non: [00:00:00] You are listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society. Eddie: Hello and welcome. You're listening to the A s Breathe Easy Podcast with me, your host, Dr. Eddie Qien, also the host of the IC and Podcast. Each Tuesday, the ATS will welcome guests who will share the latest news in pulmonary critical care and sleep medicine. Whether you're a patient, patient advocate, or healthcare professional, the ATS Breathe Easy podcast is for you. Uh, joining me today is Stephanie DeMasi. Dr. Stephanie DeMasi is an assistant professor of emergency medicine at Vanderbilt University Medical Center. Her research is focused on the evaluation of time sensitive interventions such as emergency and tracheal intubation, and is the first author on the paper titled Evidence-Based Emergency Tracheal Intubation, published in the Blue Journal July of this [00:01:00] year, 2025, which will also be the topic of discussion today. Uh, welcome Stephanie. Stephanie: Thanks, Eddie. Thanks for that really kind introduction. I'm excited to be here and talk with you today. Eddie: Yeah, so we we're gonna, we're gonna talk. About the, the details of the intubation procedure and, and what you uncovered in this paper and review. But, but first, tell me why, why should I read this review paper compared to other review papers that I, I might find on the same topic? Stephanie: Yeah, good. Good question. Uh, other than the fact that we wrote it Eddie: and Stephanie: we like each other, we're friends, um, is that this review paper we sought out to, to differentiate it and that we included data from randomized trials. And over the last two decades or so, there have been a series of trials that have now informed how we perform this procedure. So we, we strictly focus this review on, on evidence from randomized trials. Eddie: Yeah, I mean there really, there really has just been an [00:02:00] explosion of randomized evidence, randomized trials from, from your group with the P-C-C-R-G putting out a lot of these, but also from all around the world. Um, I think there we're in a also kind of like a boom, we talk about the AI boom and then like informatics boom, but it's really a boom of, uh, evidence and a high quality evidence. And so it's, I think it is really good that we have this. Review paper to kind of figure out where we are. And then also I think what one of the things we'll get into is where we're going. Uh, I think they're really, really helpful things. The, the listeners will, will have to read the paper, uh, which I think we can link in the show notes below to get all the information. But, but I think let's, let's talk through some of these points. And I, I think in particular. The figures and the tables really do provide a great summary of a lot of these information. Uh, figure one is a, breaks down the procedure into distinct phases and time points. So endotracheal intubation as a procedure, you might say, oh, well you know this. It's just one, it's just one intervention. It's one thing. Just you're gonna go, go intubate the, the [00:03:00] trachea, but you've broken it down to. Four steps. The initiation of preoxygenation, the induction of anesthesia, the initiation of laryngoscopy, and then, then finally, intubation in the trachea. Why, why, why is it important for you to, to highlight these phases for the reader and for anybody who's interested in and explore the evidence in this space. Stephanie: That's a good question. I, I think it's important, um, both clinically and the way we perform the procedure because each one of those four steps has different decisions, uh, along with each one of them. Um, and it also helps with how we describe the intervention in each one of the trials. So I think it helps understand how you. Break down the procedure and then where the evidence fits into each one of those categories. So when we talk about preoxygenation, we're talking about the time period before the induction medicine is [00:04:00] pushed, and we're talking about between induction and laryngoscopy, it's medicine pushed. To when the laryngoscope enters the mouth. And then between laryngoscopy and the time the endotracheal tube is placed inside the trachea is the the third sort of sequence of events. Uh, and again, there's different decisions at each one of those time points. So it's helpful both clinically and to understand the trials and, and which interventions affected which time points, and some of them multiple. Eddie: Yeah, that's, that's, that's really interesting. Yeah. They just, like you said, there's, there's multiple different interventions. We'll, we'll go through some of these in more detail, but what are some of the examples of, of things that fall into these categories, these decisions, like multiple decisions. It's, it's one procedure. There's multiple time points and multiple decisions within these time points. What are some of the examples of the breadth of decisions that we're making? Stephanie: Yeah. A a lot of things go into that, right in the. First phase. So between, uh, the time of preoxygenation and induction