Background: Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods: We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results: The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions: Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management. Trial registration: The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260). Keywords: Airway management, Air ambulances, Emergency medical services, Intubation, Data accuracy * Correspondence: firstname.lastname@example.org Norwegian Air Ambulance Foundation, Drøbak, Norway Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 2 of 16 Background simple adjuncts, such as an oropharyngeal airway”. This Pre-hospital advanced airway management (PHAAM) type of management includes the use of a supraglottic with the control of oxygenation and ventilation is vital airway device (SAD), tracheal intubation (TI), or emer- in the management of critically ill or injured patients in gency front of neck access (eFONA). the field and may contribute to better outcomes [1–3]. Results from research on PHAAM are challenged by Data variable heterogeneity in provider competence, airway tech- A data variable should be clearly defined to avoid misin- niques, and the quality of data collected in many airway terpretation. Data points should be simple to register studies . To improve pre-hospital critical care and to and possible to integrate into existing registries . develop evidence-based guidelines, research based on This requires a data variable dictionary containing infor- standardised high-quality data is important [5, 6]. Using mation on data number, name, type of data, categories a common and uniform set of data definitions may be or values and definition of data variable . the first step in such a process . In pre-hospital critical care research, there has been an Group of experts acceptance and tradition for using structured consensus The recruited experts were clinicians with leadership ex- methods to evaluate interventions, to develop guidelines, perience from pre-hospital critical care, had made sub- and for educational and research purposes [8, 9]. Tem- stantial contributions to airway management research or plates for documenting and reporting of standardised airway management guidelines, or were considered ex- data have been developed by similar methodology for perts in the field of PHAAM. They were recruited from out-of-hospital cardiac arrest, paediatric advanced life networks such as European Pre-hospital Research Alli- support, in-hospital cardiac arrest resuscitation, major ance (EUPHOREA) and the European Airway Manage- incidents and disaster management, laboratory cardio- ment Society (EAMS). The experts were invited by pulmonary research, major trauma, emergency medical individual email and were not aware of the composition dispatch, physician staffed emergency medical services of the group until the final consensus meeting. and drownings [10–19]. Developments in airway man- agement devices, airway management strategies and The modified nominal group process training, along with patient safety issues; require that The mNGT is a systematic qualitative method involving such templates are updated on a regular basis like clin- questionnaires in repeated rounds with a final meeting ical guidelines and recommendations . aimed at consensus . Our mNGT included three An Utstein-style airway template was published in email rounds with questionnaires and answers (QA), and 2009 by an international airway expert group . The a one-day consensus meeting for plenary discussions. A feasibility of collecting standardised airway data across fourth email round was included after the meeting for different patient populations and international emer- minor adjustments or comments. The results from each gency medical services (EMS) have been described . round were used to guide the development of the ques- The aim of this study was to update and revise the tionnaires for the following round. A third party distrib- Utstein-style template for the reporting of PHAAM data, uted and managed the responses from the experts in using a nominal group technique (mNGT) with inter- individual emails and anonymised the answers. The national experts to identify which data variables would mNGT was run from February to August 2017. The final be most important to document today. dataset was forwarded to the experts for approval. Methods Study design First email round The revision of the Utstein-style airway template was An Excel spreadsheet (Microsoft Corporation, Redmond, performed using a modified nominal group technique WA, USA) with the original template variables was sent (mNGT) consensus process, which has previously to the experts (Additional file 1: Table S1). The experts proven useful in the development of templates and were instructed to rate each variable on a 5-point Likert guidelines for pre-hospital critical care [9, 14]. scale (from 1 = “totally disagree” to 5 = “totally agree”) according to how important the variable was considered Pre-hospital advanced airway management to be for PHAAM and to indicate whether the original In the original template, advanced airway management variable should be changed. The experts were then re- was defined as the attempted insertion of an advanced quested to suggest between three and five new variables. airway adjunct or the administration of ventilatory as- Additional free-text comments were allowed. These sistance, in this context being “any airway management comments were not distributed to the other experts but beyond manual opening of the airway and the use of were used to revise the variables. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 3 of 16 Second email round First email round The revised variables were organised in the original tem- The experts made 127 unique suggestions for changes in plate sections, with the suggested new variables in the variable names, categories or values in 28 (44%) of the “optional variables section” (Additional file 2: Table S2). original variables. After merging similar suggestions and The experts were instructed to rank the most important variables, 15 variable names and 22 categories were re- variables within each section. Where relevant and for vised. Fifteen new variables were added to the dataset the ranked variables only, the experts indicated whether before the second email round (Additional file 2: Table changes were warranted. Additional free-text comments S2). This process is detailed in the flowchart (Fig. 1). were also possible in this round. Second email round Third email round The experts indicated that change was warranted for 24 The instructions for ranking and suggestions were similar (18%) variables and suggested 43 unique changes. to those of the previous round, with the revised variables Twenty-nine additional comments to improve the vari- now grouped in core-system, core-patient, core-post- ables were submitted. After ranking and merging similar intervention, or fixed-system sections (Additional file 3: suggestions, 27 variables were cut, leaving 51 variables Table S3). to be included in email round three. Following the ex- perts’ suggestions, the optional section was removed, The consensus meeting and its variables were distributed in the remaining sec- The aim of the consensus meeting was to finalise the tions (Additional file 3: Table S3). variable set and discuss items that had not been cleared during the first three rounds. The main results after the Third email round email rounds were presented, and the expert comments In this round, the experts indicated a need for change in from the preceding rounds were used to guide the dis- the variable name, category or definition for 23 (45%) cussions. The experts agreed by consensus on the variables, and provided ten additional comments to im- changes to the template structure or variables. prove the variables. The remaining variables were re- vised and formed the starting point for the discussions Ranking in the consensus meeting (Additional file 5: Table S4). We measured expert commitment towards each variable as the number of times the individual variable was nomi- The consensus meeting nated by the experts. Within each section, the variables The experts discussed the remaining 41 variables and rated as “most important” received the highest score, 10 “runner-up” variables. The experts agreed on a and those rated as “least important” received the lowest dataset including 32 operational variables with an score. If two variables scored equally, the variable with additional six system variables that were identical the highest number of individual nominations, compared across all missions, compared to 63 variables in the to those with highest rating, was ranked higher. original template (Tables 1, 2, 3, 4). Of the original variables, only one variable (age) remained un- Results changed. Nineteen original variables were modified in Experts terms of the variable name, category, definition or Twenty-one experts were invited to join the mNGT- value, and the experts added 16 new variables to the process, of whom sixteen participated in all email revised dataset. The experts agreed on a new template rounds. The experts were recruited from Australia, structure with time, patient, airway management and United States of America, and Europe. The level and system sections. The recording of PHAAM data was type of airway experience, along with country of origin to cover the interval from the patient encounter on of the expert group, is described in Additional file 4.Of scene to when post-intervention ventilation was estab- the experts who participated, eight attended the final lished, and survival to hospital (short-term survival). consensus meeting, along with five members of the pro- ject steering group. Discussion Main results Definition of PHAAM Using a modified nominal group process with inter- The expert group decided to keep the definition of national airway experts, supported by clinical study re- advanced airway management unchanged from the sults with the original template described in the recent original template, as “the attempted insertion of an AIRPORT studies, we have revised the template for the advanced airway adjunct or administration of ven- reporting of standardised data from PHAAM [22, 23]. tilatory assistance”. The updated dataset includes new data points that Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 4 of 16 Fig. 1 Flowchart describing the modified nominal group technique. The original variables were modified or deleted, and new variables inserted according to the experts’ comments and suggestions at each stage. Similar suggestions and variables were merged Table 1 Final time variables FINAL TIME VARIABLES (data provided by provider performing the intervention) Number Data Type of Data variable Definition of variable name data categories or values data variable 1 Response Continuous Minutes Time from the Emergency Medical Dispatch (EMD) initiated time transmission of message to the EMS unit, until the time of arrival of the EMS unit at the patient. 2 On-scene Continuous Minutes Time from EMS unit arrival at the patient until time of patient time leaving scene (or time of death if dead on scene). 3 Transport Continuous Minutes Time from patient departure from scene until patient arrival time at hospital. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 5 of 16 Table 2 Final patient variables FINAL PATIENT VARIABLES (data provided by provider performing the intervention) Number Data variable Type of Data variable categories Definition of data variable name data or values Choose only one option unless otherwise stated. 