Emergency Department Airway Management and Post-Intubation Practices in Obstructive Lung Disease

Introduction: Intubated patients with obstructive lung disease (OLD) exacerbation are a rare, high-risk population in the emergency department (ED). Optimal management includes a low set respiratory rate (RR) to allow exhalation. Little is known about how these patients are initially managed. We sought to characterize ventilator management in this group and hypothesized that patients with OLD would be set to a lower RR but similar other settings compared to those without OLD.


Methods: Retrospective chart review of adults with OLD intubated across eight EDs in 2019. Adults were included if they had an ED intubation note, history of asthma or COPD and received epinephrine, albuterol, ipratropium, magnesium and steroids. Patients were excluded if intubated for a non-respiratory issue. Two independent researchers confirmed reason for intubation and a third settled discrepancies. Data were extracted by trained research assistants blinded to the hypothesis and entered into a REDCap database. Demographics, medications and peri-intubation course were collected. Summary statistics included median [IQR], n (%), and mean ± SD. Groups were compared with Wilcoxon rank sum test.


Results: 380 of the 2,078 patients intubated in 2019 had a history of OLD. Of these, 116 were excluded due to intubation for non-respiratory issue. Of these, 19 received all listed medications. Five were excluded as they were not intubated for severe OLD exacerbation leaving 14 patients in the final analysis. The OLD patients were similar to not OLD patients in age (60.5 [42.8-69.8] years in OLD group vs. 61 [48.0-71.0]), gender (43% vs. 57% male), and race (57.0% vs. 62% black). There were no differences in set initial RR between the OLD cohort (14 [12.5, 19.5]) and comparison group (16 [14.0, 18.0]) (p=0.54). Six of 14 patients were started on a set RR ≥ 18. Set PEEP was 5.0 regardless of history of OLD (p=0.46) and VT was similar in both groups (424.6+59.9 in OLD vs. 446.9+57.7 in other).


Conclusions: These data support that intubation for OLD is rare and suggest patients were started on similar ventilator settings, including RR, regardless of severe OLD exacerbation. Limitations include the retrospective definition of OLD cohort and the small size with unequal comparator group.