-24. (Prospective clinical trial)
109. *Salhi B, Stettner E. In defense of the use of lidocaine in rapid sequence intubation. Ann Emerg Med. 2007;49(1):84-86. (Editorial)
110. Weingart S. Additional thoughts on the controversy of lidocaine administration before rapid sequence intubation in patients with traumatic brain injuries. Ann Emerg Med. 2007;50(3):353. (Editorial)
111. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J. 2001;18(8):453-457. (Best evidence topic)
112. *Villancourt C, Kapur AK. Opposition to the use of lidocaine in rapid sequence intubation. Ann Emerg Med. 2007;49(1):86-87. (Editorial)
113. Yamamato LG, Emergency airway management – rapid sequence intubation. In: Textbook of Pediatric Emergency Medicine, 5th edition. Fleisher GR, Ludwig S, Henretiq FM, eds. Lippincott Williams & Wilkins, Philadelphia 2006:81. (Book chapter)
114. Gerardi M, Sacchetti A, Cantor R, et al. Rapid sequence intubation of the pediatric patient. Ann Emerg Med. 1996;28(1):55-74. (Review article) 115.
115. Bozeman WP, Idris AH. Intracranial pressure changes during rapid sequence intubation: a swine model. J Trauma. 2005;58(2):278-283. (Animal study)
116. Lanier WL, Iaizzo PA, Milde JH. Cerebral function and muscle afferent activity following intravenous succinylcholine in dogs anesthetized with halothane: the effects of pretreatment with a defasciculating dose of pancuronium. Anesthesiology. 1989;71(1):87-95. (Animal study)
117. Ducep JP, Deppe SA, Foley KT. A comparison of the effects of suxamethonium, atracurium, and vecuronium on intracranial haemodynamics in swine. Anesth Intensive Care. 1989;17(4):448-455. (Animal study)
118. Thiagarajah S, Sophie S, Lear E, et al. Effect of suxamethonium on the ICP of cats with and without thiopentone pretreatment. Br J Anaesth. 1988;60(2):157-160. (Animal study)
119. Cotterell JE, Hartung J, Giffin JP, et al. Intracranial and hemodynamic changes after succinylcholine administration in cats. Anesth Analg. 1983;62(11):1006–1009. (Animal study)
120. Stirt JA, Grosslight KR, Bedford RF, et al. “Defasciculation” with metocurine prevents succinylcholine-induced increases in intracranial pressure. Anaesthesiology. 1987;67(1):50-53. (Prospective; 12 patients)
121. Minton MD, Grosslight K, Stirt JA, et al. Increases in intracranial pressure from succinylcholine: prevention by prior non-depolarising blockade. Anaesthesiology. 1986;65(2):165-169. (Prospective; 13 patients with increased intracranial pressure)
122. Brown MM, Parr MJ, Manara AR. The effect of suxamethonium on intracranial pressure and cerebral perfusion pressure in patients with severe head injuries following blunt trauma. Eur J Anaesthesiol. 1996;13(5):474-477. (Prospective; 11 head-injured patients)
123. Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity or the electroencephalogram in patients with neurologic injury. Anesth Analg. 1994;78(3):469-473.
124. McLesky CH, Cullen BF, Kennedy RD, et al. Control of cerebral perfusion pressure during induction of anaesthesia in high-risk neurosurgical patients. Anesth Analg. 1974;53(6):985-992.
125. *Clancy M, Halford S, Walls R, et al. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373-375. (Best evidence topic)
126. Imran M, Khan FH, Khan MA. Attenuation of hypotension using phenylephrine during induction of anesthesia with propofol. J Pak Med Assoc. 2007;57(11):543. (Prospective; 135 adult patients)
127. Dhungana Y, Bhattarai BK, Bhadani UK, et al. Prevention of hypotension during propofol induction: a comparison of preloading with 3.5% polymers of degraded gelatin (Haemaccel) and intravenous ephedrine. Nepal Med Coll J. 2088;10(1):16-19. (Prospective randomized; 120 adult patients)
128. Ozkocak I, Altunkaya H, Ozer Y, et al. Comparison of ephedrine and ketamine in prevention of injection pain and hypotension due to propofol induction. Eur J Anesthesiol. 2005;22(1):44-48. (Prospective; 75 adult patients)
129. Zed PJ, Abu-Laban RB, Harrison DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Acad Emerg Med. 2006;13(4):378-383. (Prospective; 522 adult patients)
130. Zuckerbraun NS, Pitetti RD, Herr SM, et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. Acad Emerg Med. 2006;13(6):602-609. (Prospective; 77 pediatric patients)
131. Sokolove PE, Price DD, Okada P. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21. (Retrospective; 100 pediatric patients)
132. Guldner G, Schultz J, Sexton P, et al. Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events. Acad Emerg Med. 2003;10(2):134-139. (Retrospective; 105 pediatric patients)
133. *Jabre P, Cornbes X, Lapostolle F, et al. KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374(9686):293-300. (Prospective controlled trial; 655 patients)
134. Dewhirst E, Frazier WJ, Leder M, et al. Cardiac arrest following ketamine administration for rapid sequence intubation. J Intensive Care Med. 2012 May 29. [Epub ahead of print]. (Case report; 2 patients)
