大野 孝生

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.

ABSTRACT Introduction Tracheal intubation is an aerosol‐generating procedure that poses a high risk of infection for healthcare workers. While Level 3 personal protective equipment (PPE) is recommended, its effect on procedural performance remains uncertain. The objective of this study was to evaluate the association among Level 3 PPE use, first‐pass success, and adverse events during emergency department (ED) intubation. Methods We analyzed data from the Japanese Emergency Airway Network‐V, a multicenter prospective registry of 12 EDs in Japan. Adult patients, aged ≥ 18 years, who underwent emergency intubation between 2020 and 2022 were included. Level 3 PPE included disposable gloves, fluid‐repellent gowns or coveralls, filtering face piece 3 respirators, and eye protection. The primary outcome was first‐pass success, while secondary outcomes included major and minor adverse events, including hypotension, hypoxemia, cardiac arrest, and airway injury. Logistic regression with stabilized inverse probability of treatment weighting was performed to adjust for confounding variables. Results Of the 2431 patients, 1159 (47.7%) were intubated with Level 3 PPE. The unadjusted first‐pass success rate was higher with PPE (83.4% vs. 79.6%; p  = 0.02); however, adjusted first‐pass success did not differ significantly (risk difference−0.4%, 95% CI–6.3 to 5.5; p  = 0.88). After adjustment, major (0.8%, 95% CI–7.1 to 8.7) and minor (0.5%, 95% CI–2.2 to 3.2) adverse events showed no significant differences. Conclusions The use of Level 3 PPE was not associated with decreased success or increased adverse events, supporting its safe use during high‐risk procedures.

Abstract Background Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently discovered severe disorder that predominantly affects adult males, characterized by systemic inflammation and hematologic abnormalities. Despite its profound impact on patient outcomes, awareness of VEXAS syndrome among critical care providers remains severely limited, often leading to delayed recognition, diagnosis, and initiation of appropriate treatment. This study aims to address this knowledge gap by conducting a scoping review on VEXAS syndrome in the critical care setting. Methods This scoping review followed the PRISMA-ScR guidelines and Joanna Briggs Institute methodology, analyzing data from Cochrane CENTRAL, MEDLINE via PubMed, EMBASE, and Web of Science on May 19, 2024. We included studies that reported clinical features and treatments of patients with VEXAS syndrome requiring critical care. Results Of the 1262 reports identified, 78 reports met the inclusion criteria, including 45 case reports/series, 17 observational studies, 15 reviews, and one systematic review. Analysis of 55 cases revealed a median age of 69 with a strong male predominance (54/55). ICU admission rates ranged from 28 to 33%, with mortality rates between 18 and 40%. Critical manifestations included shock, hemophagocytic lymphohistiocytosis, acute respiratory distress syndrome, thrombosis, and airway edema. Sepsis was the leading cause of death, followed by other causes including VEXAS syndrome related organ failure, cardiovascular events, and intestinal perforation. Treatment approaches combined conventional critical care measures with immunosuppressive and immunomodulatory therapies, although infectious complications were frequently reported. Conclusion This review revealed the lack of systematically analyzed studies focusing on VEXAS syndrome in the critical care setting, suggesting a significant gap in understanding the clinical characteristics and optimal treatments for VEXAS syndrome. Further research focused on VEXAS syndrome in the critical care setting is essential to improve early recognition, develop standardized treatment protocols, and ultimately improve patient outcomes in this complex patient population.