A Novel Difficult-Airway Prediction Tool for Emergency Airway Management: Validation of the HEAVEN Criteria in a Large Air Medical Cohort


Edward Kuzmack, DO1, Travis Inglis, DO1, David Olvera, EMT-P, Allen Wolfe, RN, Kona Seng, DO1, and Daniel Davis, MD1,2,3

1Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California

2Air Methods Corporation, Englewood, Colorado

3California University of Science and Medicine, San Bernardino, California


Background: Difficult-airway prediction tools help identify optimal airway techniques, but were derived in elective surgery patients and may not be applicable to emergency rapid sequence intubation (RSI). The HEAVEN criteria (Hypoxemia, Extremes of size, Anatomic abnormalities, Vomit/blood/fluid, Exsanguination, Neck mobility issues) may be more relevant to emergency RSI patients.

Objective: To validate the HEAVEN criteria for difficult-airway prediction in emergency RSI using a large air medical cohort.

Methods: This was a retrospective analysis using a large air medical airway registry using data from 160 bases over a 1-year period. Standard test characteristics (sensitivity, specificity, positive predictive value, negative predictive value [NPV]) for the HEAVEN criteria were calculated for overall intubation success, first-attempt success, and first-attempt success without desaturation. In addition, multivariable logistic regression was used to quantify the independent association between each of the HEAVEN criteria, as well as the total number of criteria present and intubation success after adjusting for age, gender, and clinical category (burn, medical, trauma, non-traumatic shock).

Results: A total of 2419 patients undergoing air medical RSI were included. Excellent NPV was observed (97% for each of the HEAVEN criteria except ‘‘Exsanguination,’’ which had an NPV of 87% but specificity of 99%). First-attempt success was lower for each of the HEAVEN criteria, with an inverse relationship observed between total HEAVEN criteria and intubation success (first-attempt success with no criteria = 94% and with 5 + criteria = 43%). Multivariable logistic regression revealed independent associations between each of the HEAVEN criteria, as well as total number of criteria and intubation success.

Conclusions: The HEAVEN criteria seem to be a useful tool to predict difficult airways in emergency RSI.

Keywords: airway management; intubation; prediction tool; emergency; difficult airway; rapid sequence intubation

Click below to read the full study published by The Journal of Emergency Medicine, Volume 54, Issue 4, P395-401, April 01, 2018