May 2023 Critical Care Case of the Month: Not a Humerus Case

Carli S. Ogle¹ DO

Billie Bixby² MD

Janet Campion² MD

Departments of Family and Community Medicine¹ and Internal Medicine²

Banner University Medical Center-South Campus

Tucson, AZ USA

History of Present Illness:

A 57-year-old woman with history of bone disease presented with a 3-day history of cough with thick yellow phlegm and progressive shortness of breath. No fever, chest pain or abdominal pain was noted. In the emergency department, she had SpO2 of 55% on room air, and then 90% on 15L NRB.

Past Medical History/Social History/Family History

• Bone disease since birth
• Asthma
• Severe scoliosis
• Gastrointestinal reflux disease
• Cholecystectomy
• Spinal growth rods
• Lives in adult care home, supportive family
• No smoking or alcohol use
• No illicit drug use
• There is no family history of any bone disease

Home Medications:

• Albuterol MDI PRN
• Alendronate 10mg daily
• Budesonide nebulizer BID
• Calcium carbonate BID
• MVI daily
• Lisinopril 10mg daily
• Loratadine 10mg daily
• Metformin 500mg BID
• Metoprolol 12.5mg BID
• Montelukast 10mg daily
• Naprosyn PRN
• Omeprazole 20mg daily
• Simvastatin 10mg daily
• Tizanidine PRN
• Vitamin D 2000 IU daily

Allergies:

• Cefazolin, PCN, Sulfa - all cause anaphylaxis

Physical Examination :

• Vital signs: BP 135/95, HR 108, RR 36, Temp 37.0 C Noted to desaturate to SpO2 in 70-80s off of Bipap even when on Vapotherm HFNC
• General: Alert, slightly anxious woman, tachypneic, able to answer questions
• Skin: No rashes, warm and dry
• HEENT: No scleral icterus, dry oral mucosa, normal conjunctiva
• Neck: No elevated JVP or LAD, short length
• Pulmonary: Diminished breath sounds at bases, no wheezes or crackles
• Cardiovascular: Tachycardic, regular rhythm without murmur
• Abdomen: Soft nontender, nondistended, active bowel sounds
• Extremities: Congenital short upper and lower limb deformities
• Neurologic: Oriented, fully able to make health care decisions with family at bedside

Laboratory Evaluation:

• Na 142, K 4.3, CL 100, CO2 29, BUN 15, Cr 0.38, Glu 222
• WBC 21.9, Hgb 13.6, Hct 42.9, Plt 313 with 83% N, 8% L, 1% E
• Normal LFTs
• Lactic acid 2.2
• Venous Blood Gases (peripheral) on Bipap 10/5, FiO2 90%: pH 7.36, pCO2 58, pO2 55
• COVID-19 positive

Radiologic Evaluation:

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative images from thoracic CT scan in lung windows (A,C) and soft tissue windows (B,D).

The CT images show all the following except: (Click on the correct answer to be directed to the second of seven pages)

1. Severe scoliosis
2. Diffuse ground glass opacities
3. Right lower lobe consolidation
4. Pneumothorax
5. Atelectasis in bilateral lower lobes

Cite as: Ogle CS, Bixby B, Campion J. May 2023 Critical Care Case of the Month: Not a Humerus Case. Southwest J Pulm Crit Care Sleep. 2023;26(5):76-79. doi: https://doi.org/10.13175/swjpccs018-23 PDF

Essentials of Airway Management: The Best Tools and Positioning for First-Attempt Intubation Success

Evan D. Schmitz MD

Pulmonary and Critical Care Medicine

Abstract

Head position during endotracheal intubation affects first-attempt success, as does the different tools available and the location. It is important to be skilled in the operation of a variety of laryngoscopes (video or direct) as well as introducers (plastic/steel stylets and bougies). Difficult airways should always be anticipated and proper preparation such as upper airway assessment performed. The following is a review of endotracheal intubations performed outside of the operating room.

Objectives

• Discuss how different locations in the hospital can affect endotracheal intubation success.
• Learn the difference between simple head positioning and the sniffing position and why one should be chosen over the other. MRI images of the head and neck in each position will be reviewed.
• Learn about different types of laryngoscope blades.
• Understand the dangers of video laryngoscopy as well as the benefits and when to choose direct laryngoscopy.
• Define endotracheal intubation first-attempt success.
• The benefits of using a bougie as opposed to a stylet to increase first-attempt success rate with a review of the supportive literature.
• Case presentations.

Abbreviations

• AF – atrial fibrillation
• ARDS – acute respiratory distress syndrome
• BiPAP – bilevel positive airway pressure
• CAD – coronary artery disease
• COPD – chronic obstructive pulmonary disease
• Ó – delta
• DM – diabetes mellitus
• DVT – deep vein thrombosis
• ED – emergency department
• ETT – endotracheal tube
• FiO2 – fraction of inspired oxygen
• HFNC – high flow nasal canula
• HTN – hypertension
• ICU – intensive care unit
• LA – laryngeal axis
• LV – line of vision
• MRI – magnetic resonance imaging
• NIDDM – non-insulin dependent diabetes mellitus
• NRB – non-rebreather mask
• OA – oral axis
• OR – operating room
• OSA – obstructive sleep apnea
• PA – pharyngeal axis
• PCO2 – partial pressure of carbon dioxide
• PE – pulmonary embolism
• RCA – right coronary artery
• SpO2 – pulse oximeter oxygen saturation
• Sz – seizure

Introduction

Ideal positioning can make the difference between a successful endotracheal intubation or death. Many times, intubations are performed in emergency situations, and positioning is not always ideal depending on the type of surface. In the OR, ideal conditions exist regarding adequate supplies and time (1). Conditions can be very different outside of the operating room (OR) especially during a code blue. The average time of intubation is 37 seconds in the emergency department (ED) (2). During the COVID-19 pandemic, intubations were being performed as quickly as 15 seconds in the intensive care unit (ICU) to prevent cardiac arrest in patients with severe adult respiratory distress syndrome (ARDS) (3).