4 Age Continuous YY Years rounded down. Ages under 1 year are reported in decimals (e.g. 6 months = 0.5 year) 5 Gender Nominal 1 = Female Patient gender 2 = Male 3 = Other / Unknown 6 Patient Nominal 1 = Trauma - Blunt Dominating reason for category 2 = Trauma – Penetrating emergency treatment 3 = Trauma - Head injury TBI = Traumatic Brain Injury (including TBI) 4 = Trauma - Other (including burns, strangulation, drowning, or asphyxiation) 5 = Medical - Cardiac arrest 6 = Medical - Respiratory distress or breathing difficulties 7 = Medical – Intoxication 8 = Medical - Infection (including sepsis) 9 = Medical - Other (e.g. endocrinology or other medical emergencies) 10 = Neurology - Stroke (including cerebral haemorrhage or infarction) 11 = Neurology - Other (excluding stroke) 12 = Psychiatry (e.g. agitation/psychosis) 13 = Obstetrics 14 = Other emergencies, describe: ______ 15 = Unknown 7 Indication for Nominal 1 = Decreased level of consciousness Indications for airway airway 2 = Hypoxemia intervention. intervention 3 = Ineffective ventilation Select all that apply. 4 = Existing airway obstruction 5 = Impending airway obstruction 6 = Combative or uncooperative 7 = Humanitarian (e.g. relief of pain or distress) 8 = Cardiac arrest 9 = Pre-existing airway device (e.g. SAD) not working adequately 10 = Other, describe: ____________ 8 Patient risk Nominal 1 = No risk factors for difficult intubation Airway assessment factors for 2 = Prior difficult intubation before or during intervention difficult 3 = Reduced neck mobility, showing patient risk factors intubation neck-immobilization device or for difficult intubation, e.g. poor manual in-line stabilisation (MILS) visualisation, foreign 4 = Severe obesity or thick/short neck body, blood or saliva. 5 = Limited mouth opening or SAD = Supraglottic inter incisor distance < 4 cm airway device 6 = Short Thyroid-Mental-Distance (< 6.5 cm) Select all that apply. 7 = Significant maxillofacial or upper airway trauma 8 = Blood, vomit, mucus or hypersalivation in airways 9 = Pre-existing airway device (e.g. SAD) not working adequately 10 = Other, describe: ______ 11 = Risk factors not assessed. 9 Aggravating conditions for Nominal 1 = Patient entrapped Patient entrapped means airway management during airway management physically restrained in 2 = Not 360-degree access wreckage, etc. to patient during airway management Not 360-degree access means 3 = Suboptimal provider positioning restricted access for providers 4 = Bright light/sunlight to all parts of patient, e.g. cannot 5 = Darkness move freely around patient or 6 = Hostile environment patient cannot be positioned on 7 = In moving helicopter/ambulance half-high stretcher for intubation. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 6 of 16 Table 2 Final patient variables (Continued) FINAL PATIENT VARIABLES (data provided by provider performing the intervention) 8 = In stationary Suboptimal provider helicopter/ambulance positioning means suboptimal 9 = Other, describe: ____ intubating positioning, e.g. patient flat on ground during CPR with provider kneeling low or lying. Hostile environment means environment containing physical, chemical, biological, radioactive or other threats to provider safety (e.g. “active shooter” scenario). Select all that apply. 10 Respiratory rate, initial Continuous 1 = Number, describe Initial value (Baseline) and 2 = NA: Did not measure recorded on scene. Nominal 3 = NA: Could not measure NA = Not available 11 Blood pressure, initial Continuous 1 = Number, describe Initial value (Baseline) and (Syst-BP/Dias-BP (MAP)) recorded on scene. Nominal 2 = NA: Did not measure NA = Not available 3 = NA: Could not measure 12 SpO , initial Continuous 1 = Number, describe Initial value (Baseline) and 2 = NA: Did not measure recorded on scene. Nominal 3 = NA: Could not measure NA = Not available 13 Blood pressure, Continuous 1 = Number, describe Lowest value prior to lowest prior to and (Syst-BP/Dias-BP (MAP)) airway management airway management 2 = NA: Did not measure recorded on scene. Nominal 3 = NA: Could not measure NA = Not available 14 SpO , lowest prior to Continuous 1 = Number, describe Lowest value prior to airway management and 2 = NA: Did not measure airway management Nominal 3 = NA: Could not measure recorded on scene. NA = Not available 15 Blood pressure, Continuous 1 = Number, describe Lowest value during lowest during and (Syst-BP/Dias-BP (MAP)) airway management airway management Nominal 2 = NA: Did not measure recorded on scene. 3 = NA: Could not measure NA = Not available 16 SpO , lowest during Continuous 1 = Number, describe Lowest value during airway management and 2 = NA: Did not measure airway management Nominal 3 = NA: Could not measure recorded on scene. NA = Not available 17 Glasgow Coma Score Continuous 1 = Sum GCS Initial value (Baseline) (GCS), initial and (Motor + Verbal + Eyes) recorded on scene. Nominal 2= NA NA = Not available 18 Glasgow Coma Score Continuous 1 = Sum GCS (Motor + Verbal + Eyes) Lowest value prior to (GCS), lowest prior to and 2= NA airway management airway management Nominal recorded on scene. NA = Not available reflect risk factors for difficult PHAAM, the use of populations and services, these intervals are valuable for checklists and standard operating procedures (SOPs), describing the EMS response, which is also closely strategies for pre-oxygenation, the use of drugs in linked to the efficiency of the dispatch process . PHAAM, airway currency training, developments in air- way devices, airway management strategies, and patient Patient variables safety issues not previously described in the Utstein-style Patient age and sex should be included in any study airway template. population demographics . We have previously shown a non-linear association between patient age and the Time variables first-attempt TI failure rates and that a significant age Three time intervals are important for describing a pre- difference exists between trauma and non-trauma pa- hospital response adequately: the response time, on- tients intubated by physician-staffed helicopter emer- scene time, and patient transport time to the hospital. In gency medical services (HEMS), indicating that it is comparing EMS or dispatch services across patient important to include age in a PHAAM dataset . A Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 7 of 16 Table 3 Final airway management variables FINAL AIRWAY MANAGEMENT VARIABLES (data provided by provider performing the intervention) Number Data variable Type of Data variable Definition of name data categories or values data variable Choose only one option unless otherwise stated. 