EBM Mini-Presentation Summaries 10/12/16

Head of Bed Elevated Intubation

By Dr. John Laack

Brief patient presentation
An adult patient with respiratory failure that still has pulses needs intubation.

Clinical question – PICO
P: In adult patients not undergoing CPR, what is the best patient positioning to suggest successful endotracheal intubation.
I: Head of bed elevated positioning, maintaining ear to sternal notch
C: Supine positioning as classically approached
O: Head of bed elevated intubations facilitate fewer intubation related complications or difficult airway scenarios. They also have great physician satisfaction compared to the classic supine approach.

Available research – list references
• Khandelwal, et al. Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and ICU. Anes & Analg. 4/2016 – Retrospective study with endpoint of intubation related complications (difficult intubation, hypoxia, esophageal placement, aspiration). Took into account obesity, Mallampati score, ASA, LEMON, and non anesthesiologist intubations. It included all intubations outside of the OR, but patients undergoing CPR and pediatrics were excluded. N=528 with 336 patients in the traditional supine position and 192 in the elevated position. The supine group had at least one complication in 22% compared to 9% in the head elevated position. This trend was consistent even when factoring in the more difficult patient factors (such as ASA and Mallampati). Furthermore, the head elevated group had less hypoxia, fewer attempts, less aspiration, and less esophageal placement.
• Turner, et al. Cross-over study of novice intubators performing ET intubation – upright versus supine position. Intern Emerg Med. 6/2016. – Cross over study that compared tracheal success rate in supine vs elevated positions. Secondary outcomes were time to placement, the view obtained, and provider satisfaction. This was performed on SIM mannequins by 34 medical students, 84 PA students, and 8 EMS students. They all received a brief training period prior to the first intubation attempt. These students had a 90.5% success rate in the supine position vs 97.6% in the elevated position (p=0.283). This was only a trend and not statistically significant, but there was a statistically faster intubation time, higher Grade 1 view, lower perceived difficulty, and higher satisfaction in the head elevated group.

Apply a level of evidence to each reference
First study is likely a Level III as it is retrospective. Second study is likely Level IV as it is a cross over study.

Does the literature in your search answer the question?

Does your search reveal a POEM?
Yes. Any maneuver to decrease difficult intubations or intubation related complications is meaningful to a vast number of patients

How will you proceed the next time this problem is encountered?
I will at least attempt this approach on my next non CPR intubation

MDI’s vs. Nebs for Ventilated Asthma/COPD patients


By Dr. Yevgenia Shmelkova

Brief patient presentation
76 yo M with COPD presenting in respiratory distress, after prolonged course of increse work of breathing he becomes progressively more somnolent and can no longer safely remain on BiPAP. Decision made to intubated pt. What therapy will you start in the ED prior to pt being transferred to ICU to decrease morbidity and mortality associated with intubating an individual with COPD?

Clinical question – PICO
In mechanically ventilated patients with underlying disease process of COPD / Asthma is there a benefit to morbidity and mortality with the utilization of nebulized treatments vs MDI?

• A comparison of bronchodilator therapy delivered by nebulization and metered-dose inhaler in mechanically ventilated patients. Chest. 1999 Jun ;115(6):1653-7. (level 2 evidence)
• Bronchodilator therapy with metered-dose inhaler and spacer versus nebulizer in mechanically ventilated patients: comparison of magnitude and duration of response.
• Respir Care. 2000 Jul ;45(7):817-23. (Level 2 evidence)
• Inhalation therapy in invasive and noninvasive mechanical ventilation. Dhand R.Curr Opin Crit Care. 2007 Feb; 13(1):27-38. (Level 1 evidence)
• Metered dose inhalers versus nebulizers for aerosol bronchodilator delivery for adult patients receiving mechanical ventilation in critical care units. Cochrane Database Syst Rev. 2013 Jun 6 ;(6):CD008863. doi: 10.1002/14651858.CD008863.pub2. (Level 1 evidence)

Does your search reveal a POEM?
No. Evidence is inconclusive to support either MDI or nebulizer therapy, both have proven to be beneficial in reducing airway resistance and last for similar time span when used appropriately. Many factors need to be calculated into establishing most benefit to the patient, including but not limited to respiratory therapist protocol, ventilators utilized, ventilator settings, etc.


Treating Ischemic Stroke in Patient with LVAD

By Dr. Alexander Gutfraynd 

Brief patient presentation
35 year old female with LVAD presenting with right homonymous hemanopsia. Ischemic stroke on CT head. How do you treat an ischemic stroke in a patient with an LVAD?

Clinical question – PICO
P – problem, – ischemic stroke in LVAD patient
I – intervention – treatment with heparin/lytics
C – Comparison – no heparin/lytic
O – outcome – resolution of neuro deficits

Available research – list references
Thrombolytics in VAD management – A single-center experience
Nair et al; International Journal of Cardiology June 2016

  • Addresses VAD thrombus, not ischemic stroke, but shows that TPA is safe in VAD thrombus and that VAD exchange has slightly more favorable results
  • Level III observational

Thromboembolic stroke in patients with HeartMate-II LVAD – the role of anticoagulation

Van den Bergh et al; Journal of cardiothoracic surgery Oct 2015

  • Doesn’t address treatment of stroke, but shoes that overall incidence of stroke is lower in patients with INR >2.0
  • Level III observational

Cerebrovascular complications of LVAD

Backes et al; European Journal of Cardiothoracic Surgery Oct 2012

  • Again, treatment is not addressed. Shows benefit of Coumadin and aspirin in prevention of stroke incidence in LVAD patients
  • Level III, observational

Does your search reveal a POEM?
My literature search did not answer the clinical question. I could not find articles specifically looking at the treatment of ischemic stroke in LVAD patients. Most studies looked at ideal level of anticoagulation to prevent stroke. One study (Nair et al), looked at the VAD thrombus treatment, which came closest to answering the question at hand. Based on that study, TPA is safe and effective in treatment in VAD thrombus and seems that it would be safe in the treatment of ischemic stroke in these patients. In the end, consulting with the LVAD team and transfer to LVAD center would be my recommendation when seeing these patients in the setting of an acute stroke.

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