of anesthesia, we're focusing on [00:05:00] methods of oxygenation and or ventilation. Um, that's your primary focus. Um, could also be thinking about ways that you may prevent hypotension or cardiovascular collapse. Should you be giving a fluid bolus? How else are you resuscitating your patient? So that's sort of your pre period, your optimization period. Induction of anesthesia, of course. Is the medicines primarily that you're giving, right? Um, are you giving an additional bolus of fluid or vasopressor at that point? And then are you giving a, um, a paralytic? For induction of laryngoscopy this time period, the decisions you're focusing on are the, the tools that you're using, what type of laryngoscope is there a video associated with it? Uh, which blade itself are you using? A bougie or an, uh, intrical tube with stilet for your intubating device? And then what size endotracheal tube, and then anything after that, you know, confirmation of your [00:06:00] endotracheal tube position and so on and so forth. Eddie: Yeah. No, this is, this is really great. I, I think, you know what, one of the, the highlights of this, this paper to me, it, it really is the, is table one. Like, there's, there's so much great information that, that you and your co-authors have. Uh, collated it together, um, and, and really summarize really well. But when you're talking about a framework, you highlighted several sections. Uh, there are interventions. We have evidence of benefit interventions, which we have an evidence of, a lack of benefit. Um, and then where is more evidence required? Uh, if, if, if you're okay with that, uh, do you wanna step through those? Yeah, that sounds great. Yeah. So, so, so, uh, in that first bucket where you say, okay, we have evidence for benefit, I think if I can count correctly, there, there are five things that are listed there. Uh, uh, rather than going through each one of those like one by one, are, are there any one of those that you want to highlight? [00:07:00] Stephanie: Yeah, I guess I'll first maybe point out that it seems like, you know, we've had so many trials in this space in the last several decades, and it still kind of surprised me that the longest list is like, uh, more evidence required. Mm-hmm. Uh, I'll just point that out, but yeah. Um, the trials for evidence of benefit, I think maybe highlighting the pre oxy trial as one of the latest trials in the last two years, that showed a pretty remarkable benefit. Uh, and again, this isn't that in that first phase. So going back to figure one, that preoxygenation phase, the pre oxy trial was a multicenter trial through the pragmatic critical care research group. Network then enrolled, uh, at 24 sites across the United States. And it compared the use of a face mask, oxygen, uh, compared to non-invasive oxygen for that preoxygenation period. And the intervention was. Three or more minutes. Um, and the primary outcome was [00:08:00] hypoxemia, which they defined in this trial as less than 85%. So it was a binary yes or no, um, and it was significantly, uh, improved or less hypoxemia with use of non-invasive, uh, 18.5%. Experienced hypoxemia in the oxygen mask group and 9.1% in the noninvasive group. So, um, this was a huge trial for me. Uh, my background being in emergency medicine where it was sort of dogma you did not put noninvasive on patients that were about to be intubated for this fear of aspiration. Um, but this trial, not only did they show it decrease the incidence of hypoxemia, uh, it did not increase the risk of aspiration. So this was a, a hugely, uh, beneficial trial or, or a positive trial in the airway space. Eddie: Yeah, it really is. It really is so interesting to me. So being in a primarily, primarily medical intensive care unit, critical [00:09:00] care background, to hear about some of these practice differences and also just to highlight some of the great work that, that you're doing as far as you, you know, you, if there truly was, uh, I could lack of complete lack of equipoise that we wouldn't even have the information in this space, right? So all of the work that kind of goes in before that I think is really, really important as well. The, um, the, so there are, there are other things in this, in this category, and so there's talking about, uh, video versus direct laryn, uh, laryngoscope, um, looking at, uh, using a stylet compared to using an endotracheal tube. Alone. And then there's that oxygenation in that second phase you were talking about, uh, having positive pressure between the induction of anesthesia and the beginning of laryngoscopy. One of the things that I found interesting that was, that y'all included in this one is, is one that, you know, I, I learned about when we were learning about doing, uh, intubations and, and certainly still like here and now I teach and talk about. It's, uh, [00:10:00] laryngoscopy intubation with patients in the sniffing position may increase incidences of successful intubation on the first attempt compared to a ramped position. This is, this, this is an interesting one to kind of like put