Jason Zurba BSc RRT Supervisor Royal Columbian Hospital

Jason Zurba BSc RRT Supervisor Royal Columbian Hospital

Outline Why we started looking at this What our own data has shown us What the literature tells us about intubation What we have changed How this applies to Neonates

Nursing Royal Columbian Hospital Airway Committee Respiratory Therapists Physicians: ICU Emergency Anesthesia Administration

Mandate Leave your ego at the door Airway Incidents Equipment Protocols Education

Intubation Data Collection at Royal Columbian Hospital

July 2012 to November 2014 582 DOCUMENTED INTUBATIONS

INDICATIONS RESP FAIL DEC LOC SHOCK OTHER NO DATA

Urgency

BVM Class

Techniques

Complications Severe: SBP <70mmHg if >90 mmhg O2 Sat n <80% if >90% Esophageal intubation Other: aspiration, dental trauma, endobronchial intubation, pneumothorax Cardiac Arrest or Death

Key findings 1 Attempt (n =224 ) >1 Attempt (n=108) Other Complications 20 44 % Severe Complications 18 32 8.9% vs 41% 8.0% vs 30% 1. Others Complications: Aspiration, dental trauma, endobronchial intubation, pneumothorax or any severe complication 2. Severe Complication: - Hypotension: Systolic blood pressure <70mmHg if >90mmHg prior to attempt - Hypoxia: oxygen saturation <80% if >90% prior to attempt -Esophageal intubation -Cardiac Arrest -Death within 30 Min of Intubation

Greater than one attempt at ETI was associated with a 4-fold increase in severe, and a 5-fold increase in total complications. Although previous publications found greater than 2 attempts associated with increased complications, recent publications found this association with greater than one attempt, consistent with our findings.

Should RTs be intubating? A. Yes, of course B. No, are you nuts?

Is It just Us? Do we Just Suck at Intubation at RCH? Fiberoptic intubation gone horribly wrong

Do we suck at RCH? A. Yup, you suck B. Nope, that sounds normal C. Nope, you guys are some kind of A/W wizards

Complications Rates Authors Jaber 2006 (ICU)N=253 Griesdale (unpublished) (ICU) Jaber 2010 (ICU) N=121 Sackles 2013 N=1828 RCH Data, 2012-13 N=332 Total complications Severe Complications 50% 28% 38% 24% 34% 21% 25% 19% 15%

How do we measure up to others

Complications Increase with >1 Attempt Authors Griesdale 2008 n=136 Sackles 2013 n=1828 RCH Data n=332 Absolute Risk of Adverse Event 18% 38% 14% 53% 8% 41%

Prospective cohort study of pts intubated by ICU team N=136 Excluded Cardiac arrest pts >1 attempt associated with risk of severe complications OR 3.31 (95% CI:1.30,8.40, p=0.01)

Retrospective analysis of 4 years of QI data N=1828 1 attempt complications 14.2% (95% CI12.4%-16.2% >1 attempt complications 47.2%(95% CI 41.8%-52.7%)

What are some things we can fix?

First pass success PGY-1 38% PGY-2 52% PGY-3 66% Anesthesia Resident 85% Higher year of training RR.74 95%[CI].54-.93 P<.01 Anesthesia Resident RR.52 95%[CI].2-1 P=.03

Lessons People with more experience have better success

N=322 Anesthesia Residents out of OR intubations Complications decreased with attending Supervision 21.7% vs 6.1% P=.0001

Lesson Anesthetists are the experts

So.. How many intubations does it take to become good?

How many Intubations should you do to show competency A. 5 B. 10 C. 20 D. 30 E. >30

57 successful intubations to have 90% success rate Still improving into the 80s

472 intubations by 20 trainees (msi, RT, EMT) All pts prescreened to be easy intubations Analysis of data predicted 90% success after 47 intubations existing Direct laryngoscope intubation training..is inadequate for non-anaesthesia healthcare workers Emphasis should be placed on effective ventilation and oxygenation using BVM

Small number of ER residents (3) 342 intubations over 2 years 74.7 intubations to achieve 90% successful intubation (95% CI 62.0-87.3)

Lesson RT intubation competency programs are probably not adequate.

