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National Clinical Guideline Centre (UK). Major Trauma: Assessment and Initial Management. London: National Institute for Health and Care Excellence (NICE); 2016 Feb. (NICE Guideline, No. 39.)

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Major Trauma: Assessment and Initial Management.

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6Airway management

6.1. Introduction

Due to the injuries trauma patients sustain they may require support pre-hospital to maintain their airway. This may include patients who stop breathing, those that are unable to maintain adequate ventilation, or those that require airway support for head and chest trauma management. A lack of oxygen pre-hospital can result in a higher risk of mortality, and can also cause brain injury, which can have long-term implications for function and patient quality of life. The effective airway management pre-hospital is therefore a critical clinical issue. There are a number of airway strategies currently used pre-hospital:

  • Basic airway adjuncts (including bag valve mask, naso and oro-pharyngeal airway). Bag valve mask enables clinicians to provide adequate ventilation for patients requiring airway support and allows enough time to establish a more controlled approach to airway management, such as tracheal intubation. Oropharyngeal airways should be used in unconscious (unresponsive) patients as they are quite stimulating and generate a gag reflex. A nasopharyngeal airway is an adjunct for use in patients with potential or actual airway obstruction, particularly in circumstances where an oropharyngeal airway is inappropriate (e.g. patient has trismus or an intact gag reflex )
  • Laryngeal masks are a type of supra-glottic device. They are designed to be used above the vocal cords, or glottis opening. They're placed using a blind technique and create a seal around the glottic opening but do not cross the vocal cords. They cannot be used in patients with an intact gag reflex.
  • Tracheal intubation (Drug assisted, non-drug assisted, Rapid sequence induction of anaesthesia). Tracheal intubation is where an orotracheal tube is placed under direct vision or assisted vision (e.g videolaryngoscopes) through the larynx into the trachea. It has the advantage of providing a protected airway whilst enabling ventilation, a route for oxygenation and suctioning. In the unconscious patients with no gag or laryngeal reflex, tracheal intubation can be performed without the use of drugs.
  • Rapid sequence induction (RSI) of anaesthesia and intubation is a method to facilitate emergency tracheal intubation. The overall aim is to rapidly provide optimal conditions for tracheal intubation, as this is thought to reduce the risk of aspiration. RSI of anaesthesia and intubation is the administration of a potent induction agent (anaesthetic) followed by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation
  • Surgical airway (cricothyroidotomy). This procedure provides a temporary emergency airway in situations where there is obstruction at or above the level of the larynx, such that oral/nasal tracheal intubation is impossible

This review considers the optimum airway management strategy that should be used for trauma patients pre-hospital

6.2. Review question: What is the most clinically and cost effective strategy for managing the airway in patients with trauma pre-hospital?

For full details see review protocol in Appendix C.

Table 8PICO characteristics of review question

PopulationChildren, young people and adults experiencing a traumatic incident, including:
  • people able to be intubated without drugs (GCS=3),
  • people unable to maintain or protect their own airway (GCS <9, <12 and <15), and
  • people who are able to maintain their own airway, but who need to be intubated for other reasons (for example, people who may lose their airway during transport and people who require ventilatory support for chest or head trauma management)
Intervention(s)
  • Drug-assisted tracheal intubation
  • Non-drug assisted tracheal intubation
  • Rapid sequence induction of anaesthesia (RSI)
  • Supraglottic devices
  • Surgical airway/assisted tracheal placement (cricothyroidotomy)
Comparison(s)
  • Basic airway adjuncts (including bag-valve mask, naso- and oropharyngeal airway)
  • No intervention
  • A comparison of those listed above
OutcomesCritical:
  • Mortality at 48 hours, 30 days/1 month, 1 year
  • Health-related quality of life (Glasgow outcome scale or ther functional outcome score; SF-36, functional independence measure (FIM), rehabilitation complexity scale, SF-12, EQ5D)
  • Brain injury management (oxygenation, control of carbon dioxide levels)
  • Aspiration events
  • Failure to intubate or secure airway
  • Adverse events (hypotension, unrecognised oesophageal intubation)
Important
  • Patient reported outcomes (psychological wellbeing)
Study designRCTs or systematic reviews of RCTs; cohort studies that use multivariate analysis to adjust for key confounders (injury severity, age, depth of shock, degree of head injury) or were matched at baseline for these if no RCTs retrieved

We searched for RCTs and cohort studies that compared airway management strategies as listed in the review protocol. Studies were excluded if (i) the intervention received by patients was unclear, (ii) patients in the same group may have received different interventions, or (iii) patients received multiple interventions (for example, if an intervention was unsuccessful).

6.3. Clinical evidence

No clinical evidence was found to be relevant for this question.

6.4. Economic evidence

Published literature

No relevant economic evaluations were identified.

