DR. EDWARD BITNER. Thank you. Good afternoon. Again, I'm going to be presenting at least the first half of the rapid sequence intubation guidelines. I'm Edward Bittner. I'm an anesthesiologist and intensivist at Mass General Hospital in Boston. Let's see. It's not working. There we go. I have no financial conflicts of interest to disclose. I am an author of one of the articles that's utilized in the guidelines. So I want to start off with a little bit of rationale for the guidelines. Emergency airway management is a commonly performed procedure in critically ill patients, and it is associated with significant risk of life-threatening complications. It certainly involves very complex decision-making. And one of the most common approaches to emergency airway management is rapid sequence intubation. That is the administration of a sedative hypnotic together with a neuromuscular blocking agent in rapid succession to facilitate the endotracheal intubation. Now, RSI is designed to minimize the risk of some of these life-threatening complications, in particular aspiration and hypoxemia, but also needs to take into account some of the other complications related to severe hypotension and cardiovascular collapse. And despite this being a very common practice, there are a number of controversies and practice variations that exist related to RSI, and hence the motivation for these guidelines. In terms of the methods that the guidelines used, the American College of Critical Care Medicine organized a multidisciplinary panel of 20 practitioners. These were physicians with backgrounds in emergency medicine, anesthesiology, critical care. Also include pharmacists, respiratory therapists, and there was one nurse practitioner. And these were providers with experience and expertise in airway management. The panel submitted 35 PICO questions for consideration to be considered in the guidelines. The panelists voted on those questions, and ultimately 10 questions were selected for inclusion. The guidelines used the GRADE methodology and had access and highly utilized both a methodologist as well as a librarian in this process. It consisted of a literature search, evidence evaluation, consensus meetings, and then ultimately the panelists voted on the statements that were issued. And those statements were based on the quality of the evidence that was available, broken down into recommendations, suggestions, and then a couple of best practice statements. One question actually had insufficient evidence to make any statement at all. So I'm going to be focusing on the first five questions. And four of those questions were related to the pre-induction period. The fifth one was peri-intubation. Question one was focused on the semi-fouler position versus other positioning. The second question was high flow or non-invasive positive pressure ventilation for pre-oxygenation. The third question was related to medication-assisted pre-oxygenation. Question four was related to the issue of nasogastric tube decompression. And finally, question five focused on peri-intubation vasopressors versus fluids. Now, I'm going to talk about questions one through three based on the evidence that was available to come up with a recommendation. In questions four and five, there were best practice statements that we won't be talking about today. So question one, again, this is focused on positioning. In critically ill patients undergoing RSI, is there a difference between the semi-fouler position, that is the head and trunk inclined during intubation versus the supine position, with regard to the outcomes of first pass success, the incidence of oxygen desaturation, or pulmonary aspiration? Now, the rationale that was utilized by the committee focused on a number of observational studies, a randomized controlled trial, as well as some other studies that were performed in the operating room or on cadavers, but not on critically ill patients. So an accumulation of that evidence. The evidence table you can see to the right here for those outcomes that I mentioned. And basically, to kind of summarize the findings, three of the observational studies found improvements in first pass intubation success with a semi-fouler positioning. The fourth observational study, there was no difference. Unfortunately, despite there being a randomized controlled trial, it was felt by the panel that it had some significant limitations. There was no standardization of the degree of positioning, intubator experience, or even the laryngoscopic technique. And as I mentioned before, there were a number of studies that were considered and utilized by the committee that came from the operating room that suggested benefits of the semi-fouler position in terms of speed of intubation, prolonged time until critical desaturation. In terms of evidence gaps, again, really focusing on the critical variables that were not standardized across studies. Again, the angle of positioning, intubator experience, and laryngoscopic technique. And certainly, the studies were limited in terms of some of those subgroups of patients where this positioning might be particularly beneficial, such as patients with morbid obesity, increased aspiration risk, pregnancy, and anticipated difficult intubation. Nonetheless, the ultimate statement from the guidelines was a suggestion for the use of the semi-fouler position during RSI. Question two, related to pre-oxygenation. In critically ill patients undergoing planned RSI, is there a difference in pre-oxygenating with high-flow nasal cannula versus using face mask, bag mask, or non-invasive positive pressure ventilation with respect to the occurrence of desaturation, gastric insufflation, or pulmonary aspiration risk? Slightly larger number of studies compared to question one, including a number of randomized controlled trials. I think what we have to say about these is that they were variable in terms of definitions of severity of hypoxemia, the subgroups of critically ill patients that were examined, as well as measures of success. But what was concluded in general from the panel was that compared to face mask, high-flow nasal cannula appeared to reduce desaturation rates, prolong the safe apnea times, and limit the degree of desaturation. Furthermore, and for this particular question, the panel came up with a second statement, and that was with regard to non-invasive positive pressure ventilation. And that was based on the evidence of a strong evidence base for the use of non-invasive positive pressure ventilation for preventing critical desaturation in the setting of severe hypoxemia. Again, as I mentioned before, there were some significant evidence gaps. In particular, the subgroup of patients where there was an anticipated difficult airway or prolonged laryngoscopy. Nonetheless, the suggestions from the committee were pre-oxygenation with high-flow nasal cannula when laryngoscopy was expected to be challenging, and the suggestion for the use of non-invasive positive pressure ventilation in the setting of severe hypoxemia, in particular when P to F ratios were less than 150. The third question, medication-assisted pre-oxygenation. So in critically ill patients in whom RSI is planned, but the patient is agitated, delirious, or uncooperative, is there a difference between medication-assisted pre-oxygenation versus the usual care with face mask, assisted mask, non-invasive positive pressure ventilation, or high-flow with regard to the outcomes of desaturation or hemodynamic instability? The evidence that was utilized by the committee was fairly limited. Two observational studies. One multi-center study from the emergency department. Another one that was a pre-hospital study from the helicopter. Both of those studies used ketamine as the medication to provide sedation in providing the pre-oxygenation. But based on those two studies, there was at least a, there was either an improvement in oxygen saturation or not a decline with the utilization of ketamine. Again, very low certainty of evidence. But, and certainly there are significant evidence gaps with this statement. Things such as what is the optimal medication for assisted pre-oxygenation? What are the safe doses? What are the hemodynamic consequences? And are there other risks such as increasing aspiration and hemodynamic instability? But based on the evaluation by the panel, the suggestion was medication-assisted pre-oxygenation for patients undergoing RSI who are not able to tolerate pre-oxygenation by other means. Thank you for your time. And I'll turn it over to Dr. Patanwalla for the second five questions. Thank you. Applause.

Rapid Sequence Intubation

Emergency Airway Management

Pre-oxygenation

Hypoxemia

GRADE Methodology