Hiroko Watase

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.