1. Title of the project: Deriving a Physiological Airway Scoring System to predict post intubation adverse effects for patients undergoing endotracheal intubation in the Emergency Department. 2. Type of Study: Prospective study- cross sectional study 3. Aims & objectives (hypotheses if applicable): AIM: To derive a physiologically difficult airway scoring system for identifying patients at risk of post-intubation adverse events using physiological parameters collected in the Emergency Department OBJECTIVES: •Primary Objective: To derive a predictive scoring system for identifying patients at risk of post-intubation hypotension, cardiac arrest using key physiological parameters collected prospectively in the Emergency Department (ED). •Secondary Objectives: Clinical profile of patients undergoing endotracheal intubation in the ED, and estimate the incidence of Post intubation hypotension and cardiac arrest 4. Justification for study (whether of national significance with rationale): Airway management is a critical aspect of emergency medicine that requires prompt and accurate decision-making to optimize patient outcomes. Airway management for critically ill and injured patients require quick decision making and active intervention with array of skills by physicians in the Emergency Department (ED). Although endotracheal intubation as part of airway management is a life- saving intervention, it carries risks, including post-intubation hypotension and cardiac arrest, which contribute significantly to patient morbidity and mortality in the Emergency Department (ED). Traditional airway triage systems often rely on anatomical variables, which may fail to identify patients at risk for these adverse events. Anatomical scoring systems usually predict the difficulty in the process of intubation rather than post intubation adverse effects. The current scoring systems like Simplified Airway Risk Index(SARI),MTAC Scoring, Wilson’s Score lack important physiological parameters. Post intubation adverse effects like hypotension and cardiac arrest constitute a significant risk for patients in the ED. Predicting post intubation adverse effects using a triage scoring system may potentially help emergency physicians for optimizing airway management in the ED. This study aims to derive an airway triage system that leverages objective physiological parameters to predict the risk of post-intubation hypotension and/or cardiac arrest (post-intubation adverse events), thereby improving airway decision-making and patient safety in the ED. (Reference: Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008 Oct;34(10):1835-42. Crawley S, Dalton A. Predicting the difficult airway. BJA Education. 2015 Oct;15(5):253-8.) 5. Departments involved: Department of Emergency Medicine, KMC Manipal, MAHE 6. Study period: November 2025-June 2027(19 months) 7. Sample size: On the basis of study done by Dr Pranav Prakash ,Dr Jayaraj MB, Dr Nisarg, assuming p=28.6%(Prevalence of Post intubation hypotension) with 95% Confidence Interval & allowable error, the sample size estimated is 327 (Reference-Prakash P, S N, Balakrishnan JM, Alli SD, S RG, Naik SR. Right ventricular dysfunction: a key predictor of post-intubation hypotension in the emergency department. Int J Emerg Med [Internet]. 2025;18(1):183.)
8. Materials and methods: a) Inclusion and exclusion criteria: Inclusion Criteria: Adult patients(Age more than 18 years) requiring endotracheal intubation in the ED. Exclusion Criteria: 1. Patients/Surrogate not providing consent 2. Patients undergoing intubation during cardiac arrest 3.Patients requiring Re-intubation
b) Statistical methods: Descriptive statistics such as Mean Standard Deviation, Median, Interquartile range will be used to summarize continuous variables. Categorical variables will be represented as percentages. Chi square test will be used test the association between the scores and post intubation complications. Univariate and multivariate logistic regression will be used to identify the determinants of Post intubation hypotension.ROC Curve will be used to determine the cutoffs for the scores- Physiological Airway Scoring System. P<0.05 will be considered to be statistically significant. Sensitivity, specificity, PPV will be used.
9. Detailed description of procedure / processes: Data will be prospectively collected from ED patients with potential airway compromise at the time of presentation to the ED. Variables will include demographics, vital signs (e.g., respiratory rate, oxygen saturation, heart rate, blood pressure), arterial blood gas values, laboratory values, Glasgow Coma Scale (GCS) scores, Safe apnea time, point of care ultrasound including echo (including TAPSE) and airway ultrasound variables, provisional diagnosis, human factors including experience of airway manager and other relevant clinical parameters. In addition, details of the airway management procedure, time to decision making(from the time patient arrives in ED to communication for consent), time to intubation/ securing the airway and the occurrence of post-intubation complications—specifically hypotension (e.g., a defined drop in blood pressure) and/or cardiac arrest—will be documented. Patient will be monitored for 60 minutes post intubation for adverse effects. Consent will be taken before the patient is intubated.
10. Outcome measures a) Post intubation hypotension b) Post intubation cardiac arrest 11. Potential risks and benefits: RISK-MINOR INCREASE OVER MINIMAL RISK BENEFIT-The results of the study will help us identify post intubation adverse effects in future patients. This will help us in optimizing airway management in the ED 12. Ethical considerations and methods to address issues: IEC clearance.
Institutional Review Board (IRB)/CTRI approval will be obtained before data collection. Informed consent will be obtained from all participants/ surrogates. Patient confidentiality and data security will be maintained in accordance with ethical guidelines. 13. Budget (give details) and proposed funding source: (remove the table if not required. If more rows are required, you can add.) Sl.No Details Justification Funding agency INR 1. Self funded Stationary Self 3000 14.Review of literature- Emergency airway management has evolved from being purely anatomical to a comprehensive, physiology-based approach that accounts for the patient’s physiological state, potential complications, contextual factors, and human elements. Early studies (Mort, 2007) documented the high incidence of complications during endotracheal intubation (ETI), including post-intubation hypotension (PIH), hypoxemia, aspiration, and trauma. These findings emphasized the need for hemodynamic optimization and first-pass success to reduce risk. Griesdale et al. (2008) reinforced these findings, reporting a 28% complication rate in ICU intubations, with higher risk in sicker patients and repeated attempts. A major conceptual shift occurred with the introduction of the “physiologically difficult airway” by Heffner et al. (2013) and Mosier et al. (2015), who highlighted conditions like hypoxemia, hypotension, acidosis, and right ventricular failure as key predictors of adverse events. These studies emphasized pre-intubation physiological stabilization to prevent complications such as cardiac arrest. Subsequent research deepened this physiological focus: Vaporidi et al. (2020) described the impact of respiratory drive and patient–ventilator interactions on outcomes. Mann et al. (2021) showed that even anatomical differences, such as smaller airways in females, influence respiratory physiology. Sakles et al. (2017) demonstrated that advanced techniques like video laryngoscopy and neuromuscular blockade improve first-pass success and safety in the ED. Kuzmack et al. (2018) introduced the HEAVEN criteria, integrating both anatomical and physiological risk factors for predicting difficult airways. Crawley and Dalton (2015) advocated for a multifactorial assessment approach using history, examination, and various predictive tools. Huitink (2024) proposed the “Airway Triage” concept, which replaces the narrow “difficult airway” idea with a holistic framework considering physiology, context, and human factors. Modern emergency airway management emphasizes holistic assessment — integrating anatomical, physiological, and contextual factors — to anticipate and mitigate complications. The shift from “difficult airway” to “Airway Triage” represents a paradigm aimed at improving safety, standardizing practice, and reducing post-intubation adverse events in critically ill patients.
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