into this, this category. What kind of discussions did you guys have about, about the sniffing versus ramped position? Stephanie: Yeah. Um, I, I, Matt similar, I think snuck this one in there being as one of his very first airway trials, I think it was from almost a, a decade ago. And it was a small to moderate trial of fellows intubating at a medical, in a medical intensive peer unit. Um, and the sniffing position again is when like your torso is supine, your neck is flexed and your head's extended. Uh, but the head of the bed is. Flat compared to ramped is when it's up about 25 degrees. Um, they, this made it in there because one of the secondary outcomes showed benefit, um, to the sniffing [00:11:00] position, uh, with a, uh, increase incidence of successful innovation on the first attempt. Um, the primary outcome was, um. Uh, arterial oxygen saturation, which was not different between groups, but I think it's reasonable against small to moderate trial showing benefit of of the sniffing position. Eddie: Yeah. It's always, it's always so interesting to me do, this is a little bit more of like a, a meta comment thinking about, okay, well, you know, you mentioned this was like 10 years ago, and in the middle, in the interim, we've had more evidence and more information and are, are our intubation intubating conditions sufficiently different enough that it would, it would change this? And I think the answer is we don't. We don't know. Uh, but it, but it was, it did it kind of catch caught my eye when I, when I saw that one there. Stephanie: That's a really good point, Eddie. 'cause I don't know off the top of my head, but I wonder how many were being intubated with a video laryngoscope in this trial. I don't know. Eddie: Yeah. I'm, I'm, Stephanie: yeah. Eddie: I'm, I'm doubtful Maybe, maybe that, maybe we should move that one back down into that need more evidence, [00:12:00] uh, a bucket. But we can, we can, we can talk about that a little bit later. The, uh, two, two intervention, two interventions you have listed here have an evidence for a lack of benefit. Uh, is there anything that you wanted to say about either either of those? Stephanie: Uh, so in, in, in this category, the fluid bolus trial, so they prepare one and prepare two trials, which examine giving a fluid bolus, uh, prior to intubation, uh, on the effect of cardiovascular collapse, or did it prevent cardiovascular collapse? It did not, it didn't In the first, the Prepare one trial, which was a, a small to moderate 330 something patient trial. Um, and then the second Prepare two trial was an extension of that, where they saw. Potentially a benefit in the group receiving non-invasive, um, and that were maybe higher risk for developing cardiovascular collapse. So they examined it in just the [00:13:00] patients receiving positive pressure and prepared to, um, in both of these trials, however, the administration of a fluid bolus did not prevent hypotension, vasopressor receipt, or cardiac arrest. Maybe important to, to mention that, um, about 200 to 300 ccs I think was the median volume that got in before patients were intubated. So it didn't evaluate the effect of an entire fluid bolus. Um, something interesting in coming down the pipeline is, um. In terms of the topic of preventing cardiovascular collapse, is the flu a trial, which is the fluid bolus versus a low dose norepinephrine trial, um, that's currently enrolling. So sort of more to come on how to prevent cardiovascular collapse, but at this point, flu bolus alone does not show benefit. Eddie: Is this. So I think every once in a while, I think a lot of the, you know, providers and clinicians who are, are listening to this episode may have, may [00:14:00] say like, well, I, I've, I've given a fluid BOLs before. Is this something that I should, should never do or just should be not even a consideration or Stephanie: good question. I. I think it, it would be reasonable, um, to, to, if you have clinical suspicion or sort of worried about your patient's shock index, for example, just understanding that it may not have a clinical benefit. Eddie: And then, and, uh, just so, so everybody's on the same page, including myself, shock shock index, or worried about their shock. Stephanie: Uh, yeah. Yeah. It's a patient's heart rate over systolic blood pressure. Um, so we, sorry. We use this in emergency medicine, really in the trauma space frequently, and we talk about their shock in it being greater than one, so higher chance or higher risk that they're going to develop cardiovascular collapse during the intubation period. Eddie: Yeah. So having a heart rate that's higher than your systolic blood pressure. So I, I love, I love these. You know, kind of simple, like clinical intuition things. Yeah. One of my favorites is, [00:15:00] uh, threes over twos. If your blood pressure's a three digit number over a two digit number, you're probably doing okay. Stephanie: Oh, I haven't actually heard that. Eddie: That's my, that's one, that's one of my favorites. Kind of like, it's like, yeah, like, yeah, that's, that's probably okay