Integrating Rapid Cardiopulmonary and Gastric Ultrasound for Emergency Airway Management in Critically Ill Patients: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only-View in Physiologically Difficult Airway.

OBJECTIVES: Tracheal intubation in critically ill patients is associated with significant morbidity and mortality. Point-of-care ultrasound (POCUS) may help with hemodynamic optimization and customization of management plans to the patient's tenuous physiology to prevent cardiopulmonary collapse. We report the integration of POCUS in the emergency airway management (EAM) of critically ill patients at a tertiary care academic medical center. DESIGN: Our study is a retrospective, exploratory research project. We evaluated the feasibility of using Echocardiography Assessment using Subcostal-only-view in Physiologically Difficult Airway (EASy-PDA) protocol to prevent peri-intubation hemodynamic compromise during EAM. SETTING: This study took place at a tertiary academic medical center where requests for EAM were answered by anesthesiologists. SUBJECTS: The EASy-PDA protocol was performed on 30 patients with PDA outside of the operating room in need of EAM. INTERVENTIONS: The EASy-PDA protocol included the acquisition of subcostal four-chamber (SC4C) and inferior vena cava (IVC) images, supplemented by focused lung and gastric ultrasonography. Trained anesthesiology residents performed EASy-PDA examinations before airway management, and subsequently assigned hemodynamic phenotypes based on qualitative assessment of biventricular chamber size, myocardial wall thickness and function, and IVC size and collapsibility. Management was then tailored based on hemodynamic phenotyping. MEASUREMENTS AND MAIN RESULTS: The mean time to complete the EASy-PDA examination was 2.40 minutes. SC4C image could not be obtained in one patient due to severe abdominal pain. Images obtained solely via the EASy-PDA examination were sufficient to inform further patient management in 26 patients (86.7%), with one patient requiring emergent pericardial window creation and two patients requiring gastric decompression before intubation based on examination findings. CONCLUSIONS: We were able to show the feasibility of integrating the EASy-PDA protocol into the management of emergent airways. In our case series, we observed that the EASy-PDA examination findings guided hemodynamic optimization before EAM in critically ill patients. This approach may help reduce intubation-associated morbidity and mortality. Further studies are needed to assess the impact of integration of EASy protocol during EAM on patient outcomes.