BACKGROUND: Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI.
OBJECTIVE: This paper evaluates key evidence-based updates concerning ETI for the emergency clinician.
CONCLUSIONS: ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube.
CONCLUSIONS: An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

BACKGROUND: High-flow nasal oxygen (HFNO), or transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), is a technique providing apneic oxygenation and a degree of ventilation during microlaryngeal surgery. Its use with laser has been questioned due to concern for airway fire. For fire to occur, a triad of ignition source, oxidizer, and fuel source must be present. By using HFNO and eliminating an endotracheal tube (fuel source), it is hypothesized that airway fire risk is minimal. We tested this theory with human cadavers using HFNO with increasing levels of FiO2 while performing microlaryngeal laser surgery.
METHODS: HFNO was placed on two cadavers, and oxygen was administered at incrementally increasing fraction of inspired oxygen (FiO2) concentrations (30%-100%). Laryngeal microsurgery was conducted with CO2 and KTP lasers applied for 30 s. Oxygen readings were taken at several anatomic locations along the body assessing oxygen concentrations in correlation with increasing FiO2 administration.
RESULTS: The use of CO2 and KTP laser on cadaveric vocal folds produced char but no spark or airway fire at any of the tested oxygen concentrations. Apart from the mouth, there was minimal increase in oxygen levels at the surrounding anatomic sites despite elevating FiO2 levels.
CONCLUSIONS: HFNO may be safe to use during microlaryngeal laser surgery. By eliminating the endotracheal tube as a fuel source, risk of airway fire may be negligible. Our study safely applied CO2 and KTP lasers for an uninterrupted 30 s with HFNO at 70 L/min and 100% FiO2 producing no spark or fire.
METHODS: NA Laryngoscope, 2024.

BACKGROUND: The apnea test (AT) is an important component in the determination of brain death/death by neurologic criteria (BD/DNC) and often entails disconnecting the patient from the ventilator followed by tracheal oxygen insufflation to ensure adequate oxygenation. To rate the test as positive, most international guidelines state that a lack of spontaneous breathing must be demonstrated when the arterial partial pressure of carbon dioxide (PaCO2) ≥ 60 mm Hg. However, the loss of positive end-expiratory pressure that is associated with disconnection from the ventilator may cause rapid desaturation. This, in turn, can lead to cardiopulmonary instability (especially in patients with pulmonary impairment and diseases such as acute respiratory distress syndrome), putting patients at increased risk. Therefore, this prospective study aimed to investigate whether a modified version of the AT (mAT), in which the patient remains connected to the ventilator, is a safer yet still valid alternative.
METHODS: The mAT was performed in all 140 BD/DNC candidates registered between January 2019 and December 2022: after 10 min of preoxygenation, (1) positive end-expiratory pressure was increased by 2 mbar (1.5 mm Hg), (2) ventilation mode was switched to continuous positive airway pressure, and (3) apnea back-up mode was turned off (flow trigger 10 L/min). The mAT was considered positive when spontaneous breathing did not occur upon PaCO2 increase to ≥ 60 mm Hg (baseline 35-45 mm Hg). Clinical complications during/after mAT were documented.
RESULTS: The mAT was possible in 139/140 patients and had a median duration of 15 min (interquartile range 13-19 min). Severe complications were not evident. In 51 patients, the post-mAT arterial partial pressure of oxygen (PaO2) was lower than the pre-mAT PaO2, whereas it was the same or higher in 88 cases. In patients with pulmonary impairment, apneic oxygenation during the mAT improved PaO2. In 123 cases, there was a transient drop in blood pressure at the end of or after the mAT, whereas in 12 cases, the mean arterial pressure dropped below 60 mm Hg.
CONCLUSIONS: The mAT is a safe and protective means of identifying patients who no longer have an intact central respiratory drive, which is a critical factor in the diagnosis of BD/DNC. Clinical trial registration DRKS, DRKS00017803, retrospectively registered 23.11.2020, https://drks.de/search/de/trial/DRKS00017803.

Transnasal humidified rapid-insufflation ventilator exchange (THRIVE) has been reported to have better efficacy during anesthesia induction compared to conventional mask ventilation, including improved oxygenation and prolonged safe apnea time. This study reports on the effectiveness of the THRIVE system during modified electroconvulsive therapy (mECT) for a patient experiencing severe hypoxia. A 78-year-old female patient with bipolar disorder received maintenance mECT every four weeks. She previously experienced a significant hypoxic event, with oxygen saturation (SpO2) dropping to 50% following electrical stimulation. In response, we employed the THRIVE system, designed to deliver high-flow, 100% oxygen, thereby extending apnea tolerance. The implementation of THRIVE ensured a stable oxygen supply, maintaining oxygen saturation levels above 95% throughout the mECT procedure. THRIVE is useful for treating hypoxia that occurs due to the unavoidable lack of ventilation during mECT.

