Use of HEAVEN Criteria for Predicting Difficult Intubation in the Emergency Department

Overview

Journal Clin Exp Emerg Med

Specialty Emergency Medicine

Date 2022 Mar 31

PMID 35354232

Authors

Nin Ern Tan

Khadijah Poh Yuen Yoong

Hj Mohammad Fadhly Yahya

Affiliations

Soon will be listed here.

Abstract

Objective: Most airway prediction tools only consider anatomical factors. The HEAVEN criteria incorporate both anatomical and physiological elements, but have never been studied in the emergency department. This study aimed to evaluate the association between HEAVEN criteria and intubation difficulty.

Methods: We conducted a prospective cross-sectional study from April 1, 2020 to January 31, 2021 in the emergency department of a tertiary public hospital. All patients requiring rapid-sequence or delayed-sequence intubation were included. Patients intubated during cardiopulmonary resuscitation were excluded. We enrolled 174 patients. Study endpoints were first pass success and intubation complications.

Results: The presence of any HEAVEN criteria was associated with a decrease in the first pass success rate (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.02-0.43; P < 0.01). The anatomical challenge was the only criterion associated with first pass sucess (OR, 0.13; 95% CI, 0.05- 0.29; P < 0.01), whilst other criteria (hypoxemia, extremes of size, vomit/blood/fluid, exsanguination, and neck mobility) were not (P > 0.05). All anatomical factor criteria were associated with difficult airway view (P < 0.05). Intubation complications occurred more in the presence of hypoxemia (OR, 7.44; 95% CI, 2.82-19.63; P < 0.01) and vomit/blood/fluid (OR, 5.55; 95% CI, 2.39-12.92; P < 0.01).

Conclusion: Anatomical challenge in HEAVEN criteria can predict first pass success. All anatomical factors in HEAVEN criteria could predict difficult airway view and peri-intubation hypoxemia could be used to anticipate intubation complications. More validation studies are still needed to evaluate the use of HEAVEN criteria as a predictor tool for difficult airway.

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References

Bodily J, Webb H, Weiss S, Braude D . Incidence and Duration of Continuously Measured Oxygen Desaturation During Emergency Department Intubation. Ann Emerg Med. 2015; 67(3):389-95. DOI: 10.1016/j.annemergmed.2015.06.006. View

Koh L, Kong C, Ip-Yam P . The modified Cormack-Lehane score for the grading of direct laryngoscopy: evaluation in the Asian population. Anaesth Intensive Care. 2002; 30(1):48-51. DOI: 10.1177/0310057X0203000109. View

De Jong A, Molinari N, Terzi N, Mongardon N, Arnal J, Guitton C . Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med. 2013; 187(8):832-9. DOI: 10.1164/rccm.201210-1851OC. View

Hagiwara Y, Watase H, Okamoto H, Goto T, Hasegawa K . Prospective validation of the modified LEMON criteria to predict difficult intubation in the ED. Am J Emerg Med. 2015; 33(10):1492-6. DOI: 10.1016/j.ajem.2015.06.038. View

Mort T . Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004; 99(2):607-13, table of contents. DOI: 10.1213/01.ANE.0000122825.04923.15. View

Reed M, Dunn M, McKeown D . Can an airway assessment score predict difficulty at intubation in the emergency department?. Emerg Med J. 2005; 22(2):99-102. PMC: 1726680. DOI: 10.1136/emj.2003.008771. View

Huitink J, Bouwman R . The myth of the difficult airway: airway management revisited. Anaesthesia. 2014; 70(3):244-9. DOI: 10.1111/anae.12989. View

Hung O, Murphy M . Context-sensitive airway management. Anesth Analg. 2010; 110(4):982-3. DOI: 10.1213/ANE.0b013e3181d48bbb. View

Nausheen F, Niknafs N, MacLean D, Olvera D, Wolfe Jr A, Pennington T . The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis. Scand J Trauma Resusc Emerg Med. 2019; 27(1):50. PMC: 6480652. DOI: 10.1186/s13049-019-0614-6. View

10.

Dunford J, Davis D, Ochs M, Doney M, Hoyt D . Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003; 42(6):721-8. DOI: 10.1016/s0196-0644(03)00660-7. View

11.

Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown 3rd C . Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012; 60(6):749-754.e2. DOI: 10.1016/j.annemergmed.2012.04.005. View

12.

Kuzmack E, Inglis T, Olvera D, Wolfe A, Seng K, Davis D . A Novel Difficult-Airway Prediction Tool for Emergency Airway Management: Validation of the HEAVEN Criteria in a Large Air Medical Cohort. J Emerg Med. 2018; 54(4):395-401. DOI: 10.1016/j.jemermed.2017.12.005. View

13.

Soyuncu S, Eken C, Cete Y, Bektas F, Akcimen M . Determination of difficult intubation in the ED. Am J Emerg Med. 2009; 27(8):905-10. DOI: 10.1016/j.ajem.2008.07.003. View

14.

Davis D, Olvera D . HEAVEN Criteria: Derivation of a New Difficult Airway Prediction Tool. Air Med J. 2017; 36(4):195-197. DOI: 10.1016/j.amj.2017.04.001. View

15.

Mosier J, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles J . The Physiologically Difficult Airway. West J Emerg Med. 2016; 16(7):1109-17. PMC: 4703154. DOI: 10.5811/westjem.2015.8.27467. View

16.

Perbet S, De Jong A, Delmas J, Futier E, Pereira B, Jaber S . Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: a multicenter observational study. Crit Care. 2015; 19:257. PMC: 4495680. DOI: 10.1186/s13054-015-0975-9. View

17.

Sakles J, 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; 20(1):71-8. PMC: 4530518. DOI: 10.1111/acem.12055. View

18.

Perkins G, McAuley D, Giles S, Routledge H, Gao F . Do changes in pulse oximeter oxygen saturation predict equivalent changes in arterial oxygen saturation?. Crit Care. 2003; 7(4):R67. PMC: 270702. DOI: 10.1186/cc2339. View

19.

Ahmad R, Rahmat R, Hisamudin N, Rahman N, Noh A, Mohammad N . Demographic and clinical characteristics of red tag patients and their one-week mortality rate from the emergency department of the Hospital Universiti Sains Malaysia. Southeast Asian J Trop Med Public Health. 2010; 40(6):1322-30. View

20.

Joshi R, Hypes C, Greenberg J, Snyder L, Malo J, Bloom J . Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit. Ann Am Thorac Soc. 2016; 14(3):368-375. DOI: 10.1513/AnnalsATS.201606-472OC. View