Hospital beds are cumbersome and can cause poor positioning making intubation difficult. If possible, it is always a good idea to have a few towels available to help with head positioning. Towels can be rolled up and placed between the shoulder blades to aid in simple head extension. Towels can also be used to flex the neck on the chest and extend the head on the neck into the sniffing position. Pillows can be added if needed in morbidly obese patients.

Previous studies published in the Journal of Anesthesia comparing head positioning with regards to line of vision (LV), oral axis (OA), pharyngeal axis (PA), and laryngeal axis (LA) proved that all axes can never be perfectly aligned (Figure 1) (4). The same authors concluded that routine use of the sniffing position appears to provide no significant advantage over simple head extension for tracheal intubation (5).

The sniffing position improved glottic exposure in 18% of patients and worsened it in 11% in comparison with simple head extension in patients intubated in the operating room. Multivariant analysis showed that patients with reduced neck mobility and obesity did better in the sniffing position.

The angle between the LV to the LA, ó, decreases significantly when placed in simple head extension (B) and the sniffing position (C) compared with neutral positioning (A) (Figure 1). In simple head extension ó is the smallest approximating 20^o. The smaller the ó, the easier it is to access the glottis. Bougie introducers like the AIROD® telescopic steel bougie with a 20^o bend at the proximal end as well as elastic bougies with a coude (bent) tip allow easy transition from the LV to the laryngeal axis LA in simple head extension Figure 2 (6-10).

Figure 1.  Evaluation of the four axes (mouth axis [MA], pharyngeal axis [PA], laryngeal axis [LA], line of vision [LV] and the α, β, and ό angles in the three positions (4).

Figure 2. AIROD® aligned perfectly with the laryngeal view (LV) with the head in simple extension. Transition to the laryngeal axis (LA) is easy due to the specialized 20^o tip.

The different video laryngoscopes all offer indirect views of the glottis (Figure 3).

 

Figure 3. Different types of video and direct laryngoscopes.

For those on C-spine precautions, a hyperangulated Glidescope® or C-MAC® can help with the acute angles involved without the need for significant neck movement. Although video laryngoscopes may improve the view of the glottis because they do not guarantee a direct pathway to the vocal cords, disaster may occur during intubation. Additional tools and expertise should be available immediately because once sedatives and paralytics are given you may no longer be able to ventilate the patient.

In 2017 Baptiste et al. (11) published a study showing that severe life-threatening complications were higher in those ICU patients who were intubated using video laryngoscopy 9.5% vs 2.8% in those who were intubated with direct laryngoscopy with the numbers needed to harm of 14.6. Blood, emesis, secretions, damaged screen, and sudden battery failure can all obscure the video images, complicating intubation with video devices. It is therefore recommended that operators be comfortable using direct laryngoscopes as well as bougies in case of video device failures.

Prior to intubation, airway assessment should be performed to determine whether a difficult airway may be present. If any of the following characteristics are present, then a difficult airway should be expected and precautions taken:

• Mouth opening < 3.5 cm
• Thyromental distance < 6.5 cm
• BMI > 30 kg/m²
• Amplitude of head and neck movement < 80^o
• Mallampati score > 3
• Cormack and Lehane classification > 2

Figure 4. Mallampati scores classes 1-4 and Cormack and Lehane classification grades 1-4.

In addition to these measurements, a difficult airway is present if the airway is obstructed by emesis, blood, foreign object or swelling; if the patient has a short neck, large tongue, facial trauma; or if cervical spine immobilization is needed.

Increased complications arise during intubation when a difficult airway is present, especially in an unstable patient. Adverse events related to endotracheal intubation in the ED have been reported at 12% (11). Only 70% of patients intubated in the ICU are successfully intubated upon first-attempt (12). A successful first-attempt intubation is defined as the placement of an endotracheal tube into the trachea upon the initial insertion of the laryngoscope into the oropharynx. If the laryngoscope must be removed and a second-attempt performed, it is considered a failure. Failure to intubate with the first-attempt contributes considerably to morbidity and mortality (13).

The choice of the correct endotracheal introducer can make the difference between first-pass success and failure (Figure 5).

Figure 5. Types of airway introducers.

The standard endotracheal tube stylet is used most often during direct laryngoscopy. This stylet may be bent when used with a curved Macintosh blade or without a bend when used with a straight Miller blade. The former is the most common method. An elastic bougie has an advantage over the standard stylet as it can be placed through the vocal cords and into the trachea, allowing better access especially with anterior airways during direct laryngoscopy with a Macintosh or Miller blade.

The BEAM (Bougie Use in Emergency Airway Management) trial is attracting renewed interest in intubation with a bougie rather than a stylet (2). In the BEAM trial, first-attempt success using an elastic bougie was compared to a stylet during laryngoscopy in an emergency department.

First-attempt success was achieved in 98% of patients compared to 87% in all patients. In patients with at least one difficult airway characteristic, first-attempt success using an elastic bougie was 96% compared to 82% using a stylet.

In the First-Attempt Endotracheal Intubation Success Rate Using a Telescoping Steel Bougie (3), intubation first-attempt success rate was 97% in the ICU. Subgroup analysis of first-attempt intubation success using the AIROD® to intubate in patients with a difficult airway was 96%.

The average time to intubate was 15 seconds. During multiple intubations, the AIROD® was used to lift the epiglottis and move excess oropharyngeal tissue, improving the view of the glottis without causing any trauma to the airway (Figure 6).

Figure 6. Video of AIROD® lifting the epiglottis.

The hyperangulated Glidescope® stylet can be used with the Glidescope®, curved Macintosh blade, and C-MAC® blade. The AIROD® can be used with any direct or video laryngoscopy in any configuration: curved, hyperangulated, or straight.

The elastic bougie cannot make the acute turn required with hyperangluated laryngoscopes and should be avoided with this device unless the hyperangulated Glidescope® stylet is placed first and becomes caught up on the superior angle of the vocal cords. If this occurs, leave the Glidescope® in position and gently remove the hyperangulated Glidescope® stylet. While maintaining the acute angle, introduce an elastic bougie into the ETT and advance the tip into the trachea. Then slide the ETT down the bougie and into the trachea. 

An alternative is to use the AIROD® steel bougie from the beginning, along with the Glidescope®. Load an ETT from the bulbous tip of the AIROD®, then shape to accommodate airway anatomy (Figures 7 and 8).

