Background: Rapid Sequence Intubation (RSI) is a common procedure performed by both emergency clinicians and intensivists. Although the procedure is complex, the major pieces are pre-oxygenation, administration of a sedative agent in close proximity with a paralytic, laryngoscopy and placement of an endotracheal tube without the provision of any ventilations during the process. The avoidance of bag-mask ventilations (BMV), or any positive pressure breaths, rests on the belief that those breaths can distend the stomach and lead to regurgitation and aspiration. For this to happen, the force of the breath must exceed the pressure of the lower esophageal sphincter (~ 20 mm Hg). Critically ill patients presenting with airway compromise cannot be guaranteed to have a fasting state, regurgitation and aspiration is a major concern.
However, there’s another side to this. Many of our patients who are critically ill have intrapulmonary shunting; portions of the lung are atelectatic, filled with fluid, blood, or pus and not being oxygenated though they are being perfused. Blood running through these portions of the lung will be deoxygenated and will lower the overall O2 content of blood entering the systemic circulation after mixing with blood coming from ventilated regions. This shunting at least partially explains why we see patients rapidly desaturating during intubation. Positive pressure can recruit atelectatic portions of the lung that are not involved in gas exchange thus decreasing the physiologic shunt and increasing the patient’s oxygen reserve.
Despite decades of experience with RSI we continue to look for better approaches since the procedure still poses serious risks to the patient. Recent modifications that have seen wide adoption include using the bed-up-head-elevated (BUHE) position, suction assisted laryngoscopy for airway decontamination (SALAD) and bougie first intubation, though there are many more. Now, a publication in the NEJM makes us question the core principle of BMV during RSI....Read More
Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated).6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14 The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method....Read More