The Impact of Suctioning on Oxygenation During RSI in the Emergency Department-A Multi-Center Pilot Study
Phase: NA
Conditions: RSI
Sponsor: Maimonides Medical Center

1 
 
 
TITLE:  
The impact of suctioning on oxygenation during RSI in  
 
 
the Emergency Department  – A Multi-centre Pilot Study 
 
 
 
Unique Protocol ID:  2020-01-32 
 
 
Document Date: January 2, 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
 
Rapid Sequence Intubation (RSI) is a common procedure in Emergency 
Departments (ED). However, it is a high-risk procedure and has been associated 
with significant complications including hypoxia, hypotension, airway trauma, 
aspiration, and death (1-3).  Specifically, hypoxic episodes during intubation can 
lead to poor outcomes such as dysrhythmias, haemodynamic compromise, 
hypoxic brain injury and cardiac arrest, and is therefore of primary concern 
during any intubation procedure (4,5). Aspiration is a serious adverse event and 
potential cause of hypoxia during RSI and can lead to poor patient outcomes 
downstream of the procedure. The reported incidence of aspiration during RSI in 
the ED ranges from 3 to 8% in the ED population (6,7). In order to achieve an 
optimal view of the glottis and prevent pulmonary aspiration of fluids in the 
oropharynx, , providers apply suction prior to and during laryngosopy, using a 
Yankauer or large bore suction catheter. (8).  
 
There is currently significant variation in suctioning during laryngoscopy, with 
some providers using very little suction as needed to clear heavy fluids 
(judicious suctioning), while others utilise suction aggressively (lead with 
suction) and as a part of their routine laryngoscopy technique (9, 10, 11).  
Evidence  suggests inline suction on already-intubated patients accelerates 
desaturation, but we are aware of no studies examining the impact suctioning 
has on the speed of desaturation during emergent endotracheal intubation 
(11,12). 
 
This pilot study aims to compare the effects of intermittent, as-needed 
“judicious” suctioning versus aggressive “continuous” (lead with) suctioning on 
oxygenation during rapid sequence intubation in the emergency department.  
 
 
 
 
 
 
 
 

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Methods 
 
Setting 
 
In order to enrol patients into this pilot study and to gain experience from 
International centres this study will be performed at 4 sites: the Royal Prince 
Alfred (RPA) Hospital Emergency Department, Sydney, Australia, Mount Sinai 
Hospital, Manhattan, NY, Maimonides Medical Center, Brooklyn, NY and NYC 
H+H/Lincoln Medical Centre, Bronx, New York, USA. The RPA Hospital is a Level 
1 Trauma Centre with approximately 85,000 presentations and 240 intubations 
per year. Lincoln Medical Centre is a Level 1 Trauma Hospital with 
approximately 175,000 presentations and 450 intubations per year.  Mount Sinai 
Hospital is a tertiary referral center whose ED sees approximately 125, 000 patients 
per year with around 200 intubations. Maimonides Medical Center is a level 1 trauma 
center that treats about XXX and performs about XXX intubations per year.  
 
Study Participants 
 
All adult patients requiring emergent rapid sequence intubation (RSI) in the 
resuscitation bay will be included in the study.  Patients that have a heavily 
soiled airway (i.e. secretions, vomitus, blood) as deemed by the physician 
requiring suction will be excluded.    
 
Variables measured 
 
The variables included in the study are shown on the Data collection sheet 
(Appendix 3) and will include the following:  
 
● Patient details: Age, Gender, estimated weight 
● Indication for RSI 
● C-spine immobilisation and manual inline stabilisation 
● Method of preoxygenation 
● Method of apnoeic oxygenation, if performed 
● Head up or supine position 
● Oxygen saturation and ETO2 prior to starting preoxygenation and at 
induction (completion of preoxygenation) 
● Oxygen saturation and ETO2 during procedure (at 10 second intervals 
starting with induction). 
● Time of preoxygenation 
● Induction medication and dose used 
● Paralytic and dose used 
● Induction time 
● Endotracheal intubation time 
● Method of intubation 
● Number of attempts 
● Cormack-Lehane grade of airway 
● Use of cricoid or External laryngeal manipulation 
● Continuous versus judicious suctioning 
 

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Intervention 
 
The aim of this study is to investigate the effect of suctioning (a current 
technique used conventionally in RSI) on oxygenation levels during RSI. This 
being noted, there is no new intervention being applied to the patient. 
 