Figure 7. AIROD® shaped to accommodate airway anatomy.

Figure 8. ETT advancing down the AIROD®.

Use the proximal tip to lift the epiglottis and expose the vocal cords. Then advance the AIROD® two cm into the trachea followed by the ETT.

Case Presentations

Case 1

54-year-old man with severe coronary artery disease on aspirin and Plavix® with a history of a seizures associated with alcohol withdrawal became unresponsive and a code blue was called. He was found to be apneic with oxygen saturation in the 50s. He was stimulated by the hospitalist and became responsive. He was transferred to the ICU, where he became completely unresponsive again and stopped breathing. He was immediately ventilated with a bag-valve mask, and oxygenation improved to 100%. He then bolted up out of bed and became very combative. Propofol was given and he was laid supine and ventilated with a bag-valve mask. Inspection of his oropharynx revealed a very large tongue, and some missing and multiple sharp teeth with mouth opening of only 2 fingerbreadths. There was blood and emesis in his oropharynx that was suctioned. A Miller 4 blade was inserted into the oropharynx but only a grade 4 view could be obtained. The AIROD® was inserted into the oropharynx in the fully extended and locked position and the proximal tip was used to gently lift the epiglottis, exposing the vocal cords, and improving the view to a grade 2. The AIROD® was advanced 2 cm past the vocal cords and an assistant advanced an 8.0 endotracheal tube down the AIROD® until it was grasped, and the endotracheal tube was advanced successfully past the vocal cords while the assistant held the distal end of the AIROD®. The AIROD® was removed intact without any oropharyngeal or vocal cord trauma.

Case 2

A 63-year-old  5’5 110 kg woman with COPD, morbid obesity, obstructive sleep apnea, atrial fibrillation, diabetes mellitus, and anxiety suffered a cardiac arrest and was successfully resuscitated with placement of a drug eluting stent into the right coronary artery. One week later she required intubation for acute respiratory failure. She was extubated the following day and developed stridor, which resolved with pain medication and racemic epinephrine. Two days later, she developed acute respiratory failure again, with stridor that resolved after receiving 4 mg IV Versed. A diagnosis of paroxysmal vocal cord dysfunction was made. The next day she developed similar symptoms that responded to additional Versed® and Precedex®. The next morning, she became anxious after the Precedex® was stopped and once again developed acute stridor with respiratory failure, responding to Zyprexa® and Versed® momentarily. She was comfortable throughout the day until her stridor resumed, and despite BiPAP she was unable to adequately ventilate. She became obtunded, prompting intubation.

In addition to stridor, her Mallampati was 4, she had a sharp, prominent full set of teeth, an airway opening 1.5 cm, a large tongue with excessive oropharyngeal tissue, false cords, and vocal cord swelling. The AIROD® was preloaded with a 7.0 ETT that had attached to it a 10 mL syringe onto the distal end and tucked it under the patient’s right shoulder with the tip lying flat and pointing laterally, protected with a sterile OR towel. The AIROD® lay at a 45^o to the neck. She was given 20 mg of etomidate and immediately ventilated with a bag-valve mask. A Miller 4 blade was gently inserted into the mouth, revealing a grade 4 view with purulent mucus in her oropharynx. The AIROD® was grasped and used to manipulate the false cords, revealing the true vocal cords while cricoid pressure was applied. A grade 2 view was obtained. The cords were adducted with a posterior glottal chink. The AIROD® was gently passed 2 cm through the tiny opening at the bottom of the vocal cords and used to dilate the area with the smooth bulbous tip. The ETT was then advanced into the trachea while the respiratory therapist held the distal end of the AIROD®. The AIROD® was removed intact without any evidence of oropharyngeal trauma. Successful first-attempt intubation occurred without complications. Bronchoscopy confirmed no tracheobronchial tree trauma.

Case 3

A 71-year-old  5’10’’ tall 101 kg man with non-insulin dependent diabetes mellitus, hypertension, and obesity was intubated 18 days prior for severe ARDS secondary to SARS-CoV-2. He subsequently lost his airway, and the attending physician was unable to intubate using the Glidescope®; so an emergency tracheostomy was performed with placement of a 5.0 Shiley. The evening of the 24^th day of ventilation, he was unable to be ventilated effectively with his PCO2 rising to 73 mmHg with a pH of 7.13. He was on a propofol drip and 10 mg vecuronium was given while he was being ventilated through the 5.0 tracheostomy. He was actively bleeding from his nasopharynx. A Miller 4 blade was gently inserted into his mouth revealing a bloody and swollen oropharynx. A pre-loaded AIROD® was used to gently displace tissue, revealing a grade 1 view. The AIROD® was inserted 1 cm past the vocal cords and the ETT was then advanced slowly into the trachea with no assistant holding the AIROD®. The AIROD® was pulled back as the endotracheal tube was advanced down the trachea, abutting the tracheostomy tube. The ETT balloon was inflated and the AIROD® was removed intact without any evidence of acute oropharyngeal trauma. The single-handed first-attempt intubation was performed in 19 seconds. This was followed by the exchange of the 5.0 tracheostomy for an 8.0 tracheostomy. Bronchoscopy confirmed no acute oropharyngeal or tracheal trauma with the tracheostomy in the correct position in the trachea.

Case 4

A 68-year-old 5’10 126 kg smoker with a past medical history significant for COPD, on home oxygen with multiple intubations in the past was admitted. He had a past medical history of  pulmonary embolism on Eliquis®, deep venous thrombosis with an inferior vena cava filter, obstructive sleep apnea, and obesity. He was diagnosed with COVID-19 pneumonia and treated with BiPAP at 100% FiO₂ for six days in the ICU. He developed ARDS and altered mental status, prompting intubation. Obese, large neck with limited neck mobility, micrognathia, large very dry tongue, sharp teeth with some missing, and a mouth opening 2 cm. He received propofol 200 mg IV and succinylcholine 200 mg IV. A Miller 4 blade gently inserted into oropharynx revealed an anterior glottis with false cords. The AIROD® was used to probe the false cords and advanced gently 5 cm, feeling the tracheal rings to ensure placement in the trachea. An 8.0 ETT was slowly advanced into the trachea using the single-handed first-attempt technique. An endotracheal balloon was inflated and the AIROD® removed intact without any evidence of acute oropharyngeal or tracheal trauma.

