Written by Aaron Lacy
Spoon Feed
The ACEP subcommittee made policy recommendations on what peri-procedural interventions reduce peri-intubation hypoxia and hypotension.
Don’t get left behind: follow your society guidelines
ACEP provided the following recommendations after performing systematic reviews related to each topic of interest. There is a lot of airway literature out there, and each question had thousands of articles identified in searches, with hundreds being screened and included in decision making.
In adults, what peri-procedural interventions can reduce hypoxemia?
- Level A: None
- Level B: When feasible for preoxygenation, utilize NIV over conventional oxygenation.
- Level C:
- If NIV is not feasible, consider HFNC for those already hypoxemic.
- Consider VL over DL when available.
- Consider apneic oxygenation (author consensus).
In adults, what peri-procedural interventions can reduce hypotension?
- Level A: None
- Level B: Either etomidate or ketamine can be used for induction.
- Level C: Avoid fentanyl, midazolam, or propofol as primary or co-administered induction agents.
How will this change my practice?
We’ve covered lots of airway studies on JournalFeed, and a recent, big-picture overview was really helpful. Ultimately, you decide what to do with this information. However, when a prominent specialty society speaks, if you aren’t following their recommendations, it might be time to pay more attention. You still get to decide on many topics covered in the policy papers, since they didn’t always have enough evidence for a recommendation (like bougie v.s. stylet usage); but if you aren’t doing the above, you are really going against the grain.
Source
Clinical Policy: Critical Issues in the Management of Adult Patients Requiring Endotracheal Intubation in the Emergency Department. Ann Emerg Med. 2025 Aug;86(2):e29-e68. doi: 10.1016/j.annemergmed.2025.04.003. PMID: 40685219.
