The HEAVEN Criteria Predict Laryngoscopic View and Intubation Success for Both Direct and Video Laryngoscopy: A Cohort Analysis


Fauzia Nausheen1, Nichole P. Niknafs2, Derek J. MacLean2, David J. Olvera, Allen C. Wolfe Jr, Troy W. Pennington2,3 and Daniel P. Davis1,2,3

1Department of Medical Education, California University of Science & Medicine, School of Medicine, 217 E Club Center Dr Suite A, San Bernardino, CA 92408, USA.

2Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

3Air Methods Corporation, Greenwood Village, Colorado, USA.


Background: Existing difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI).

Methods: A retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade.

Results: A total of 5137 RSI patients over 24monthswere included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria.

Conclusion: The HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI.

Keywords: Airway management, Intubation, Laryngoscopy, Resuscitation

Click below to view the full research paper published by the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 27, Article number: 50 (2019)