Case 5

28-year-old 5’9 man 97 kg with a past medical history significant for alcoholism was admitted. He was currently drinking two liters of vodka daily, had a history of  alcoholic cardiomyopathy and esophageal varices, drank hand sanitizer “to remain drunk”, and developed acute shortness of breath, and felt that his “throat was closing”. He developed very severe stridor with respiratory distress and was transferred to the ICU. Audible stridor could be heard as he arrived. He was in severe respiratory failure, sitting up, and very anxious. He was drooling bloody secretions. He was placed on a 15 L/min 100% FiO₂ non-rebreathing mask. He was obese, had a large large neck with limited mobility, mouth opening 2 cm, protruding large tongue, full set of teeth, micrognathia with severe stridor, and was barely moving any air. He was given 4 mg IV Versed®. A tracheostomy kit was at bedside with a surgeon present. He was given 100 mg IV propofol, then laid flat and quickly placed in the SNIFF position. Bag-valve-mask was performed. SpO2 100%. An additional 100 mg IV propofol was given. A Miller 4 blade barely lifted the tongue when fresh blood was encountered. The blade was advanced gently, and bloody secretions suctioned. A crowded anterior hamburger oropharynx, bleeding with mucosal sloughing and false cords was encountered. The AIROD® pre-loaded with a 6.5 ETT was gently advanced underneath the epiglottis and advanced 3 cm, followed by advancement of the 6.5 ETT. Bag-valve ventilation occurred with poor CO2 detector color change. The ETT was left in place while bag-valve-mask ventilation was performed. SpO2 100%. The AIROD® was pre-loaded with a 7.0 ETT. A second-attempt revealed an air bubble anterior to the ETT. The 6.5 ETT was removed as the AIROD® was advanced towards the air bubble. The AIROD® was used to probe the hamburger glottis and to peel back the false cords revealing a small view of the right vocal cords, followed by advancement of the AIROD® 3 cm. A 7.0 ETT was slowly advanced into the trachea and balloon inflated with no assistant holding the AIROD®. No evidence of acute oropharyngeal trauma. Bronchoscopy revealed no tracheobronchial trauma and confirmed acute adenoviral necrotizing pharyngitis.

Conclusion

Anticipation of a difficult airway should always be considered, and having the necessary tools available can improve first-attempt endotracheal intubation success. Optimizing head positioning can be performed quickly and will help with glottic exposure. Knowing how to use multiple laryngoscopes as well as introducers can make the difference between life and death.

Conflicts of Interest

Evan D. Schmitz, MD is the inventor of the AIROD® and CEO of AIROD Medical, LLC.

Acknowledgments

The author thanks H. Carole Schmitz and Bille J. Maciunas for their editorial comments.

References

1. Sasano N, Morita M, Sugiura T, Sasano H, Tsuda T, Katsuya H. Time progression from the patient's operating room entrance to incision: factors affecting anesthetic setup and surgical preparation times. J Anesth. 2009;23(2):230-4. [CrossRef] [PubMed]
2. Driver B, Prekkar M, Klein L, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation a randomized clinical trial. JAMA. 2018;319(21):2179-2189. [CrossRef] [PubMed]
3. Schmitz ED. Decreasing COVID-19 patient risk and improving operator safety with the AIROD during endotracheal intubation. J of Emergency Services. EMSAirway. 11/2020.
4. Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C. Study of the "sniffing position" by magnetic resonance imaging. Anesthesiology. 2001 Jan;94(1):83-6.[CrossRef] [PubMed]
5. Adnet F, Baillard C, Borron SW, et al. Randomized study comparing the "sniffing position" with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology. 2001 Oct;95(4):836-41. [CrossRef] [PubMed]
6. Schmitz ED, Park K. First-Attempt Endotracheal Intubation Success Rate Using A Telescoping Steel Bougie. Southwest J Pulm Crit Care. 2021;22(1):36-40. doi: [CrossRef]
7. Schmitz ED, Park K. Emergency intubation of a critically ill patient with a difficult airway and avoidance of cricothyrotomy using the AIROD®. J of Emergency Medical Services. 2021;22(1):36-40. 
8. Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-8. [CrossRef]
9. Schmitz ED. AIROD® Case Series: A New Bougie for Endotracheal Intubation. J of Emergency and Trauma Care. 2020;5(2):22.
10. Schmitz ED. The Importance of Head Positioning During Endotracheal Intubation. EMSAirway. Jul 27, 2021. Available at: https://emsairway.com/2021/07/27/the-importance-of-head-positioning-during-endotracheal-intubation/#gref (accessed 4/18/23).
11. Lascarrou JB, Boisrame-Helms J, et al. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial. JAMA. 2017;317(5):483-493. [CrossRef] [PubMed]
12. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. [CrossRef] [PubMed]
13. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015 Apr;65(4):363-370.e1. [CrossRef] [PubMed]

Cite as: Schmitz ED. Essentials of Airway Management: The Best Tools and Positioning for First-Attempt Intubation Success. Southwest J Pulm Crit Care Sleep. 2023;26(4):61-69. doi: https://doi.org/10.13175/swjpccs015-23 PDF

Single-Use Telescopic Bougie: Case Series

Evan Denis Schmitz MD

La Jolla, CA USA

Abstract

AIROD^TM is a single-use telescopic bougie that is small enough to fit into a pocket. AIROD^TM is sterile and can be expanded in hast when needed, saving precious seconds, while attempting to intubate a patient. The non-malleable bougie is able to overcome the compressive force of the oropharyngeal tissue improving the view of the vocal cords and facilitating advancement of an endotracheal tube into the trachea along with a laryngoscope. This series reports four cases of successful first pass intubation with the AIROD^TM.

