Gum Elastic Bougie​

 

Study objective

The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success.

Methods

We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation.

Results

Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]).

Conclusion

Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.

Angioedma

General Approach to Treatment

Icatibant for Angioedema

The Inside Scoop on Icatibant

Anand Swaminathan MD and Gentry Wilkerson MD   

 

Take Home Points

  • A previous phase II trial found the time to resolution of ACE-inhibitor induced angioedema was shorter after icatibant.
  • Another recent  randomized, controlled trial of icatibant compared to epinephrine, glucocorticoids and antihistamines found no benefit.
  • Our current understanding of the pathophysiology of ACE-inhibitor induced angioedema may be incorrect.

 

  • Wilkerson is a researcher in angioedema and icatibant. He has received research funding from Dyax, the makers of ecallantide and Shire, the makers of icatibant. This funding did not include salary support or speaking honoraria.

 

  • Bas, M et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. N Engl J Med. 2015 Jan 29;372(5):418-25. OPEN ACCESS LINK
    • This study found the time to resolution of ACE-inhibitor associated angioedema was significantly shorter with the use of icatibant compared to the combination therapy of glucocorticoid and antihistamine.

 

  • Glucocorticoid and antihistamines are not thought effective in ACE-inhibitor angioedema. Why not compare to fresh frozen plasma?
    • The authors state that using glucocorticoids and antihistamines are standard care in the sense that they are usual care. They do not imply that these are effective. They discuss the ineffectiveness of these medications in the introduction to the paper.
    • It would not be appropriate to study one unproven medication versus another unproven medication to see which is better. There are 13 case reports of FFP working in the treatment of ACE-inhibitor induced angioedema. These aren’t studies of effectiveness.

 

  • The natural course of angioedema is to get better; our role is to protect the patient until it does. While FFP contains the ACE enzyme which can break down accumulated bradykinin, it also contains high molecular weight kininogen which is a precursor to bradykinin. Theoretically, this could lead to increased bradykinin production.

 

  • We don’t have any proven treatment and we don’t know enough about the disease to design treatment. We think that the disease is due to bradykinin accumulation but we do not have proof.

Pathophysiology

 

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