19 Use of checklist Ordinal 1 = Written Written checklist for airway checklist available for airway management management and used on scene including rapid sequence 2 = Written checklist induction (RSI) available in available, but not used service and used on-scene 3 = No checklist available (challenge and response system). 20 Oxygenation Ordinal 1 = Preoxygenation with Oxygenation strategies strategy for non rebreathable face used before or during airway management mask before airway attempt advanced airway management. 2 = Preoxygenation with Select all that apply. Bag-valve-mask (BVM) before airway attempt 3 = Apnoeic oxygenation during airway attempt 4 = No preoxygenation 21 Sequence Nominal ☐☐ Emergency Medical Specify level of EMS of providers Technician provider in sequence, performing ☐☐ Paramedic who performed each airway management ☐☐ Nurse (non-anaesthesia) airway management ☐☐ Nurse (anaesthesia) attempt, numbered in ☐☐ Physician (General practitioner order of attempt. or other non-EP/ICU/ Select all that apply. Anaesthesiologist) Specify number of ☐☐ Physician (Emergency attempt alongside Physician - EP) corresponding provider ☐☐ Physician (Intensivist - ICU) with “1” and if more ☐☐ Physician (Anaesthesiologist) attempts “2”, “3”,“4”. ☐☐ Unknown E.g.: If paramedic fails first attempt, then physician has two attempts, this is recorded as: “1” Paramedic. “2–3” Physician. Select all that apply. 22 Sequence of airway Nominal ☐☐ Bag-valve-mask ventilation (BVM) Specify first attempt devices used for ☐☐ Supraglottic airway device with with “1” and if more airway management suction attempts “2”, “3”,“4”. ☐☐ Supraglottic airway device E.g.: If first attempt without suction fails with endotracheal ☐☐ Direct laryngoscopy with intubation and direct endotracheal tube laryngoscopy, and the ☐☐ Direct laryngoscopy with next two attempts are endotracheal tube and stylet endotracheal intubation ☐☐ Direct laryngoscopy with with video laryngoscopy, bougie and endotracheal tube this is recorded as: ☐☐ Video laryngoscopy “1” Direct laryngoscopy (Macintosh or Miller like blade) with endotracheal tube with endotracheal tube “2–3” Video laryngoscopy ☐☐ Video laryngoscopy (Macintosh or Miller like blade) (Macintosh or Miller like blade) with endotracheal tube with endotracheal tube and stylet BVM = Bag-valve-mask ☐☐ Video laryngoscopy ventilation, includes (Macintosh or Miller like blade) insertion of oro/ with bougie and endotracheal tube nasopharyngeal airway. ☐☐ Video laryngoscopy If bag-valve-mask ventilation (hyperangulated blade) prior to RSI, choose “BVM” as “1”. with endotracheal tube Video laryngoscopy (VL) ☐☐ Video laryngoscopy differentiates between: (hyperangulated blade) VL with Macintosh/miller with endotracheal tube and stylet like blade VL with hyperangulated blade Select all that apply. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 8 of 16 Table 3 Final airway management variables (Continued) FINAL AIRWAY MANAGEMENT VARIABLES (data provided by provider performing the intervention) ☐☐ Video laryngoscopy (hyperangulated blade) with bougie and endotracheal tube ☐☐ Surgical emergency airway equipment ☐☐ Percutaneous emergency airway equipment ☐☐ Jet-ventilation equipment ☐☐ Other, describe: _______________ ☐☐ Unknown 23 Airway management Ordinal 1 = Successful airway ET = Endotracheal tube results management with SAD = Supraglottic ET as planned airway device 2 = Successful airway management with SAD as planned 3 = Successful airway management with surgical airway as planned 4 = Failure of primary airway plan, and airways secured by alternative technique 5 = Final airway management failed (loss of airways) 6 = Unknown 24 Airway manoeuvres Nominal 1 = Cricoid pressure released Airway manoeuvres following failed 2 = BURP/ELM manoeuvres following unsuccessful airway attempt. 3 = Release MILS airway management attempts. 4 = Reposition patient BURP = Backwards 5 = Ramping patient upwards rightwards pressure. 6 = None / Not applicable. ELM = External laryngeal manipulation MILS = Manual In-line stabilisation Ramping = The head and trunk are elevated or supported to align the external auditory meatus with the sternal notch in the horizontal plane Select all that apply. 25 Drugs used Nominal 1 = None Drugs used to facilitate to facilitate 2 = Thiopental the actual airway intervention, airway management 3 = Ketamine not including sedation in the 4 = S-ketamine post-intervention 5 = Propofol or transport phase. 6 = Fentanyl Vasopressor includes any 7 = Alfentanil drug used as vasopressor 8 = Morphine during airway management, 9 = Midazolam e.g. phenylephrine. 10 = Diazepam Local anaesthetic includes 11 = Suxamethonium any drug used as local or 12 = Rocuronium regional anaesthetic, e.g. lidocaine. 13 = Vasopressor Select all that apply. 14 = Lidocain 15 = Etomidate 16 = Other, describe: ________________ 26 Complications Nominal 1 = ET misplaced Complications recognised during airway in oesophagus AND during airway management management recognised/corrected immediately or device verification 2 = ET misplaced in (and NOT present oesophagus and NOT before the airway management). recognised/corrected immediately Select all that apply. 