Introduction

There are approximately 50 million intubations performed a year with 1/3 of those occurring in the USA. A multicenter registry of ED intubations, reporting data from 2002-2012, found that approximately 12% of intubations resulted in adverse intubation-related events such as death (1). In order to reduce the likelihood of adverse events it is imperative that the first attempt at endotracheal intubation is successful (2). Despite increasing adoption of expensive video laryngoscopy first-attempt intubation success rates are only 85% (1). The BEAM trial reported a 96% success rate in first-attempt intubation of a difficult airway with a bougie vs only 82% with endotracheal tube + stylet (3).

AIROD^TM was designed to aid in the advancement of an endotracheal tube past the vocal cords with the use of a laryngoscope (Figure 1).

Figure 1. Single-Use Telescopic Bougie in the closed (A) and extended (B) position with an endotracheal tube loaded at the distal end.

AIROD^TM can also improve the view of the vocal cords during intubation by displacing oropharyngeal tissue. The following case series demonstrates the usefulness of the AIROD^TM: each of the 4 intubations were successful on the first attempt and facilitated by the single-use telescopic bougie without causing any trauma. All intubations were performed by the author.

Case 1

A 70-year-old woman with severe COPD not on home oxygen presented with an oxygen saturation of 70%. She was found to have multi-lobar pneumonia predominately in the right upper and middle lobes. Despite bilevel positive airway pressure (BiPAP) therapy her hypoxia worsened, and she required intubation. Inspection of her oropharynx prior to intubation revealed very prominent 1^st incisors as well as canines that were eroded at the roots left worse than right. Multiple black, necrotic molars were noted, right worse than left, with a putrid odor. Her oxygen saturation, despite being on 15L nasal cannula, hovered in the low 90s. In anticipation of a difficult airway the AIROD^TM was prepared by extended the rods and ensuring the rods were in the locked position. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 2 view (larynx plus the posterior surface of epiglottis) was obtained. This was immediately followed by gentle insertion of the AIROD^TM which was advanced just distal to the vocal cords. An 8.0 endotracheal tube was advanced down the AIROD^TM by the respiratory therapist while the AIROD^TM was held in position. As the endotracheal tube was advanced into the oropharynx, hand position was changed from holding the AIROD^TM to holding the tip of the endotracheal tube while the respiratory therapist held the distal end of the AIROD^TM. The endotracheal tube was then advanced past the vocal cords and into the trachea while the respiratory therapist removed the AIROD^TM with ease. No complications occurred. No trauma occurred to the oropharynx, vocal cords or trachea. The patient was successful ventilated and oxygen saturations improved to high 90s.

Case 2

A61-year-old man with severe schizophrenia and acute delirium had a PaO2 of 61 mmHg despite BiPAP 14/6 on 90% fio2 with a minute ventilation of 18 L/min from multi-lobar pneumonia. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 1 view (whole vocal cords seen; the epiglottis is not seen at all) was obtained. The AIROD^TM was gently advanced 2 cm past the vocal cords followed by an assistant advancing a 7.5 endotracheal tube down the AIROD^TM until grasped, then the endotracheal tube was slid into the trachea while the assistant held the distal end of the AIROD^TM. The AIROD^TM was then removed intact with no evidence of airway trauma.

Case 3

A 54-year-old man with severe coronary artery disease on aspirin and Plavix with a history of a seizure disorder associated with alcohol withdrawal became unresponsive and a code blue was called. He was found to be apneic with oxygen saturation in the 50s. He was stimulated by the hospitalist and woke up. He was transferred to the ICU where he became completely unresponsive again and became apneic. He was immediately ventilated with a bag-valve mask and oxygenation improved to 100%. He then bolted up out of bed and became very combative. Propofol was given and he was laid supine and ventilated with a bag-valve mask. Inspection of his oropharynx revealed a very large tongue, some missing and multiple sharp teeth with mouth opening of only 2 fingerbreadths. There was blood and emesis in his oropharynx that was suctioned. A Miller 4 blade was inserted into the oropharynx but only a grade 4 view (the anterior tip of the epiglottis is seen and encroaching on the view of vocal cords obstructing <50% of view) could be obtained. The AIROD^TM was inserted into the oropharynx in the fully extended and locked position and the proximal tip was used to gently lift the epiglottis exposing the vocal cords and improving the view to a grade 2. AIROD^TM was advanced 2 cm past the vocal cords and an assistant advanced an 8.0 endotracheal tube down the AIROD^TM until it was grasped, and the endotracheal tube was advanced successfully past the vocal cords while the assistant held the distal end of the AIROD^TM. The AIROD^TM was removed intact without any oropharyngeal or vocal cord trauma.

Case 4

A 48-year-old obese who was an alcoholic and a smoker was critically ill with an admission albumin of 0.9 and lactic acid of 9 with multiorgan system failure from an intra-abdominal abscess with septic shock on 15 mcg/min of epinephrine and 25 mcg/min of Levophed. He was obtunded and in acute respiratory failure. The AIROD^TM was pre-loaded with an 8.0 endotracheal tube onto the distal end of the AIROD^TM prior to providing sedation with Etomidate and bag-valve mask ventilation in anticipation of a difficult airway: full beard, mouth opening 2 cm, large tongue, collapse of the walls of the oropharynx as well as false cords. Using a Miller 4 blade a grade 2 view was obtained and the AIROD^TM was advanced 1 cm past the vocal cords followed by the endotracheal tube while an assistant held the distal end. There was no significant desaturation or trauma to the vocal cords or oropharynx. Pre-loading the AIROD^TM with the endotracheal tube improved the speed and autonomy of the intubation.

Discussion

AIROD^TM is a single-use telescopic endotracheal intubation bougie. It is rigid, made of stainless steel and sterilized. It telescopes to two feet and has a specialized 20-degree angled tip. Once expanded it locks so it cannot be retracted. An endotracheal tube 7.0 or greater can be advanced over the telescoping bougie for smooth placement in the adult trachea.

AIROD^TM is non-malleable and can gently displace oropharyngeal tissue, it does not sag and pull like plastic bougies, the unique locking mechanism prevents collapse and the square handle improves dexterity as well as spatial awareness of the proximal tip.

AIROD^TM telescopes open allowing for storage in small spaces such as a pocket or a crash cart without damaging its integrity like so many bougies that are ruined when bent for storage. Because of its small size, it can be stored in a myriad of places and easily accessed by emergency personnel in the field, emergency department, intensive care unit and operating room.