for most people. Stephanie: I have an inappropriate one that I won't say on this recording. Eddie: Um. The, uh, the, you, you, Stephanie, are very active in this world of research, and, and as you had already alluded to, there are a number of, I didn't bother to count, I can't count that high. Uh, where more evidence is required. Which, which one of these do you wanna spend a little bit of time talking about on the, on the podcast here? Stephanie: I am, I'm trying to decide whether I should start with my own bias, which is my personal trial. Yeah, sure. This Eddie: is that. Okay. You're the, you're the guest. Start with you. Oh, Stephanie: yeah. I'll, I'll, uh, disclose my conflicts of interest in, which is my, my K 23, which is around the use of neuromuscular blockade. [00:16:00] So you said this earlier, interestingly, about the rim rammed versus sniffing position like. Innovation has changed in the last 10 years. Like, do we think we need to reevaluate this question now that we are using video laryngoscopy and, and have better medicines, et cetera? The same sort of idea is how we came up with this neuromuscular blockade question, and that is, uh, in the era of video laryngoscopy, is it still required to give your patients a paralytic during every single routine emergency intubation? Or, um, do the risks of neuromuscular blockade now outweigh any potential benefit? So, um, I, we have a trial that I'm, um, putting into the IRB and is currently funded on sedation only, intubation versus sedation plus neuromuscular blockade. And it will be a, a small trial, but the idea is that, um. If we're not paralyzing patients, we're allowing them to continue to spontaneously breathe [00:17:00] independently, and therefore they may have less risk for developing hypoxemia. Um, so it's the Inspire trial. Um, so more to come there and, you know, there is, I will accept there's a world in which neuroma blockade is still required. And if it is, then I think an interesting unanswered question is, which one? We've seen this like, yeah. Rise in rocuronium when I, it first was in training, it was sexal choline and it's more and more and more used of rocuronium without a head-to-head trial in the emergency space showing benefit of rocuronium. So I think, you know, if we say or we find that RAC is required then then having a comparative effectiveness trial of sexal choline versus rocuronium has got to be in the future. No, Eddie: this is, this is really fascinating. There's so many ways that, that, that we could take this, but I, I find it, I find it very interesting when you're talking about like, oh, there's just, there's just been a rise of, of rocuronium that you've noticed in, in your, in your [00:18:00] practice and the practice of your peers. And, and it, there's, there's so much to be said about like, you know, trends and trends in medicine and I don't know, you know, the social media might play a role in this, you know, you know, podcasting platform might play, play a role in this as well. Um, but one, one of the things that I have, uh, noticed recently, and I'm this is a leading question, is that there's been a rise talk about sedation. There's been a rise in the use of, of ketamine. This is not something I even heard about when I was learning how to intubate patients. And then all of a sudden now there's, there's so much ketamine use. Uh, any, any comments on, on, on that, Stephanie? Stephanie: Yes. Um, uh, uh, good question. I too, I trained at an institution in which we only use and, um, have noticed this, the uptrend in use. Of ketamine over the years. And I can say actually when I moved to my most recent institution two years ago, uh, where we were enrolling in the RSI trial, the randomized trial of Sedative Choice for [00:19:00] intubation, uh, I have only used ketamine when I was assigned to receive ketamine. Um, but I think we can now talk about the results of the RSI trial, um, which was recently published. Um. On December 10th, uh, and this was a comparative effectiveness trial at six centers across the United States. And it, in this review paper, um, that we're talking about was in the category of we don't know which medicine is better, which induction agent, um, uh, is associated with improved outcomes. And the RSI trial found that their primary outcome was 28 day in hospital Mortality was not different between groups, however, their secondary outcome. Was a composite of cardiovascular collapse, and that included a systolic blood pressure less than 65, uh, newer increases of vasopressors or cardiac arrest between induction and two minutes after intubation. So again, focusing on that. Figure [00:20:00] one period that peri intubation period, and there was significantly more cardiovascular collapse with ketamine and a 5.1% absolute risk difference between the groups. And this, uh, was the first, now the first trial that has shown, um, uh, a strategy. We now have a preventative mechanism use of accommodate that prevents cardiovascular collapse. So it's the first trial in the airways. Space that we now have evidence to prevent