3 = ET misplaced in left or right ET = Endotracheal tube, main stem bronchus SAD = Supraglottic airway device Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 9 of 16 Table 3 Final airway management variables (Continued) FINAL AIRWAY MANAGEMENT VARIABLES (data provided by provider performing the intervention) 4 = Incorrect positioning or The following definitions difficult ventilation with SAD are used:Hypoxia: Adults 5 = Dental trauma and children: SpO2 < 90% 6 = Aspiration or Hypotension: vomiting during infants < 1 year: SBP < 70 mmHg airway management children 1 to 10 years: SBP < 70 + (2 × age) (and NOT present before) children > 10 years: SBP < 90 mmHg 7 = Cardiac arrest during adults: SBP < 90 mmHg or decrease > airway management 10% from baseline value 8 = Hypoxia during Bradycardia airway management newborn to 3 years: 9 = Bradycardia during < 100 bpm airway management 3 to 9 years: < 80 bpm 10 = Hypotension 10 to 16 years: < 60 bpm during airway management adults: < 50 bpm 11 = Complications during Select all that apply. surgical or percutaneous airway (e.g. bleeding or pneumothorax) 12 = No complications (confirmed) during airway management 13 = Insufficient data recording, complications unsure. 27 Total number Ordinal 0 = < 10 Total number of of successful 1= 11–25 successful endotracheal endotracheal 2= 26–50 intubations the provider intubations the 3= 51–100 has performed in patients provider has 4 = 101–250 in hospital and pre-hospital performed 5 = 251–1000 service, not including mannequin in patients 6 = 1001–2500 intubations or SAD. 7 = > 2500 28 Blood pressure, Continuous 1 = Number, describe Value recorded after finalised and (Syst-BP/Dias-BP (MAP)) within 1–3 min after airway management Nominal 2 = NA: Did not measure finalised airway management 3 = NA: Could not measure 29 SpO , after Continuous 1 = Number, describe Value recorded finalised airway and 2 = NA: Did not measure within 1–3 min after management Nominal 3 = NA: Could not measure finalised airway management 30 EtCO , after Continuous 1 = Number, describe Value recorded finalised airway and 2 = NA: Did not measure within 1–3 min after management Nominal 3 = NA: Could not measure finalised airway management 31 Ventilation, after Nominal 1 = Spontaneous ventilation Main mode of ventilation finalised airway 2 = Controlled manual ventilation on-scene and during management 3 = Controlled mechanical transport of patient ventilation (ventilator) following finalised 4 = Mixed ventilation airway management. 5 = Unknown If both spontaneous and controlled ventilation, choose “mixed ventilation” 32 Survival to hospital Nominal 1 = Dead on-s Patient survival status cene after ALS interventions limited to pre-hospital 2 = Alive on hospital treatment and arrival at arrival (including patients being transported with hospital (Short term survival) on-going mechanical ALS = Advanced Life Support chest compressions or ECPR) ECPR = extracorporeal 3 = Unknown cardiopulmonary resuscitation sex difference has also previously been described in itself. While the patient category is among the vari- emergency airway management . ables most consistently reported (86%) in airway stud- Category describes the dominating reason for the ies, indication is less frequently reported (36%) . emergency treatment, while indication describes the Describing trauma cases, differentiating between blunt dominating indication for the airway intervention trauma and penetrating trauma may be important, as Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 10 of 16 Table 4 Final system variables FINAL SYSTEM VARIABLES (data provided by Medical Director EMS) Number Data variable Type of data Data variable Definition of data variable name categories or values Choose only one option unless otherwise stated. 33 Established Ordinal 1 = Yes, SOP with SOP including airway management Checklist algorithm for difficult procedure (SOP) 2 = Yes, SOP only intubation 3 = No SOP (expected/unexpected) available in EMS service. 34 Type of Nominal 1 = Clinical rotation Clinical rotation: airway currency with regular airway describes system training in service management practise with regular airway (e.g. anaesthesia) management currency 2 = Regular airway (e.g. anaesthesia practise). management currency Regular airway management assessments (e.g. RSI simulation) currency assessment 3 = Regular mannequin training (e.g. RSI simulation) 4 = Regular cadaver training describes systems with 5 = Other, describe simulation or virtual training for airway management currency. Cadaver and mannequin describes systems with regular airway management skill training. Select all that apply. 35 Type of tracheal Nominal 1 = Auscultation only Capnometry is a tube confirmation 2 = Capnometry only measurement of technique used 3 = Waveform capnography ETCO i.e., analysis alone) in service 4 = Colorimetric detector (e.g. Easycap) without a continuous 5 = Ultrasound written record or waveform. 6 = Other, describe: _______________ Waveform capnography 7 = None includes waveforms of inspiration and expiration pattern along with values for ETCO . Select all that apply. 36 Airway management Nominal 1 = Bag-valve-mask ventilation Airway devices devices used in service 2 = Supraglottic airway available in service device with suction and provider who 3 = Supraglottic airway knows how to use it. device without suction Bag-valve-mask 4 = Direct laryngoscopy ventilation includes with endotracheal tube insertion of (including bougie and/or stylet). oro/nasopharyngeal airway. 5 = Video laryngoscopy Video laryngoscopy with Macintosh or Miller (VL) differentiates between: like blade and endotracheal VL with Macintosh/ tube (including bougie and/or stylet). miller like blade 6 = Video laryngoscopy VL with hyperangulated blade with hyperangulated blade Select all that apply. and endotracheal tube (including bougie and/or stylet). 