AIROD^TM can be used with multiple different varieties of laryngoscopes. My preference is a Miller 4 laryngoscope because of the ability to lift the epiglottis and visualize the vocal cords especially in patients with a large tongue, limited mouth opening and decreased neck mobility. The AIROD^TM can be slid along the length of the laryngoscope blade if needed to overcome the force of oropharyngeal tissue. Once the AIROD^TM is advanced a few centimeters past the vocal cords the rigidity of the AIROD^TM allows advancement of the endotracheal tube with ease because it can withstand the forces applied by the oropharyngeal tissue without significant bending. I have also used a Macintosh laryngoscope with the AIROD^TM which allows for displacement of the tongue and oropharyngeal tissue but placement into the vallecula above the epiglottis can limit exposure to the vocal cords. The AIROD^TM can overcome the limitation of the Macintosh laryngoscope by directly lifting the epiglottis, exposing the vocal cords then the AIROD^TM can be gently slid along the posterior surface of the epiglottis past the vocal cords followed by advancement of an endotracheal tube for successful intubation. Because the AIROD^TM is made of steel, similar to the Gliderite stylet used with the Glidescope as well as laryngoscopes and rigid bronchoscopes, it is possible that if used incorrectly trauma to the oropharynx as well as the trachea may occur, and caution is advised.

The cost of the AIRODTM is similar to the Glidescope’s disposable covers that are used with each intubation. Because of the loss of direct sight and acute angles involved in the process of advancing an introducer during intubation with the Glidescope I do not recommend using the AIRODTM with the Glidescope. The AIRODTM was designed only to be used with adults.

Conclusion

AIROD^TM is a sterile single-use telescopic bougie that is used along with a laryngoscope when performing endotracheal intubation. Because of its small size it is easily stored in a pocket, helicopter, ambulance, crash cart, operating room, emergency department, intubation box and in the intensive care unit. Its rigidity helps displace oropharyngeal tissue improving the view of the vocal cords and it facilitates advancement of an endotracheal tube. It can also be used in the closed position as a stylet making it an ideal instrument for first-attempt intubation along with a laryngoscope.

Conflict of Interest Disclosures

The author Evan Denis Schmitz, MD is the inventor of the AIROD^TM.

References

1. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015 Apr;65(4):363-70. [CrossRef] [PubMed]
2. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013 Jan;20(1):71-8. [CrossRef] [PubMed]
3. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA. 2018 Jun 5;319(21):2179-89. [CrossRef] [PubMed]

Cite as: Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-8. doi: https://doi.org/10.13175/swjpcc005-20 PDF 

Editor's Note: On April 19, 2020 Dr. Schmitz has submitted a video showing a 6 second intubation using the AIROD and a mannequin which is below.

Airway Registry and Training Curriculum Improve Intubation Outcomes in the Intensive Care Unit

Joshua Malo MD¹

Cameron Hypes MD²

Bhupinder Natt MBBS¹

Elaine Cristan MD¹

Jeremy Greenberg MD¹

Katelin Morrissette MD¹

Linda Snyder MD¹

James Knepler MD¹

John Sakles MD²

Kenneth Knox MD¹

Jarrod Mosier MD²

¹ Department of Medicine, University of Arizona College of Medicine, Tucson, AZ

² Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ

Abstract

Background: Intubation in critically ill patients remains a highly morbid procedure, and the optimal approach is unclear. We sought to improve the safety of intubation by implementing a simulation curriculum and monitoring performance with an airway registry. 

Methods and Methods: This is a prospective, single-center observational study of all intubations performed by the medical intensive care unit (ICU) team over a five-year period. All fellows take part in a simulation curriculum to improve airway management performance and minimize complications. An airway registry form is completed immediately after each intubation to capture relevant patient, operator, and procedural data.  

Results: Over a five-year period, the medical ICU team performed 1411 intubations. From Year 1 to Year 5, there were significant increases in first-attempt success (72.6 vs. 88.0%, p<0.001), use of video laryngoscopy (72.3 vs. 93.5%, p<0.001), and use of neuromuscular blocking agents (73.5 vs. 88.4%, p<0.001). There were concurrent decreases in rates of desaturation (25.6 vs. 17.1%, p=0.01) and esophageal intubations (5 vs. 1%, p=0.009). Low rates of hypotension (8.3%) and cardiac arrest (0.6%) were also observed.

Conclusions: The safety of intubation in critically ill patients can be markedly improved through joint implementation of an airway registry and simulation curriculum.

Introduction

Airway management is one of the highest risk procedures that can be performed in the intensive care unit (ICU). Despite technologic advances in methods for performing intubation, recent studies continue to report frequent adverse events associated with tracheal intubation, and complications occur in up to 40% of procedures (1-3). Even in the absence of anatomic predictors of a difficult airway, critically ill patients are particularly vulnerable to desaturation, hemodynamic instability, and cardiac arrest due to poor physiologic reserve (4, 5). Repeated or prolonged intubation attempts exhaust any physiologic reserve these patients may have, leading to more frequent adverse outcomes (6). Thus, maximizing first attempt success without an adverse event is the goal for airway management in this high-risk population (7, 8).

Much of the clinical practice regarding airway management in the ICU has been extrapolated from studies performed during elective intubations in the operating room (4). In recent years, there has been a greater focus on management strategies and outcomes in critically ill patients in the emergency department (ED) and ICU (3, 9, 10). In 2012, we initiated a comprehensive airway management quality improvement program to measure variables related to airway management in the ICU and identify targeted opportunities for intervention to improve outcomes (11). We first established a prospectively collected registry of all intubations performed in the medical ICU. After evaluation of the first year of data, a simulation-based curriculum for the pulmonary and critical care fellows was developed with a focus on identifying high-risk features, minimizing adverse events, and maximizing first-attempt success. Lastly, research questions were evaluated periodically to identify targeted opportunities for improvement. This paper will describe the outcomes after the first 5 years of our program.

