HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Fig. 4. Techniques used to establish airway for each attempt for each cohort. DL = Direct Laryngoscopy; LMA = Laryngeal Mask Airway; VL = Videolaryngoscope.

DISCUSSION Our retrospective study revealed that angioedema involving the larynx is a predictor of intubation or surgi- cal airway, and that the DART program allowed adequate time and resources for airway evaluation prior to airway intervention, increased the use of fi beroptic-guided intu- bation, and decreased the number of attempts required to secure an airway in angioedema patients with dif fi cult airway. Predictors of Airway Intervention Angioedema involving laryngeal structures was a strong predictor of airway interventions. In a review of 367 angioedema patients in three tertiary hospitals, Tai et al. reported age, stridor, hoarseness, dysphagia, drool- ing, and multiple affected sites to be associated with intu- bation or tracheostomy. 7 McCormick found involvement of three or more sites to be correlated with the need for airway intervention (39%). 11 Speci fi cally, involvement of anterior or base of the tongue and the larynx correlated with the need for intubation or tracheostomy. 11 In addi- tion, Kieu et al. found that involvement of the soft palate was also associated with the need for airway interven- tion. 10 In our study, we did not have a strict criteria for

angioedema more frequently in the post-DART (72.2%) than in the pre-DART cohort (42.9%). The fi rst-time rate of success in the securement of the airway was signi fi - cantly higher in the DART cohort (77.8%) than in the pre- DART cohort (42.9%) ( P = 0.04). The number of patients who required more than two attempts for airway secure- ment was higher in the pre-DART cohort (8 [57.1%]) than in the post-DART (4 [22.2%]) cohort (Fig. 4). One patient in each of the pre- and post-DART cohorts received a cricothyroidotomy. The pre-DART patient had received multiple attempts of intubation by the emergency department physicians prior to otolaryngologists being con- tacted. By the time the otolaryngologist arrived, the patient ’ s clinical situation had deteriorated signi fi cantly, requiring a cricothyroidotomy for a de fi nitive airway. For the patient in the post-DART cohort, an early decision was made to man- age the airway in the operating room; however, a cricothyroi- dotomy was performed after two unsuccessful attempts with nasal fi beroptic intubation and worsening oxygen satura- tions. There were no airway-related deaths in either cohort. The odds of requiring an airway intervention was six times higher among patients who had an oropharyngeal angioedema involvement of the larynx regardless of pre- or post-DART cohort, controlling for age, sex, and etiology of oropharyngeal angioedema.

Laryngoscope 129: June 2019

Pandian et al.: Dif fi cult Airway

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