cardiovascular collapse, unlike the fluid bolus study that we talked about earlier. So, um, this is a, a huge landmark trial. I, we've already now shifted practice, at least locally. Um, and I'm excited to start using again. Eddie: Yeah, no, it, it really, it really is, it really is exciting and I think. I think one of the things just is, and I've said this a couple of times, just to highlight all the, all the work that you're doing to kind of help the care of patients all over the country, all over the world. So that's, that's really great. Um, is, [00:21:00] is, is there anything else that you wanted to highlight in this Needs more evidence or, um. Stephanie: Perhaps highlighting the type of laryngoscope blade. Um, uh, and that is, we know VL based on the device trial is the, uh, video laryngoscope as compared to direct laryngoscope, um, is the. The laryngoscope of choice. It improves your successful innovation on the first attempt. And so by far and away is, should be used most commonly, provided it, um, it is available to you. Um, now, uh, uh, digging a little bit further in the actual shape of the Laryngoscope blade itself, um, there is, uh, an area that's still unanswered or unknown, and that is. Which shape whether the hyper angulated blade, um, which has a more acutely angled shape. It's 60 to 90 degrees. Um, that allows you to see the vocal cords without really manipulating the, uh, jaw, then the head and [00:22:00] neck as compared to the standard geometry blade, which angle? 15 to 30 degrees, um, and requires a bit more manipulation in order to expose the view of the vocal cords. Um, so this is, there's actually, there's two trials. Uh, there's one ongoing in Spain, the inv blade trial that's comparing hyper angulated versus standard geometry blade. Uh, on successful innovation on the first attempt. And we're also doing a version of that with the pragmatic critical care research group. Um, so we're in the startup phase. We'll have just over 20 centers, uh, enrolling in this trial. It'll be 2,500 patients. Um, and it'll be the first trial to compare these two blades in a, in a randomized controlled fashion. So that's something exciting that's coming down the pipeline and, um, perhaps we could talk about it next time. Eddie: Yeah, no, absolutely. I know I've, I have so many, I have so many thoughts on that, but I don't, I don't think we have enough time to really cover all of my thoughts there. So, uh, you know, you know what I, I guess to, to, [00:23:00] to close out here, unless you have any other suggestions or things you wanna to, to touch on, why don't, why don't you walk me through, uh, your approach to emergency endotracheal intubation considering all of the available evidence from, from randomized trials. How, how are, how are you approaching these? Stephanie: Yeah, good question. And, and this is something that, um, I'm teaching my residents on shift and, and how I'm educating and performing intubation myself. So if, if, uh, I'm intubating in my local emergency department, I'm pre oxygenating my patient with non-invasive ventilation through the ventilator and IV settings on the ventilator, unless there's an obvious contraindication. And for me, that would just be. Fluids actively coming out of their mouth and otherwise I'm using noninvasive and I'm going to do it for three or more minutes. Um, uh, provided there is enough time, uh, to do so for my induction agent of choice, after they are a side trial, I mentioned that [00:24:00] I will use etomidate. I will continue preoxygenation with non-invasive until the time of laryngoscopy. So, um, we didn't highlight, uh, that before, but I will continue from the point of preoxygenation all the way until laryngoscopy continue on non-invasive to, uh, provide both oxygenation and ventilation, um, to my patient before I, uh, perform laryngoscopy. For laryngoscopy, I'm gonna use a vl, and I think at this point using a standard geometry or hyper angulate blade is. Reasonable and I would use either a bougie or an endotracheal tube with a stylet. Again, either is reasonable to do so, um, and uh, that is how I would do emergency innovation. Yeah. Eddie: No, that's great. That's really great. And it's really great to see kind of like all, all these things come together from each decision, each trial, each individual piece, uh, of the, the procedure to see the all the procedure come together. So it really is great. Um, but, uh, [00:25:00] I'll thank everybody for joining us for today's ATS Brief, easy episode. Please subscribe and share this episode with your colleagues. Put it on your calendar to register for the ATS conference in Orlando in May. Early registration opens January, uh, 2026. So to conference thoracic.org today, members get a discount on conference registration, so become a member. Renew your membership to take advantage of the savings, and we'll see you next time. non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ATS Breathe Easy Podcasts on transistor, YouTube, apple podcasts and Spotify. Don't forget to like, comment, and subscribe so you never miss an episode.