33 airway cases identified Identified contributing issues Lack of airway assessment Failure to alter technique when difficult a/w Lack of airway strategy Failure to alter failing technique

Lessons Assess Plan and communicate an airway strategy If it looks tough, do something different If something isn t working, don t do it again

With anticipated DTI 70% anesthetists didn t change technique > 60% progressed to CICV SGA regularly rescued failed intubation Transtracheal jet high complications rate of death when used as rescue

Lesson Change technique for difficult A/W Don t use transtracheal jet SGAs are pretty cool

How many of you regularly see DL fail during intubation and the second attempt is DL again?

When first attempt DL unsuccessful, repeated DL 80% failure rate. Recommend identification and detailing difficult A/W details

Lesson If it isnt working, don t keep doing it no matter how tempting Clearly identify Difficult A/W

Previous difficult intubation (DTI) 6 times more likely to be DTI again Previous failed intubation 22 times more likely to fail again. As a result of findings Denmark created database

Lesson Clearly identify people with difficult A/W Listen if someone says it was difficult

But I Gotta Intubate! It s an Emerrrrrrgency!

They Can Usually Wait Less than 1/3 of our pts were Emergent Intubations of Critically ill are usually urgent, not emergent (Griesdale 2011)

N=649,359 Favourable Neurological outcome; Intubation SGA BVM

N=649,359 Favourable Neurological outcome; Intubation 1.0% (95% CI 0.9%-1.1%) SGA 1.1% (95% CI 1.1%-1.2%) BVM 2.9%(95% CI 2.9%-3.0%)

Lesson It may be better to use BVM than intubate (at least in cardiac arrest)

But what if I can t manually ventilate them?

4 year observational study N=53,041 77 cases of impossible mask ventilation Only 19 of these were difficult a/w

Lesson Impossible mask ventilation is extremely rare. Even if you do meet them, they will probably be easy to intubate

N=128 Apneic oxygenation Decreased desaturation during intubation absolute risk reduction 16.7% P=0.016

Lesson Apneic oxygenation may further decrease your risk of desaturation during intubation

What if you put it all together?

Two phase Multi-center Use of Intubation Bundle Preoxygenation, 2 operators, RSI, Cricoid, EtCO2, Protective ventilation, Fluid loading N=244 (123 before, 121 after) life threatening complications 34%-21% other complications 21%-9%

Griesdale et al 2011 (unpublished) Use of a checklist Serious Complication

Lesson Use a checklist, they work!

307 Hospitals 4 Countries 1 year Prospective ICU, ED, OR Airway Cases: Death Brain Damage Unexpected ICU

NAP 4 4 Common themes identified 1) Lack of airway assessment 2) Lack of airway strategy 3) Avoidance of awake techniques 4) The failure to plan for Failure: repeated attempts using the same people/equipment

NAP 4 98/133 no documented airway exam 66 may be difficult -1 change in airway strategy needle Cricothyrotomy: Rate 64% (16/25) Failure Failure to use capnography implicated in 82% of ICU airway deaths and brain damage

NAP4 Recommendations Develop a checklist for intubation Standardize Difficult A/W equipment Including SGA and Aintree catheters Do more awake FOB intubations Investigate A/W critical incidents Appoint an A/W lead anesthetist in all institutions. Capnography is mandatory

NAP4 Reccomendations Identify Difficult A/W patients Establish good communication between ICU, ER, and Anesthesia Establish clear lines of communication to escalate A/W events to individuals with appropriate skills.

