Incidence of aspiration after urgent intubation

doi:10.1016/S0735-6757(97)90157-1

The American Journal of Emergency Medicine

Volume 15, Issue 6, October 1997, Pages 562-565

https://doi.org/10.1016/S0735-6757(97)90157-1 Get rights and content

Abstract

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

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Cited by (37)

The occurrence of aspiration pneumonia after emergency endotracheal intubation
2018, American Journal of Emergency Medicine
Citation Excerpt :
A patient could only be classified into one of the categories presented in Table 1; those with aspiration prior to intubation were not evaluated for the development of aspiration or other types of pneumonia. The definition of aspiration pneumonia was taken from previous literature [4]. The primary outcome measure was aspiration pneumonia that was deemed to be possibly related to intubation (not present on admission but developed within 48 h of intubation).
Adverse events, including aspiration, occur during Emergency Department (ED) intubation, but their contemporary incidence is not well described. We sought to estimate the rate of aspiration pneumonia potentially related to emergency intubation.
We conducted a prospective observational study of adult patients who were endotracheally intubated in the ED. Using a standard definition, we determined the proportion of patients who developed aspiration pneumonia after intubation. Aspiration pneumonia was defined as any of the following in patients without a diagnosis of community acquired pneumonia, healthcare-associated pneumonia, or aspiration prior to intubation: pathogenic growth in sputum culture, unexplained hypoxemia, or radiographic evidence of pneumonia in the first 48 h after intubation. Baseline characteristics and intubation details were compared for those with and without aspiration pneumonia.
879 patients were enrolled over a 30-month period. Intubation was facilitated by video laryngoscopy (49%), direct laryngoscopy (45%), nasal intubation (4%), a intubating laryngeal mask airway (1%), and a surgical airway (0.1%). 85% were intubated on the first attempt, 12% on the second, 3% on the third or more attempts. 25% of patients experienced an oxygen saturation < 90% during the intubation. After excluding patients not eligible for the outcome assessment (those who died within 48 h without findings of pneumonia), 66/823 (8%) developed aspiration pneumonia potentially related to ED intubation. In comparing those with and without aspiration pneumonia, there were no differences between first intubation attempt parameters and the occurrence of aspiration pneumonia.
Aspiration pneumonia occurred commonly in this cohort. Although we did not identify any intubation factors that differed between those with and without with aspiration pneumonia, these findings should remind emergency physicians that emergency endotracheal intubation remains a high-risk procedure, and all care should be taken to minimize the risk of peri-intubation complications.
Use of cricoid pressure during rapid sequence induction: Facts and fiction
2012, Trends in Anaesthesia and Critical Care
Citation Excerpt :
At such low incidence, tens of thousands of patients would have to be studied to detect a clinically meaningful, statistically robust decrease in the incidence of pulmonary aspiration. While there is lack of convincing evidence for CP to reduce the incidence of pulmonary aspiration, numerous surveys, case reports, confidential enquiries, medico-legal reviews and epidemiological studies have reported aspirations despite the use of cricoid pressure.24–28 In summary, the belief that CP pressure reduces the incidence of pulmonary aspiration, is more fiction than fact.
Cricoid pressure (CP) was introduced into anaesthetic practice based on a single case series that lacked information on the force applied and on the method of application. Up to now, there are no controlled, prospective randomised trials which document that CP pressure reduces the incidence of regurgitation of gastric content and pulmonary aspiration. On the other hand, numerous studies have shown that CP has multiple adverse effects, the most important one being interference with airway management. In addition, numerous surveys have shown that most anaesthetists lack adequate knowledge about all aspects of CP. Despite lack of evidence for its beneficial effect, CP is still considered by many anaesthetists an integral part of any rapid sequence induction of anaesthesia.
Cricoid pressure provides incomplete esophageal occlusion associated with lateral deviation: A magnetic resonance imaging study
2012, Journal of Emergency Medicine
Citation Excerpt :
Aspiration of gastric contents continues to be a significant and concerning complication during rapid sequence induction and intubation (1). The reported incidence of aspiration that occurred in emergency departments after the performance of a rapid sequence induction ranges from 0% to as high as 22% (2–4). Since Sellick’s initial study 50 years ago, cricoid pressure (CP) is routinely used to reduce the risk of aspiration on induction (5).
Cricoid pressure is a routine component of rapid sequence induction and is designed to reduce the risk of reflux and its associated morbidity. Recent studies have raised questions regarding the efficacy of cricoid pressure in terms of changes in the pharyngeal and esophageal anatomy.
This current descriptive study was designed to observe the anatomical effect of cricoid pressure on the occlusion of esophageal lumen in conscious volunteers using magnetic resonance imaging (MRI).
We quantitatively assessed esophageal patency before and during application of cricoid pressure in 20 awake volunteers utilizing MRI.
Target cricoid pressure was achieved in 16 of 20 individuals, corresponding to a mean percentage reduction in cricovertebral distance of 43% (range 25–80%). Cricoid pressure was applied incorrectly in 4 (20%) individuals as evidenced by no change in the cricovertebral distance. Incomplete esophageal occlusion was seen in 10 of 16, or 62.5% (95% confidence interval 35–85%) of individuals when appropriate cricoid pressure was applied. Incomplete esophageal occlusion was always associated with a lateral deviation of the esophagus. None of the 6 subjects with complete occlusion had esophageal deviation during the appropriate application of cricoid pressure.
Effective application of cricoid pressure by an experienced operator frequently resulted in lateral deviation of the esophagus and incomplete occlusion of esophageal lumen. Reliance on cricoid pressure for esophageal occlusion requires further evaluation utilizing functional studies.
Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?
2012, Annales Francaises d'Anesthesie et de Reanimation
Part 8: Advanced life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, Resuscitation
Citation Excerpt :
Cricoid pressure prevented movement of liquid from the oesophagus into the pharynx in 5 cadaver studies (LOE 5)60–64; however, in 1 LOE-2 study65 of 4891 obstetric patients undergoing anaesthesia, no significant difference was observed in regurgitation rates between patients who received cricoid pressure and those who did not. There are case reports where prevention of aspiration is ascribed to the application of cricoid pressure (LOE 4)66–68 and other case reports documenting that aspiration occurs despite the application of cricoid pressure (LOE 4).69–73 The routine use of cricoid pressure to prevent aspiration in cardiac arrest is not recommended.
Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis
2007, Annals of Emergency Medicine
Citation Excerpt :
Given the dynamic nature of emergency airways, the fact that many critical patients aspirate before tracheal intubation or ED arrival, and differences in definition, the rate of clinically significant aspiration associated with the procedure itself is unknown. It has been reported in anywhere from 0% of ED-performed rapid sequence tracheal intubations to as high as 22%.10,42-53 Some of the reported variation may also result from an increasing incidence of aspiration associated with repetitive attempts.
Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.

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Original contributionIncidence of aspiration after urgent intubation

Abstract

Am J Emerg Med

Ann Emerg Med

J Oral Maxillofac Surg

Am J Med

Am J Surg

Death and other complications of emergency airway management in critically ill adults

Anesthesiology

The value of intubating and paralyzing patients with suspected head injury in the emergency department

J Trauma

Original contribution
Incidence of aspiration after urgent intubation