7 = Surgical emergency airway equipment 8 = Percutaneous emergency airway equipment 9 = Jet-ventilation equipment 10 = Other, describe: _______________ 11 = Unknown 37 Drugs for Nominal 1 = None Drugs used for airway airway management 2 = Thiopental management, available available in service 3 = Ketamine on scene and someone c 4 = S-ketamine ompetent to administer them. Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 11 of 16 Table 4 Final system variables (Continued) FINAL SYSTEM VARIABLES (data provided by Medical Director EMS) 5 = Propofol Select all that apply. 6 = Fentanyl 7 = Alfentanil 8 = Morphine 9 = Midazolam 10 = Diazepam 11 = Suxamethonium 12 = Rocuronium 13 = Vasopressor 14 = Lidocain 15 = Etomidate 16 = Other, describe: ______________ 38 Highest Level Nominal 1 = Emergency Highest level of EMS provider Medical Technician (EMT) of EMS provider involved in airway management on-scene 2 = Paramedic present on scene 3 = Nurse (non-anaesthesia) and involved in 4 = Nurse (anaesthesia) airway management; 5 = Physician including assessment, (General practitioner or drugs or intervention. other non-EP/ICU/Anaesthesiologist) 6 = Physician (Emergency Physician - EP) 7 = Physician (Intensivist - ICU) 8 = Physician (Anaesthesiologist) 9 = Unknown strategies for both airway management and haemor- Glasgow coma score (GCS), the experts also found that rhage control can differ between these groups . recording the lowest value prior to and during the air- Traumatic brain injury (TBI) is another major cat- way intervention was important. The recording of end- egory where treatment options may differ, and airway tidal carbon dioxide (ETCO ) after finalised PHAAM is management competence is linked to mortality in this important to confirm tube placement but may also be group . In non-trauma patients, the experts beneficial for optimising advanced life support (ALS) agreed that distinguishing between cardiac arrest; . neurological emergencies; respiratory distress or breathing difficulties; intoxication; infection (including sepsis); and other medical emergencies may be im- Airway management variables portant when describing PHAAM. The use of pre-TI checklists for PHAAM to reduce ad- Airway assessment is an integral part of providing verse events and improve patient safety is recommended safe pre-hospital anaesthesia and advanced airway man- . However, a recent multicentre randomised trial of agement. Patient risk factors for difficult bag-valve- checklist use in rapid sequence intubation (RSI) found mask (BVM) ventilation or TI were not included in the no reduction in complication rates compared to stand- original template. Optimal patient positioning may ard practice without checklists . While experienced maximise the chance of successful PHAAM . And, providers may rely on mental checklists, inexperienced the pre-hospital setting contains some unique external providers may depend on written checklists in a chal- factors, which may influence access to the patient and lenge and response system. The experts agreed that the hence airway management success [28, 29]. The expert airway dataset should only document whether a written panel agreed that such risk factors should be described checklist is available on scene and whether the checklist in the dataset. was used. Key vital signs are commonly used to assess the The Difficult Airway Society recommends that pre- physiological status of patients in many clinical settings induction airway plans are briefed to the team and that . The experts agreed that single values, not ranges failure of primary or secondary airway plans are clearly of measurements, should be recorded in general. declared to facilitate control of the patients’ airways and Agreeing on the necessity of an initial baseline meas- to avoid complications . Although a prediction of a urement of the patient’s respiratory rate (RR), blood difficult airway is not always reliable, a planned and ver- pressure, peripheral oxygen saturation (S O )and balised pre-induction airway plan should be in place P 2 Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 12 of 16 prior to an RSI [20, 34]. The experts agreed that record- integral part of a patient safety culture. Rescue manoeu- ing whether PHAAM was successful as planned and vres, such as backwards-upwards-rightwards-pressure or documenting whether the final airway attempt failed external laryngeal manipulation are manoeuvres com- were important. monly used to optimise TI conditions .This was not There is evidence for an association between airway included in the original template, but the experts found management skills and patient outcomes in PHAAM that describing these manoeuvres in the revised dataset [27, 35]. Poorly performed airway management carries was useful. significant mortality and morbidity risks, and adequate In recent years, video laryngoscopy (VL) has been in- training and experience is important for patient safety creasingly used in airway management [42, 43]. Al- . As success and complication rates are also associ- though VL may improve the glottic view and be ated with provider competence and experience, the ex- beneficial in the context of a difficult airway, little evi- perts found that recording the level and sequence of dence exists today showing that VL reduces the number providers performing the actual airway interventions of TI attempts or airway complication rates, compared was necessary . Specifying the sequence of providers to direct laryngoscopy (DL) [44, 45]. As a technique in- may provide new knowledge of PHAAM, especially volving an airway device, VL was not included in the ori- where primary airway management fails and an unantici- ginal template. The benefit of VL in PHAAM still needs pated difficult airway in the field must be handled. Fur- to be demonstrated, therefore the main types of VL and thermore, the results