Materials and Methods

This is a prospective single-center observational study of all intubations performed in the medical ICU from January 1, 2012 to December 31, 2016. The study has been granted an exemption from full review and is approved by the University of Arizona Institutional Review Board. The primary outcome of interest was first attempt success, while secondary outcomes included adverse events, drug and device selection, and method of preoxygenation.

This study took place at a large academic medical center with 20+ bed medical ICU. A medical ICU team consisting of an attending intensivist, a pulmonary/critical care or emergency medicine/critical care fellow, and internal medicine, emergency medicine, and occasionally family medicine residents assumes primary management of all patients admitted to the medical ICU service. All patients admitted to the ICU undergoing airway management by the medical ICU team were included in the study.

We have maintained a continuous quality improvement (CQI) database for all episodes of airway management performed by our medical intensive care teams since January 1, 2012. After each intubation, the operators record data pertinent to the procedure, including difficult airway characteristics, drug and device selection, and number of attempts, using a standardized form. The study primary investigator crosschecked a report generated by the electronic health record against the database to ensure forms were completed for all intubations. Forms were reviewed for completeness and internal consistency. Inconsistent or absent data were resolved by interview of the operator. The variables captured in the form have been previously described (11) and are adjusted occasionally to evaluate new variables of interest.

Our Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) fellowship programs implemented an 11-month, simulation-based airway management curriculum beginning on July 1, 2013. The curriculum is designed to improve situational awareness in the peri-intubation period as well as to emphasize techniques that will optimize chances of first-attempt success while minimizing complications. The general outline for the simulations has been previously described in detail (11). Briefly, the curriculum involves clinical scenarios of varying and generally progressive complexity, each of which is meant to emphasize certain aspects of airway management. As trainees progress, the curriculum emphasizes the identification and mitigation of factors that may decrease the likelihood of first-attempt success and increase the likelihood of complications. The annual fellowship complement includes 14 Pulmonary and Critical Care Medicine fellows and 2 Critical Care Medicine fellows. All fellows participate in the curriculum, which is updated to include recent advances in airway management from the literature and analysis of our own airway registry. A debriefing session following each simulation is used to emphasize specific learning points for the approach to airway management.

Statistical Analysis

Descriptive statistics were calculated for measured variables as means and standard deviations, medians and interquartile ranges (IQR), or proportions as appropriate. Categorical variables were compared using Fisher’s exact test. Comparisons between Year 1 and Year 5 were performed using the Two-Sample Test of Proportions. Categorical variables with multiple groups, such as preoxygenation, Operator PGY, and Device were evaluated with the test for trend using the likelihood ratio test. All statistical analyses were performed with Stata Version 14 (StataCorp, College Station, TX).

Results

During the 60-month study period, there were 1411 intubations performed. The patient and operator characteristics are shown in Table 1 and Table 2, respectively.

Table 1. Patient characteristics.

^aSome DACs added over time. Limited mouth opening and secretions added after the first 8 months of data collection.

Table 2. First Operator Characteristics.

During the course of the study, there was no significant change in patient age or gender, the presence of difficult airway characteristics, starting saturation, or percentage of patients intubated after failing noninvasive positive pressure ventilation (NIPPV). There was a trend for decreased intubations resulting from failed extubation. The overall characteristics of intubation attempts are described in Table 3.

Table 3. Intubation characteristics.

There was a significant increase in the number of intubations performed by PCCM operators after the first year of the study (Year 1-5 difference +19%, p<0.001) accompanied by a decrease in intubations performed by internal medicine (Year 1-5 difference -9%, p=0.006) and emergency medicine residents (Year 1-5 difference -10%, p=0.003). Likewise, there was an increase in intubations performed by PGY 4 (Year 1-5 difference +13%, p=0.002) and PGY 6 (Year 1-5 difference +11%, p<0.001) operators with a concurrent decrease in those performed by PGY 2 (Year 1-5 difference -16%, p<0.001) and PGY 3 (Year 1-5 difference -8%, p=0.004) operators.

First-attempt success (FAS) occurred in 80.7% of intubations performed during the study period. The FAS rate increased linearly throughout the study period, with FAS of 72.6% in the first year and 88.0 % in the final year when looking at all operators (p<0.001) (Table 4, Figure 1, next page). 

There was a significant increase in the number of intubations performed by PCCM operators after the first year of the study (Year 1-5 difference +19%, p<0.001) accompanied by a decrease in intubations performed by internal medicine (Year 1-5 difference -9%, p=0.006) and emergency medicine residents (Year 1-5 difference -10%, p=0.003). Likewise, there was an increase in intubations performed by PGY 4 (Year 1-5 difference +13%, p=0.002) and PGY 6 (Year 1-5 difference +11%, p<0.001) operators with a concurrent decrease in those performed by PGY 2 (Year 1-5 difference -16%, p<0.001) and PGY 3 (Year 1-5 difference -8%, p=0.004) operators.

First-attempt success (FAS) occurred in 80.7% of intubations performed during the study period. The FAS rate increased linearly throughout the study period, with FAS of 72.6% in the first year and 88.0 % in the final year when looking at all operators (p<0.001) (Table 4, Figure 1).

Table 4. Outcomes.

Figure 1. First-attempt success and complications over time.

For patients intubated by fellows only, FAS increased from 77% to 92% over the 5-year period (p<0.001).

During the entire study period, at least one complication occurred in 28.7% of intubations. The incidence of complications decreased throughout the first 48 months but increased slightly in the final 12 months of the study, driven primarily by an increase in hypotension (Table 4, Figure 2).

Figure 2. Neuromuscular blocking agent (NMBA) use, video laryngoscopy (VL) use, and occurrence of esophageal intubations, desaturation, and hypotension over time.

There was a decrease in the rate of desaturation from the first year to the final year of the study (25.6% to 17.1%, p=0.01). Esophageal intubations also decreased significantly over this time (5% to 1%, p=0.009). Hypotension and cardiac arrest occurred in 8.3% and 0.6% of intubations, respectively, during the entire study period.

There was a trend towards decreased use of midazolam and propofol throughout the study period while the use of etomidate tended to increase, although these changes were not significant (Table 3). A neuromuscular blocking agent (NMBA) was used in 77.4% of intubations during the study period, increasing from the first year to the final year (73.5% to 88.4%, p<0.001), driven primarily by an increase in the use of rocuronium.