135. Mayberg TS, Lam AM, Matta BF, et al. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy. Anesth Analg. 1995;81(1):84-89. (Prospective; 20 neurosurgical patients)
136. Kolenda H, Gremmelt A, Rading S, et al. Ketamine for analgosedative therapy in intensive care treatment of headinjured patients. Acta Neurochir. (Wien) 1996;138(10):1193-1199. (Prospective randomized trial; 35 patients with head injury)
137. Bourgoin A, Albanèse J, Wereszczynski N, et al. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003;31(3):711-717. (Prospective randomized trial; 25 patients with head injury)
138. Bourgoin A, Albanese J, Leone M, et al. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med. 2005;33(5):1109-1113. (Prospective randomized; 30 patients with head injury)
139. Schmittner MD, Vajkoczy SL, Horn P, et al. Effects of fentanyl and S(+)-ketamine on cerebral hemodynamics, gastrointestinal motility, and need of vasopressors in patients with intracranial pathologies: a pilot study. J Neurosurg Anesthesiol. 2007;19(4):257-262. (Prospective randomized; 24 patients with head injury)
140. *Filanovsky Y, Miller P, Kao J. Myth: ketamine should not be used as an induction agent for intubation in patients with head injury. Can J Emerg Med. 2010;12(2):154-157. (Systematic review)
141. Hughes S. Is ketamine a viable induction agent for the trauma patient with potential brain injury? Emerg Med J. 2011;28(11):1076-1077. (Systematic review; 5 studies)
142. Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate rapid sequence intubation? Acad Emerg Med. 2003;10(6):612-620. (Retrospective registry of ED intubations; 2380 patients)
143. Mallon WK, Keim SM, Shoenberger JM, et al. Rocuronium vs. succinylcholine in the emergency department: a critical appraisal. J Emerg Med. 2009;37(2):183-188. (Systematic review)
144. Seupaul RA, Jones JH. Does succinylcholine maximize intubating conditions better than rocuronium for rapid sequence intubation? Ann Emerg Med. 2011;57(3):301-302. (Systematic review)
145. Perry JJ, Lee JS, Sillberg VA, et al. Rocuronium versus succinylcholine for rapid sequence intubation. Cochrane Database Syst Rev. 2008 Apr 16(2):CD002788. (Systematic review)
146. Herbstritt A, Amarakone K. Is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? Emerg Med J. 2012;29(3):256-258. (Best evidence topic)
147. Taha SK, El-Khatib MF, Baraka AS, et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia. 20132010;65(4):358-361. (Randomized; 60 adult patients)
148. Tang L, Li S, Huang S, et al. Desaturation following rapid sequence induction using succinylcholine versus rocuronium in overweight patients. Acta Anaesthesiol Scand. 2011;55(2):203-208. (Randomized; 60 obese adult patients)
149. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet. 1961;2(7199):404-406. (Observational study; 26 patients)
150. *Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50(6):653-665. (Systematic review)
151. Butler J, Sen A. Cricoid pressure in emergency rapid sequence induction. Emerg Med J. 2005;22(11):815-816. (Systematic review)
152. Noguchi T, Koga K, Shiga Y, et al. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anaesth. 2003;50(7):712-717. (Prospective; 60 adult patients)
153. Ho AM, Wong W, Ling E, et al. Airway difficulties caused by improperly applied cricoid pressure. J Emerg Med. 2001;20(1):29-31. (Editorial)
154. Levitan RM, Kinkle WC, Levin WJ, et al. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med. 2006;47(6):548-555. (Prospective randomized; 1530 laryngoscopes by 104 participants)
155. *Levitan RM, Heitz JW, Sweeny M, et al. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011;57(3):240-247. (Review article)
156. Levitan RM, Mickler T, Hollander JE. Bimanual laryngoscopy: a videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002;40(1):30-37. (Prospective; 9 novice intubators for 72 cases)
157. Bhende MS, Thompson AE, Cook DR, et al. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann Emerg Med. 1992;21(2):142-145. (Prospective; 173 pediatric patients)
158. Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation. J Emerg Med. 2001;20(3):223-229. (Meta-analysis)
159. *Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med. 2011;40(6):661-667. (Review article)
160. *Dargin J, Medzon R. Emergency department management of the airway in obese adults. Ann Emerg Med. 2010;56(2):95-104. (Review article)
161. Levitan RM, Mechem CC, Ochroch EA, et al. Head-elevated laryngoscopy position: improving laryngoscopy by increasing head elevation. Ann Emerg Med. 2003;41(3):322-330. (Human cadaver study)
162. Barata I. The laryngeal mask airway: prehospital and emergency department use. Emerg Med Clin North Am. 2008;26(4):1069-1083. (Review article)
163. Reardon R, Joing S, Hill C. Bougie-guided cricothyrotomy technique. Acad Emerg Med. 2010;17 (2):225. (Image/video clip)
164. Hill C, Reardon R, Joing S, et al. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med. 2010;17(6):666-669. (Randomized trial; 21 residents)