See also the economic article selection flow chart in Appendix E.

Unit costs

Table 9. Resources and costs involved in tracheal intubation.

Table 9

Resources and costs involved in tracheal intubation.

Table 10. Resources and costs of other airway interventions and comparators.

Table 10

Resources and costs of other airway interventions and comparators.

6.5. Evidence statements

Clinical

No clinical evidence identified.

Economic

No relevant economic evaluations were identified.

6.6. Recommendations and link to evidence

Recommendations This section should be read in conjunction with section 17 in the NICE full guideline on major trauma services: service delivery for major trauma.
1.

Use drug-assisted rapid sequence induction (RSI) of anaesthesia and intubation as the definitive method of securing the airway in patients with major trauma who cannot maintain their airway and/or ventilation.

2.

If RSI fails, use basic airway manoeuvres and adjuncts and/or a supraglottic device until a surgical airway or assisted tracheal placement is performed.

Pre-hospital settings
3.

Aim to perform RSI as soon as possible and within 45 minutes of the initial call to the emergency services, preferably at the scene of the incident.

If RSI cannot be performed at the scene:

  • consider using a supraglottic device if the patient's airway reflexes are absent
  • use basic airway manoeuvres and adjuncts if the patient's airway reflexes are present or supraglottic device placement is not possible
  • transport the patient to a major trauma centre for RSI provided the journey time is 60 minutes or less
  • only divert to a trauma unit for RSI before onward transfer if a patent airway cannot be maintained or the journey time to a major trauma centre is more than 60 minutes.
The recommendations on airway management were identified as key areas to evaluate in the Major Trauma service delivery guidance scope area, ‘Access to Services’. See Major Trauma Service Guidance chapter 17 for details on the development of the airway management service delivery recommendation.
Relative values of different outcomesThe following outcomes were critical to decision making: mortality up to 12 months, health-related quality of life, brain injury management, aspiration events, failure to intubate or secure airway, and adverse events (hypotension and unrecognised oesophageal intubation). Outcomes important to decision making were patient-reported outcomes, such as psychological well-being.
Trade-off between clinical benefits and harmsThere was no published evidence to inform a recommendation on the use of airway management strategies in adult or child major trauma patients.

The GDG discussed the associated risks of RSI of anaesthesia and intubation, for example, there is a greater risk of mortality if the tube enters the oesophagus rather than the lungs. However, the GDG felt that when the procedure is delivered by a team/clinician with appropriate training and experience (including experience conducting intubation, and maintaining sedation and ventilation after induction), the benefits of drug-assisted RSI in resuscitating the patient outweigh the risks.

The GDG proposed that RSI of anaesthesia and intubation achieves improved ventilation increasing the probability of survival and reduces long-term morbidity compared with other methods of intubation. RSI is the preferred method of tracheal intubation because it results in rapid unconsciousness and neuromuscular blockade. This is important in patients who have not fasted and are at much greater risk for vomiting and aspiration.

The GDG had a strong belief that RSI of anaesthesia and intubation delivered by a competent person is the gold standard of care when maintaining the airway of both adults and children and made a recommendation for RSI of anaesthesia and intubation accordingly.

The GDG also noted that in the UK only physicians trained in RSI of anaesthesia or intubation or paramedics trained in the technique under the direct supervision of a physician can deliver this intervention as part of a team therefore availability of people in the pre-hospital setting to perform the procedure is limited. Taking this into account the GDG therefore recommended other airway management strategies that can be used to maintain a patient's airway while awaiting the clinical expertise to perform RSI of anaesthesia and intubation safely.

The GDG suggested that the second best device for airway management was the supraglottic device. This device provides less protection than RSI of anaesthesia and intubation against aspiration; however this device provides greater protection than basic airway adjuncts, and can be administered safely by in the pre-hospital environment by paramedics or physicians staff. An additional advantage of supraglottic devices over other methods is that they can be easily inserted and removed. However, the GDG noted that supraglottic devices can only be used in patients without airway reflexes to avoid stimulating vomiting or laryngospasm,, and are therefore only appropriate for use in patients with a reduced level of consciousness.

For patients with airway reflexes, where a supraglottic device cannot be used, the GDG recommended the use of basic airway manoeuvres and adjuncts until such time as RSI of anaesthesia and intubation is available.

