渡瀬 博子

BACKGROUND: The effectiveness of pre-intubation bag-valve-mask (BVM) ventilation for rapid sequence intubation (RSI) in the emergency department (ED) remains uncertain. In this study, we investigated whether pre-intubation BVM ventilation was associated with a lower risk of peri-intubation hypoxemia. METHODS: We analyzed data from a multicenter prospective observational study conducted in 14 EDs across Japan. Adult (≥18 years) patients who underwent RSI between 2020 and 2023 were included. The primary outcome was peri-intubation hypoxemia (SpO₂ <90%), and the secondary outcome was regurgitation. Missing data were imputed using multiple imputations. Propensity scores were estimated using predefined covariates (age, sex, body mass index, COVID-19, modified LEMON score, intubation indication, device, intubator's specialty, preoxygenation method, pre-intubation SpO2, and participating institutions). Treatment effects were evaluated using stabilized inverse probability of treatment weighting (IPTW) and sensitivity analysis with 1:1 matching. RESULTS: Among the 1481 patients, 589 (40%) received pre-intubation BVM. Overall, 204 patients (14%) experienced peri-intubation hypoxemia. The BVM group had a lower unadjusted risk of hypoxemia than the non-BVM group (10% vs. 16%; p < 0.001). However, after stabilized IPTW, BVM ventilation was not significantly associated with hypoxemia (adjusted risk difference -3.2%; 95% CI, -7.8% to 1.5%). Sensitivity analysis using 1:1 matching yielded consistent results (risk difference 0.9%; 95% CI, -3.8% to 5.6%). There was no significant difference in the incidence of regurgitation between the BVM and non-BVM groups (1% vs. 1%; p = 0.24). CONCLUSION: In this multicenter study, pre-intubation BVM ventilation during RSI in the ED was not associated with a reduced risk of peri-intubation hypoxemia.

BACKGROUND: During the COVID-19 pandemic, the demand for tracheal intubations increased in emergency departmeants (EDs). We aimed to describe tracheal intubations during the COVID-19 pandemic in Japan and investigate the association between COVID-19 and intubation-related adverse events in EDs. METHODS: This is an analysis of a prospective observational multicenter study involving patients who underwent tracheal intubations in the ED between April 2020 and March 2023. Patients were divided into two groups: the COVID-19 group and the non-COVID-19 group. To examine the association between COVID-19 and the risk for adverse events during tracheal intubation, a multivariable logistic regression analysis was performed. Major adverse events were defined as cardiac arrest, hypotension, hypoxemia, and dysrhythmia. RESULTS: At 14 institutions, 1984 patients underwent tracheal intubations in the ED (287 in the COVID-19 group and 1697 patients in the non-COVID-19 group). Despite a significantly higher rate of first-attempt intubation success in the COVID-19 group, the incidence of peri-intubation adverse events was significantly elevated compared to the non-COVID-19 group (51.6 % vs. 17.1 %; p < 0.001). Hypoxemia was the most common adverse event. Multivariable regression analysis revealed that the COVID-19 group was significantly associated with a higher risk of adverse events (adjusted odds ratio, 1.69; 95 % confidence interval, 1.17-2.42; p = 0.005). CONCLUSIONS: Patients with COVID-19, though undergoing successfully intubations, remained at disproportionately higher risk for critical complications during airway management.

BACKGROUND: The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED. METHODS: We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods. RESULTS: Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events. CONCLUSION: The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.