What have we done so far Difficult Airway Recognition Blue wrist band Blue sign for HOB Airway Alert form

24 hour a day response from a rover Anesthesiologist for difficult airways Empowered any member of team to escalate airway emergencies

ETCO2 monitoring at every intubation Standardize difficult intubation equipment Standardize intubation procedure Preprinted orders

Pre-printed Orders: Intubation Royal Columbian Hospital (trial) DRAFT Form ID: Rev: April 10 th 2014 Page: 1 of 1 DRUG & FOOD ALLERGIES Mandatory o Optional: Prescriber check (P) to initiate, cross out and initial any orders not indicated. 1. PREPARATION- PRE-INTUBATION Airway Competent MD, RT and RN present Airway equipment present and consideration for adjuncts discussed Planned strategy for intubation verbally communicated to all team members (see back) Airway assessment and positioning completed: Assess for contraindications prior to positioning (e.g. any cervical spine instability?) Sniffing position required? (e.g. Troop pillow, flannels/pillows) Potential for difficult airway discussed with team Breathing and Pre-oxygenation Apneic oxygenation (15lpm nasal prongs) Assisted Bag Valve Mask Non-Invasive Ventilation (NIV) as ordered by MD Circulation: RN to ensure patent IV and all medications are prepared prior to start. IV 500 ml SODIUM CHLORIDE 0.9% bolus over 15 mins Monitor BP Q 3 min during and for 20 min post intubation medications and until stable o o NOREPINEPHRINE Infusion at 5 mcg/min if MAP less than 60 mmhg PHENYLEPHRINE 50 to 100 mcg IV PRN 2. INTUBATION (consider standardized medications): o Rapid Sequence Induction (RSI) Induction / Analgesia Agents: ETOMIDATE 0.3 mg/kg IV (Prepare 20mg in syringe) KETAMINE 1.5 to 2.0 mg/kg IV (Prepare 200 mg in syringe) Fentanyl 1 to 2 mcg/kg (Prepare 250mcg in syringe) Other: Neuromuscular Blockade: o SUCCINYLOCHOLINE 1.5 mg/kg IV Prepare: Patient weight: o ROCURONIUM 1 mg/kg IV Prepare: mg IV o Awake Intubation mg IV GLYCOPYRROLATE 0.4 mg IV Topicalization with Lidocaine 5ml/kg o KETAMINE 0.25 to 0.5 mg/kg IV PRN Prepare: mg IV PRN MIDAZOLAM 0.05 mg/kg IV PRN Prepare: mg IV PRN 3. POST- INTUBATION Confirm placement with waveform CO2 and auscultation CXR Was this a difficult Airway? If yes, RT to ensure Difficult Airway Bundle implemented Date (dd/mm/yyyy) Time Prescriber Signature Printed Name or College ID#

So. Should RTs be intubating? If our competency programs are inadequate We often don t do enough intubations to maintain competency Dealing with failed A/W is beyond our scope We are unable to do awake fiberoptic intubations Open cricothyrotomy is beyond our scope Greater than one attempt significantly increases severe complications

So..Should RTs intubate? A. Yes B. No

How have the initiatives worked so far?

Difficult airway identification system Has been huge success. Every difficult airway (?) is being labelled and documented FHA is adopting system

Extubation of Difficult A/W Empowered RTs to refuse orders to extubate difficult airways Identified difficult A/W require anesthetist to be present for extubation

So, how has the order set worked? In 11 months we have had 17 uses of the order set Approx 10% usage

What about babies? Maybe RTs should intubate babies?

Neonatal ETI Data collection cards now kept in NICU Overall complication rates 54% Complication rates with 1 st pass success 29% Complication rates increase to 83% thereafter

Complications with Intubation

Maybe we suck at intubating babies?

5 level 3 NICUs One year study 2011 455 ETI attempts 203 patients

Neonatal ETI Low frequency, High-stakes events Success rates poor (at best 72%) 60% decompensation+esophageal Providers with more experience more successful

Going to get worse No routine intubations for meconium No longer ethical to practice after death Working hours for DRs reduced Reduction in invasive ventilation

50 ETI assessed Residents (25), NICU Fellows (13), RTs (12)

Why difference Adult to Neo Difficult airway uncommon Limited techniques and adjuncts Uncommon procedure even for Attending Physicians

What do you do if you cant intubate a neonate???

Telephone survey of all 59 level 3 NICU in UK 7% had CICV algorithm

Cautious Maybe Smaller, dedicated staff Take on the dedicated role Reasonable competency program