from airway studies are difficult to DL were included in the revised dataset. interpret and compare without such information. The The possibility of isolating different generic drugs used total number of successful TIs the provider has per- for PHAAM across patient categories might provide formed in patients in hospital and in pre-hospital service new knowledge, and the experts agreed to include the may be regarded as a reasonable surrogate for total air- most common generic drugs used in PHAAM today. way competence . The experts agreed that survival to hospital (short- Patient pre-oxygenation is standard practice during term survival) should be recorded. Additionally, “dead any anaesthesia induction, aiming at maximising the on arrival” implies that no ALS procedures have been oxygen reserves and delaying the onset of desaturation provided and should not be included. Rather, “dead on- for several minutes in the event of a failed or difficult scene after ALS interventions” or “alive on hospital ar- primary airway intervention . Strategies for pre- rival” should be documented. This categorisation in- oxygenation have improved over the last decades, target- cludes patients being transported to the hospital with ing both the pre-induction phase, and the apnoea time on-going mechanical chest compressions or extracor- after the induction of anaesthesia . Pre-oxygenation poreal cardiopulmonary resuscitation (ECPR) . was not included in the original template; however, the experts agreed that as pre-oxygenation might have a cru- System variables cial effect on avoiding hypoxia during the apnoeic phase SOPs, including algorithms for unexpected difficult air- of TI and should be recorded . way management, are emerging as an indispensable part Although RSI is standard practice for emergency anaes- of patient safety and quality systems . The experts thesia in patients with a risk of pulmonary aspiration, the agreed that recording whether airway management SOPs definition of RSI may not be uniform across international are available in the individual EMS is important, also EMS services [32, 40]. RSI implies a transition from full recognising the importance of developing robust clinical consciousness with intact airway reflexes to complete un- governance systems for pre-hospital critical care . consciousness. Ensuring optimal TI conditions with a high The experts agreed that the types of recurring airway first pass success rate, backed up by rehearsed airway plans management training provided by the EMS systems are should the primary TI attempts fail, is important [20, 34]. important to record. Although the use of NMBA may increase TI success rates, a setting where the patient is rendered apnoeic may be Value of standardised data challenging if primary airway management fails . To be able to compare interventions or level of care The most critical part of PHAAM may be the airway across systems, standardized research data using com- intervention itself, especially when performed during sub- mon terminology, data definitions or quality indicators optimal conditions in the field . Limiting the number are required . Developing common variables and of attempts is recommended, before declaring failed TI definitions is an on-going process and it is important to and proceeding with an alternative airway device . identify the correct variables to use in airway research Thus, specifying the number of attempts and type of de- projects and for benchmarking of airway management vice used in each attempt in sequential order may be im- across EMS . The results from consensus processes portant when documenting airway complications as an such as ours are not the endpoint, as dissemination and Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 13 of 16 implementation of the results into clinical service are Additional files the final aims . A few EMS have successfully imple- Additional file 1: Questionnaire first email round. (XLSX 24 kb) mented the original template into clinical service; how- Additional file 2: Questionnaire second email round. (XLSX 21 kb) ever, endorsement by internationally recognised airway Additional file 3: Questionnaire third email round. (XLSX 20 kb) societies, research groups, or key EMS stakeholders, Additional file 4: Expert group composition. (DOCX 140 kb) along with interoperable health information systems, Additional file 5: Questionnaire consensus meeting. (XLSX 17 kb) may be vital to secure a broad implantation of the airway template in international EMS [8, 50, 51]. The feasibility of collecting airway and trauma data Abbreviations ALS: Advanced life support; BVM: Bag-valve-mask; DL: Direct laryngoscopy; using standardised templates have been shown, and it is ECPR: Extracorporeal cardiopulmonary resuscitation; eFONA: Emergency front important that data in comparative research projects are of neck access; EMS: Emergency medical services; ETCO : End-tidal carbon collected in a uniform manner [22, 48, 52]. To date, dioxide; GCS: Glasgow coma score; HEMS: Helicopter emergency medical services; mNGT: Modified nominal group technique; NMBA: Neuromuscular twenty-two articles have described data collection blocking agents; PHAAM: Pre-hospital advanced airway management; methods adhering to, or adapted to, the original Utstein- QA: Questionnaires and answers; RR: Respiratory rate; RSI: Rapid sequence style airway template [3, 5, 8, 21–23, 50, 52–66]. A further intubation; SAD: Supraglottic airway device; SOP: Standard operating procedure; S O : Peripheral oxygen saturation; TBI: Traumatic brain injury; P 2 twenty-three articles have referred to the original publica- TI: Tracheal intubation; VL: Video laryngoscopy tion [6, 8, 13, 16, 35, 36, 41, 67–82]. However, as technol- ogy evolves, the availability of new possibilities of data Acknowledgements Our sincerest thanks go to the international airway expert group