SGEM#281: EM Docs Got an AmbuBag – The PreVent Trial

Date: January 9th, 2020 Reference: Casey et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. NEJM February 2019 Guest Skeptic: Andrew Merelman is a critical care paramedic and second year medical student at Rocky Vista University in Colorado. His primary interests are resuscitation, critical care, airway management, and point-of-care ultrasound. Case: A 60-year-old male is in your emergency department with sepsis from pneumonia. He has worsening work of breathing and a decreasing level of consciousness. You decide based on his clinical presentation that he needs to be intubated. Due to his already poor oxygenation, you are concerned about him desaturating during intubation and wonder if there is anything you can do to help prevent it. Background: Emergency medicine is often referred to as the ABC (Airway, Breathing and Circulation) specialty. We have covered airway a few times on the SGEM: SGEM#75: Video Killed Direct Laryngoscopy? SGEM#96: Machine Head – NIPPV for Out of Hospital Respiratory Distress SGEM#247:Supraglottic Airways Gonna Save You for an OHCA? SGEM#249: Ace in the Hole – Confirming Endotracheal Tube Placement with POCUS SGEM#271: Bougie Wonderland for First Pass Success Rapid Sequence Intubation (RSI) has been a mainstay of emergency airway management for years. However, there are aspects of the procedure that have been debated, one of which is how best to oxygenate the patient during the apneic period while not increasing rates of aspiration. Clinical Question: Is bag-mask ventilation (BMV) performed during the apneic period of RSI (defined as the time between administration of RSI medications and intubation) in critically ill adults safe and effective? Reference: Casey et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. NEJM February 2019 Population: Adults patients (older than 17 years of age) undergoing induction and tracheal intubation in the intensive care unit. Exclusions: Patients who were pregnant, incarcerated, had immediate need for intubation or if the treating clinicians felt that ventilation was indicated or contraindicated between induction and laryngoscopy. Intervention: Bag-mask ventilation (BMV) during the time between administration of sedation/paralysis and insertion of the laryngoscope into the mouth for intubation. Comparison: Apnea with or without nasal cannula oxygen during the time between administration of sedation/paralysis and insertion of the laryngoscope into the mouth for intubation. Outcome: Primary Outcome: The lowest oxygen saturation observed during the interval between induction and two minutes after tracheal intubation. Secondary Outcome: The incidence of severe hypoxemia (oxygen saturation of less than 80%). Authors’ Conclusions: “Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. No All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. No Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Key Results: They screened 667 patients and enrol...