There was a significant transition from the use of direct laryngoscopy (DL) to video laryngoscopy (VL) over the course of the study (p<0.001). DL was chosen as the first approach in 22.0% of intubations in the first year and only 2.9% in the final year. Conversely, the use any form of VL on the first attempt increased from 72.3% of intubations in the first year to 93.5% in the final year. Flexible fiber optic intubation was used infrequently during the entire study period, being the first device used in 4.3% of intubations.

Various methods of preoxygenation were used throughout the study period with some form of preoxygenation occurring in 97.5% of intubations. From the first year to the final year of the study, the use of bag-valve-mask (BVM) ventilation tended to decrease (30% to 12.2%) with a concurrent trend in increasing use of NIPPV for preoxygenation (19.4% to 29.7%).

Discussion

Our experience demonstrates that utilization of a comprehensive approach to airway management including an ongoing simulation-based training curriculum and CQI database is associated with an improved first-attempt success rate for the intubation of critically ill patients. This was accompanied by changes in approach to airway management, with increased use of VL and NMBA on the first attempt, as well as an increased proportion of airways being managed by more experienced operators.

While some of the observed improvement in FAS may be attributed to more experienced operators managing the airway on the first attempt, the sharp increase in fellow-level operators after implementation of the curriculum may point to increased fellow confidence or increased recognition of high-risk patients. Furthermore, as adjunctive strategies such as ramp positioning (12-14) and apneic oxygenation (15, 16) have become increasingly recognized as potentially beneficial, a continuous training curriculum provides opportunities for evaluating trainees’ knowledge of these techniques and reinforcing their incorporation into airway management.

We have previously reported on the impact of a simulation-based curriculum on operator confidence, first-attempt success, and procedural complications (11). The combination of this curriculum with a CQI database has a marked effect on the approach to management of these patients. Strategies presented and employed in the curriculum have been informed by previous reports from our database. For example, after demonstrating improved first-attempt success with the use of neuromuscular blockade (17) and video laryngoscopy (18), the didactic portion of our curriculum incorporated these findings, which were rapidly used with increasing frequency in our intensive care unit. The integration of the curriculum and CQI database facilitates adoption of best practices, leading to a significant improvement of first-attempt success rate over a relatively short time span. The continued improvement over the course of five years is likely due to the incorporation of the practices above during this time.

Tools traditionally used for predicting difficulty of airway management have focused primarily on characteristics of an anatomically difficult intubation (19, 20). More recently, there has been an expanded focus on physiologic characteristics that may lead to complications and decreased success of intubation. However, currently available instruments for ICU patients, such as the MACOCHA score, continue to put heavy emphasis on anatomic factors and are not validated for the use of VL (21). We have found difficult airway characteristics associated with decreased FAS in the setting of VL and have focused efforts at minimizing their impact (22). In our population, we noted a consistent improvement in Cormack-Lehane grade and percentage of glottic opening (POGO) score, despite a high prevalence of anatomic difficult airway characteristics. We have also noted a significant decrease in desaturations, esophageal intubations, and a trend towards decreased overall complications. In comparison to other studies of intubation complications in critically ill patients, we found generally lower rates of esophageal intubation (1, 2, 6) and similar (10) or lower rates of desaturation (1, 2) (Table 5).

Table 5. Incidence of complications in the published literature.

Our rate of hypotension is fairly low relative to several other studies (2, 10, 23) despite a fairly inclusive definition (administration of fluid or phenylephrine bolus, initiation or increase of vasopressor infusion). Moreover, cardiac arrest was extremely uncommon in our population, occurring in 0.57% of intubations.

Data regarding optimal approach have been controversial, and randomized trial results do not always coincide with observational studies. Although randomized controlled trials have called into question the benefit of VL (24-27), there are several important limitations to each of these studies to consider when interpreting the comparison between DL and VL. In some, patients were excluded either directly (25) or indirectly (24, 26) for a history of a difficult intubation or anticipated difficult intubation. The use of endotracheal tubes without a stylet may have also influenced outcomes (27).

Our experience is a pragmatic example of the effect of device selection on first attempt success in that we have >1400 patients, operators with varying experience, and have no patients excluded because of potential difficulty. Thus, while randomized trials may be ideal, they are costly and time-consuming and may delay identification and implementation of best practices. The FAS rate in our cohort in its first year was similar to that observed in several of these trials but improved substantially over the 5-year period. One reason for the improved FAS in our study may be the continuous simulation-based training with a focus on video laryngoscopy as the first technique of choice for the majority of airways. In comparison to other widely cited studies of airway management in critically ill patients (1, 21), our cohort demonstrated a very low incidence of difficult airways, only 2% in the final year, despite a similar presence of difficult airway characteristics. This may be an effect of the training program suggesting that perhaps airway training with a global view of airway management focusing on increasing FAS and reducing complications is even more important than equipment considerations.

Our study has several limitations. The single-center, observational nature of this study makes it at risk of bias despite attempts to identify and control for factors that may influence the results. Data forms were completed by the operator, introducing potential for reporting bias, although attempts to minimize this were made by intermittent correlation with the medical record. Although FAS is an accepted outcome for studies evaluating intubation strategies, data regarding mortality or late morbidity were not captured. The increase in hemodynamic complications in the final year is of interest, but data regarding this complication and its consequences were limited and should be a focus of future research. Despite these limitations, the consistent improvement in FAS and low incidence of difficult airways in the final year of the study warrant serious consideration of these findings.

Conclusion

We have found that a comprehensive strategy employing a simulation-based curriculum and continuous quality improvement database was associated with significant improvements in first-attempt success at intubation in critically ill patients throughout the 5-year study period. We suggest that wider adoption of this practice could vastly improve the safety of intubation in this high-risk patient population.

References

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Cite as: Malo J, Hypes C, Natt B, Cristan E, Greenberg J, Morrissette K, Snyder L, Knepler J, Sakles J, Knox K, Mosier J. Airway registry and training curriculum improve intubation outcomes in the intensive care unit. Southwest J Pulm Crit Care. 2018;16(4):212-23. doi: https://doi.org/10.13175/swjpcc037-18 PDF