UNASSIGNED: Since 2015, Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) has been used in general anesthesia for preoxygenation or difficult exposure airway management. Its use offers new opportunities in laryngology. THRIVE increases apnea time and frees the access to the upper airway. However, its use may be less stable than orotracheal intubation. The main objective of this work was to evaluate the feasibility of laryngeal microsurgery under THRIVE including using Laser.
UNASSIGNED: Retrospective.
UNASSIGNED: A total of N = 99 patients with laryngeal microsurgery (with or without CO2 laser) under THRIVE were included successively from January 1, 2020 to January 30, 2022.
UNASSIGNED: Medical history, comorbidities, clinical and surgical data were extracted and analyzed. Two groups were constituted regarding the \"success\" (use of THRIVE along all the procedure) or the \"failure\" (need for an endotracheal tube) of the use of THRIVE during the procedure.
UNASSIGNED: A failure occurred in N = 15/99 patients (15.2%) mainly due to refractory hypoxia. The odd ratios (OR) for THRIVE failure were: OR = 6.6 [2.9-35] for overweight (BMI >25 kg/m2); OR = 3.8 [1.7-18.7] for ASA score >2; OR = 4.7 [2.3-24.7] for the use of CO2 laser. Elderly patients and patients with pulmonary pathology were not statistically at greater risk of THRIVE failure. No adverse event was described.
UNASSIGNED: This work confirms the feasibility of laryngeal microsurgery under THRIVE, including with CO2 laser. Overweight, ASA >2 and lower fraction of inspired oxygen during CO2 laser use increased the risk for orotracheal intubation.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a safe, effective, and novel technique that is currently being used in electroconvulsive therapy (ECT). This study aimed to summarize the clinical practices of THRIVE use in ECT to aid physicians and institutions in implementing the best practice guidelines for ECT. Thus, we reviewed the current literature and presented our consensus on the application of THRIVE in ECT in daily clinical practice. This consensus provides information regarding THRIVE use in ECT, including its safety, effectiveness, procedures, precautions, special case management, and application in special populations. Moreover, it guides the standardized use of THRIVE in ECT.

Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.

OBJECTIVE: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted.
METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023.
RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS.
CONCLUSIONS: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.

OBJECTIVE: In the context of acute hypoxemic respiratory failure (AHRF), ensuring effective preoxygenation and apneic oxygenation emerges as the pivotal approach ensuring for averting hypoxemic adverse events during endotracheal intubation. To investigate this, we conducted an open-label randomized controlled trial, aiming to assess the comparative effectiveness of nasopharyngeal high-flow oxygenation in conjunction with Bag-Valve-Mask (BVM) versus standard BVM preoxygenation in patients experiencing AHRF within the emergency department (ED).
METHODS: This prospective single-center, open-labeled, randomized controlled trial enrolled patients aged 18 years and above requiring rapid sequence intubation due to AHRF in the ED. Participants were randomly assigned in a 1:1 ratio to either the intervention arm (involving nasopharyngeal high-flow oxygenation and BVM preoxygenation) or the control arm (involving BVM preoxygenation alone).
RESULTS: A total of 76 participants were enrolled in the study, evenly distributed with 38 individuals in each arm. Median (interquartile range [IQR]) SpO2 at 0 min postintubation was 95.5 (80%-99%) versus 89 (76%-98%); z-score: 1.081, P = 0.279 in the intervention and control arm, respectively. The most common postintubation complications included hypoxia (intervention arm: 56.7% vs. control arm: 66.7%) and circulatory/hypoxic arrest (intervention arm: 39.5% vs. control arm: 44.7%). There were no adverse complications in 36.7% (n = 11) of patients in the intervention arm. Despite the best possible medical management, almost half (52.6%) of patients in the intervention arm and 47.4% of patients in the control arm succumbed to their illnesses in the ED.
CONCLUSIONS: The primary outcome revealed no statistically significant difference between the two arms. However, patients in the intervention arm exhibited fewer intubation-related adverse effects.

Apneic oxygenation is a technique used during airway management procedures to maintain oxygenation and prevent desaturation during a lack of ventilation. Despite its importance, there is a lack of comprehensive information on how to achieve effective apneic oxygenation, leading to misunderstandings and suboptimal utilization of this technique. Apneic oxygenation involves several key steps. Firstly, patient selection is crucial, considering factors such as anticipated difficulty with airway management, reduced functional residual capacity, increased oxygen consumption, and medical conditions associated with impaired oxygenation. Secondly, adequate preoxygenation is essential to optimize oxygen reserves before the onset of apnea, utilizing methods like non-rebreather oxygen masks or specific breathing techniques. Thirdly, maintaining airway patency through techniques such as jaw thrust or nasopharyngeal airway placement allows for unobstructed airflow during the apneic period. Lastly, the selection of the appropriate oxygen delivery method, such as high-flow nasal oxygen or nasal cannula, depends on the patient\'s existing respiratory support. Despite the growing body of literature on apneic oxygenation, current review articles often lack a stepwise approach for its proper execution. This knowledge gap contributes to the misunderstanding and underutilization of this important tool during intubation and airway management. In conclusion, apneic oxygenation is a valuable technique for maintaining oxygenation during periods of apnea. However, the lack of comprehensive information and stepwise guidance in the current literature hinders its optimal utilization. Clear guidelines and educational resources should be developed to address this knowledge gap and ensure the safe and effective implementation of apneic oxygenation. By following a stepwise approach that includes patient selection, adequate preoxygenation, airway patency, and appropriate oxygen delivery, healthcare providers can enhance patient outcomes and minimize the risk of desaturation during airway management procedures.