Physician Assistant Intubation in the Emergency Department: An Analysis From the National Emergency Airway Registry (NEAR)

Physician assistants (PAs) play an increasing role in treating emergency department (ED) patients and may be called on to perform emergency airway management. The Society of Emergency Medicine Physician Assistants (SEMPA) practice guidelines recommend experience with intubation and difficult airway management. A 2021 SEMPA practice survey reported 67.5% of respondents performed invasive airway management but data evaluating PA performance with ED intubations are lacking. Our objective was to describe PA intubation practice using a multicenter ED intubation registry. We analyzed prospectively collected data from the National Emergency Airway Registry (NEAR) from January 1, 2016, to January 1, 2019 using descriptive statistics and 95% confidence intervals. We report total encounters, indications, first-attempt success rates, methods and devices used, and complications for PA ED intubations. The registry contained 19,071 total intubations. PAs performed intubations in 297 (1.5%) encounters with 278 medical intubations and 19 trauma intubations. Overall, first-attempt success was 80% (95% CI, 59.4 to 100) and 68.4% (95% CI, 53.2 to 83.6), respectively. The most common medical indications for intubation were non-overdose mental status change (28.4%), cardiac arrest (17.6%), and overdose (14.4%). Most intubations were performed with a GlideScope videolaryngoscope (VL) (39.9%) followed by a standardgeometry C-MAC (37.8%). First-attempt success stratified by device was 79.7% (95% CI, 59.0 to 100) for GlideScope and 85.7% (95% CI, 61.8 to 100) for C-MAC. Rapid sequence intubation was used in 81.5% of encounters. Etomidate was the most used induction agent (84.2%). Succinylcholine and Rocuronium were used at similar rates (43.8% vs. 39.5%). The most common peri-intubation adverse events were hypoxia (30.7%), hypotension (6.8%), and esophageal intubation with immediate recognition (5.7%). In this multicenter analysis, PAs performed nearly 2% of all ED intubations. Most intubations were performed using RSI and VL. First attempt success was similar to physician intubations and highest with a CMAC standard geometry blade. More data are required to validate these findings.