Factors Associated with Emergency Difficult Tracheal Intubation and Difficult Airway Management in a Non–Operating Room Setting at a Cancer Treatment Center

Difficult tracheal intubations are reported more often in the emergency non−operating room setting than in the operating setting. To identify the factors associated with emergency difficult intubation (DI) and difficult airway (DA) management in hospitalized patients with cancer, we conducted a single-center retrospective study in hospitalized patients who underwent emergency intubations in a non−operating setting from 2016 to 2019 at a cancer treatment center. Cases of DI (inability to visualize the vocal cords and/or >2 intubation attempts) and DA (DI, advanced airway device use, and/or need for a surgical airway) were included. We reviewed 763 cases; the DI and DA incidence rates were 9.8% (95% CI, 7.7-12.2) and 31.5% (95% CI, 28.2-34.8), respectively. The relationships between case characteristics with DI and DA were determined using univariate and multivariate regression. Univariate analysis revealed DI was associated with cardiopulmonary resuscitation (CPR) administration (8.1%; p = 0.0021), airway contamination (7.2%; p < 0.0001], history of head/neck pathology (cancer [5.8%; p < 0.0001], radiation [6.8%; p < 0.0001], and/or surgery [3.9%; p = 0.0016]). DA management was associated with increased body mass index (p = 0.0086), history of head/neck pathology (p < 0.0001), and airway contamination (p = 0.0203). Multivariate analysis revealed DI was associated with CPR administration during the intubation attempt (odds ratio, 4.104 [95% CI, 1.825-9.226]; p = 0.0006) and airway contamination (odds ratio 3.404 [95% CI, 1.590-7.287]; p = 0.0016). Multivariate analysis revealed DA management was associated with a history of head/neck radiation (odds ratio, 6.848 [95% CI, 2.810-16.689]; p < 0.0001) and airway contamination (odds ratio, 4.120 [95% CI, 1.959-8.666]; p < 0.0001). DI was not uncommon among emergency intubations in cancer patients and had a similar incidence rate to those reported by other institutions not specializing in cancer treatment in the non−operating room setting. The high incidence of DA suggests these cancer patients have elevated advanced airway device needs. CPR administration during the intubation attempt was associated with DI, suggesting alternatives to laryngoscopy and intubation, such as supraglottic airway use, should be considered early. A history of head/neck radiation therapy was associated with DA management, including advanced airway device use, indicating the significance of obtaining radiation therapy history during an airway evaluation at a cancer center. Airway contamination was not uncommon and associated with both DI and DA management.