If RSI of anaesthesia and intubation fails a surgical airway or assisted tracheal intubation should be performed. This is required only in a very small minority of patients, for example patients with extensive facial injuries or an obstructed upper airway

The GDG considered evidence regarding outcomes of patients related to pre-hospital scene and transfer times. The evidence suggested that outcomes were worse where there were long transport times (greater than 60 minutes) without a definitive airway, regardless of final destination. The GDG therefore concluded that where possible, RSI should be delivered at scene and within a timeframe than minimised pre-hospital time. Pre-hospitals systems should develop to make this widely available. Where pre-hospital RSI is not possible within a 45-minute window, the GDG recommended transporting the patient with supraglottic or basic airway adjuncts to a MTC within 60 minutes, otherwise to a TU. Overall, this was felt to be the most effective method of securing a definitive airway within this clinically important timeframe.
Trade-off between net health benefits and resource useNo published economic evidence was identified to inform this question. Unit costs were presented showing that basic airway adjuncts had the lowest intervention costs (£1.88), supraglottic devices had low cost (£5.55) and RSI and drug-assisted tracheal intubation had the highest unit cost (£34.52). The differential in unit cost for the devices is likely to expand once staff costs are added, in that the cheapest interventions also require the least competence to undertake, whereas RSI and drug assisted tracheal intubation needs higher skill and expertise to deliver.

The key issue is that a competent person needs to be present on scene to deliver RSI of anaesthesia and intubation. Trained doctors hold this competency and are currently only on scene when an enhanced critical care team or individual doctors (for example, BASICS) are dispatched. Dispatch of such teams is dependent on the triaging decision of the 999 call handler and/or the first attendants on scene.

There are two main ways this can be provided; RSI of anaesthesia and intubation is immediately available at the scene (this implies a person with these skills will be one of the first responders to the scene) or a team with the skills are called out.

A recommendation proposing RSI of anaesthesia and intubation is available immediately whenever an airway may need to be maintained could lead to highly qualified and costly staff members being displaced from other clinical duties and increase the overall cost of the strategy substantially. The cost effectiveness in part will depend on who is trained to undertake RSI, and also the extent other populations (such as those with acute medical emergencies) may also benefit from having expertise in RSI routinely available on scene.

In the other model of provision skilled staff could be called to the scene to provide RSI of anaesthesia and intubation. Currently, pre-hospital teams will consider whether the patient triggers the trauma bypass tool for triage direct to a major trauma centre (MTC). The severity of the patients other injuries, the time to reach the nearest ED and whether the nearest ED is a trauma unit or MTC, and whether travel time to the ED is more or less time than waiting for expertise to come to scene is all taken into account before transporting a patient. Although waiting on scene and calling out expertise only where necessary is potentially a less expensive model, this strategy is only likely to be clinically and cost effective if the on scene triage is accurate, the wait for expertise to arrive on scene is quick and there is high benefit in transport direct to an MTC without bypass.

Many of the costs and benefits accrued in each strategy depend on economies of scale (that is, the more patients needing RSI intubation on scene, the less down time of the attending specialist staff) and economies of scope (that is, the ability of the attending staff to clinically manage other aspects of the trauma beside the airway), and these economies depend on local circumstance. The most cost-effective option may differ according to local circumstance. If the value of maximising population health gain by not exceeding the £20,000 per QALY threshold is upheld, this may mean different healthcare provision (and potential health gain) according to local circumstance.

Overall, cost effectiveness of the interventions, when access implications are taken into account, remain unclear. It was GDG consensus, that RSI tracheal intubation (if undertaken by a competent person), despite having a risk of adverse events, would ensure an effective secure airway and potentially avoid downstream transfer costs. RSI leads to an increased probability of survival and reduces long-term morbidity compared with other methods of intubation. Other benefits of intubation include the administration of anaesthesia and effective ventilation (for example, in patients with significant chest injuries). It was concluded that the benefits would increase QALYs of the intervention and would offset its cost, therefore, the GDG felt this strategy would be more cost effective than the use of other airway management strategies, especially where possible to implement according to local service provision. Equally, where RSI tracheal intubation was not possible, use of a supraglottic device if possible would be more cost effective than airway adjuncts, such as bag and mask (provided the patients reflexes allow).

This recommendation is likely to be a change a practice, as traditional teaching involves beginning with the least invasive airway device (bag and mask) and increasing the complexity of the interventions until the patient's airway is secure. The aim of this recommendation, however, is to encourage beginning with RSI (if the skills are available) as this would be the definitive method of securing the airway and the most appropriate in major trauma patients who cannot maintain their own airway. This recommendation is also likely to have a cost impact as resourcing of staff capable of undertaking RSI will be an issue.
Quality of evidenceNo clinical or economic evidence was found for this question.
Other considerationsThe GDG noted the importance of the early identification and of patients who require RSI or a surgical airway and early preparation of equipment for these procedures.

The GDG noted that in a recent retrospective review of RSI performed by physician/critical care paramedics in the UK, there was only one case out of 142 of failure to intubate 87.

The GDG did not identifying any considerations specific to children.

The GDG noted that the Trauma service delivery guidance would be evaluating the service delivery impact of the access to RSI as part of the operational model assessing access to services.
Copyright © National Clinical Guideline Centre, 2016.
Bookshelf ID: NBK368090

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