who made capture from devices like video or body cameras, or this study possible: Ilkka Virkkunen, Wolfgang Voelckel, Peter Paal, Lorenz streaming of monitor data directly to hospital data sys- Theiler, Massimiliano Sorbello, Richard Lyon, Kate Crewdson, Brian Burns, Leif tems, may influence this kind of research [83, 84]. There- Rognås, Björn Hossfeld, Alasdair Corfield, Daniel Davis, Tomasz Gaszyński, and Pavel Michalek. We extend a special gratitude to international research fore, how study data are obtained may be important to coordinator Kirsti Strømmen Holm at the Norwegian Air Ambulance document to increase accuracy of data. Foundation for her invaluable work in coordinating all QAs in the email rounds with the experts and arranging the consensus group meeting. Lastly, we extend our appreciation to the Lærdal Foundation for their support Limitations towards the consensus meeting of the international airway experts. The scientific value of consensus methods, such as mNGT Funding or the Delphi surveys, have been questioned, and no Financial support and sponsorship: The Norwegian Air Ambulance method is considered a “gold standard” . Nonetheless, Foundation funds the part time PhD-grant (50%) for GAS, the full time PhD- consensus methods are useful tools to assess agreement grant for AK, and is the main funding source of the academic positions for two of the supervisors (JKH and SJMS). The SICPA Foundation granted AK for on questions for which hard evidence is difficult to obtain. a research fellowship in Norway. The participating experts received no We believe that recruiting a broad panel of experts ac- financial support for their participation in this study. A grant of 75 000 NOK cording to predefined criteria, from fourteen countries (Grant 3341) was awarded from the Lærdal Foundation towards two projects: one revising the airway template and one developing quality indicators for across Europe, Australia and United States of America, pre-hospital airway management. The grant contributed to the may have reduced a possible selection bias and yielded a accomplishment of the consensus meeting of experts. The Norwegian Air representative list of variables with scientific value. Keep- Ambulance Foundation and the Lærdal Foundation, however, had no authority in any part of the study design, project management, data ing the preliminary email rounds and proposals anonym- collection, data analysis or interpretation, writing of the manuscript or ous from round one to three was important to avoid the publication. influence of “loud-speaking” experts and to reduce the ef- fect of a strong reputation or opinion on other more “si- Availability of data and materials The datasets generated during this study are included in this published lent-speaking” experts . Each QA round was handled article. confidentially so that the experts were not aware of the answers or comments from the other experts. Authors’ contributions GAS conceived the study, designed the study protocol, was responsible for the ethical applications in Norway, developed the questionnaires for the Conclusions consensus rounds, contributed to the data collection and analysis, and wrote the first and final drafts of the manuscript. AK conceived the study, designed Using a mNGT with international experts, we have up- the study protocol, developed the questionnaires for the consensus rounds, dated the dataset to report standardised data from pre- contributed to the data collection and analysis, and helped draft the hospital advanced airway management. The dataset en- manuscript. JKH aided in the design of the study protocol, contributed to the data collection and analysis, and helped draft the manuscript. MS ables future airway management research to produce contributed to the data collection and analysis and helped draft the comparable high-quality data across emergency medical manuscript. MG contributed to the data collection and analysis and helped systems. We believe this approach will promote research draft the manuscript. AKR aided in the design of the study protocol, contributed to the data collection and analysis, and helped draft the and improve treatment strategies and outcomes for pa- manuscript. DL aided in the design of study and the drafting of the tients receiving pre-hospital advanced airway manage- manuscript. SJMS aided in the design of the study protocol, contributed to ment.’ the data collection and analysis, moderated the consensus meeting, and Sunde et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:46 Page 14 of 16 helped draft the manuscript. All authors read and approved the final 12. Idris AH, Becker LB, Ornato JP, Hedges JR, Bircher NG, Chandra NC, et al. manuscript. Utstein-style guidelines for uniform reporting of laboratory CPR research. A statement for healthcare professionals from a task force of the American Heart Association, the American College of Emergency Physicians, the Ethics approval and consent to participate American College of Cardiology, the European resuscitation council, the Not applicable. The Regional Committee for Medical and Health Research Heart and Stroke Foundation of Canada, the Institute of Critical Care Ethics in Western Norway exempted this study from ethical review as it did Medicine, the Safar Center for Resuscitation Research, and the Society for not include human research data (Reference: REK-Vest/2017/260). Academic Emergency Medicine. Writing group. Circulation. 1996;94:2324–36. 13. Kruger AJ, Lockey D, Kurola J, Di Bartolomeo S, Castren M, Mikkelsen S, et al. Competing interests A consensus-based template for documenting and reporting in physician- The authors declare that they have no competing interests. staffed pre-hospital services. 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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
– Springer Journals
Published: Jun 4, 2018