In order to investigate this, the current standard of care of suctioning will be 
used either by judicious means (i.e. in and out suction as needed) or continuous 
means (i.e. throughout the procedure, including laryngoscopy and tube placement) 
according to conventional practice at the discretion of the treating physician.  
For all patients involved in the study, there will be no new intervention applied. 
The impact of the use of suctioning, again which is standard of care and applied 
by convention, will be determined by measuring oxygen saturation as a primary 
outcome. All aspects of RSI will be at the discretion of the treating clinician, 
which is the current standard, including induction/relaxant medication, 
positioning of the patient, preoxygenation method, method of intubation and 
post-intubation sedation. At all institutions RSI is performed in a similar manner 
utilising an airway checklist (Appendix 1 and 2).  However, there are no 
‘Standard Operating Procedures’ for RSI in any ED and therefore intubation 
technique will vary depending on clinician preference and the clinical 
circumstances. 
 
Once the decision to perform RSI has been made by the treating team, the patient 
will be enrolled into either a judicious or continuous suction group at random. 
Ineither case, suctioning will be applied to the patient as determined necessary 
by the clinician. Rapid sequence intubation will then be performed in the 
standard means by the treating provider.  
 
 
Outcomes 
 
Primary Outcome 
 
The primary outcome of this study is the oxygen saturation achieved (SpO2) at the 
time of tube placement (via confirmation with first ETCO2 waveform) achieved 
during the intubation period.  
 
Secondary Outcomes  
 
The secondary outcomes measured include:  
● Incidence of desaturation (SaO2 <90%) or >10 points from baseline 
during the intubation period 
● Lowest O2 saturations at any point during the intubation period 
● The ETO2 at induction and at ETT confirmation.  
● Time from preoxygenation to endotracheal intubation 
● Complications during RSI: bradycardia, tachycardia, hypotension, 
hypertension, oesophageal intubation, aspiration, airway or dental 
trauma, equipment or medication error 
● Number of intubation attempts 

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Data Collection 
 
The data will be collected prospectively during the time of RSI by nursing and 
medical staff with the use of a data collection sheet (Appendix 3). Staff at RPA ED 
are familiar with the data collection sheets as prior studies in relation to RSI 
have been performed previously (Study number Re: X12- 0394). Similarly staff at 
Lincoln Medical centre and Mount Sinai perform routine data collection on all 
RSI’s performed in the ED for quality improvement purposes. The staff at 
Maimonides and Mount Sinai will be trained in the procedure for collecting data 
with the use of the data collection sheets. 
 
Patient risk 
 
This study investigates the effect of providing suction during RSI on SpO2 levels. 
This study will have no direct impact on patient care as it evaluates the use of a 
current accepted standard in the ED. This adds to clinical information and may 
lead to either no change or improved patient care. There are no risks to the 
patient as the patient will be receiving standard of care in both arms of the study. 
Patients will be critically ill requiring an emergency procedure and therefore, 
consent is not necessary for this study as per the criteria of the Common Rule for 
waiver of informed consent for emergency research. 
 
Sample Size 
 
A sample size calculation for this study is not possible as this is a pilot study and 
there is currently no reported data on the impact suctioning has on oxygen 
saturation during RSI in emergency department patients. For this reason we 
have decided to perform a convenience sample of 100 patients (50 in the 
judicious group and 50 in the continuous group). Data from this study will be 
used to provide statistics for a sample size and power calculation for a larger 
randomized control trial in the future. 
 
Statistical Analysis 
Descriptive statistics will be used for the cohorts. Means with 95% confidence 
intervals and medians with interquartile range will be used to describe the 
cohorts. Chi squared test will be used to compare the proportion of patients that 
experience desaturation between the cohorts. A simple student’s t-test will be 
used to compare the mean oxygen saturations and end tidal oxygen levels 
measured between the cohorts.  
 
Study Endpoints 
 
The endpoint for this pilot study will be the enrollment of 50 patients in each 
group to a total of 100 patients. 
 
 
 

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References 
 
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3. Fogg et al. Prospective observational study of the practice of endotracheal 
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