Use of HEAVEN criteria for predicting difficult intubation in the emergency department

Most airway prediction tools only consider anatomical factors. The HEAVEN criteria incorporate both anatomical and physiological elements, but have never been studied in the emergency department. This study aimed to evaluate the association between HEAVEN criteria and intubation difficulty.

We conducted a prospective cross-sectional study from April 1, 2020 to January 31, 2021 in the emergency department of a tertiary public hospital. All patients requiring rapid-sequence or delayed-sequence intubation were included. Patients intubated during cardiopulmonary resuscitation were excluded. We enrolled 174 patients. Study endpoints were first pass success and intubation complications.

The presence of any HEAVEN criteria was associated with a decrease in the first pass success rate (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.02-0.43; P < 0.01). The anatomical challenge was the only criterion associated with first pass sucess (OR, 0.13; 95% CI, 0.05- 0.29; P < 0.01), whilst other criteria (hypoxemia, extremes of size, vomit/blood/fluid, exsanguination, and neck mobility) were not (P > 0.05). All anatomical factor criteria were associated with difficult airway view (P < 0.05). Intubation complications occurred more in the presence of hypoxemia (OR, 7.44; 95% CI, 2.82-19.63; P < 0.01) and vomit/blood/fluid (OR, 5.55; 95% CI, 2.39-12.92; P < 0.01).

Anatomical challenge in HEAVEN criteria can predict first pass success. All anatomical factors in HEAVEN criteria could predict difficult airway view and peri-intubation hypoxemia could be used to anticipate intubation complications. More validation studies are still needed to evaluate the use of HEAVEN criteria as a predictor tool for difficult airway.