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Li J, Liu B, Zhou QH, Ni HD, Liu MJ, Deng K. Pre-oxygenation with high-flow oxygen through the nasopharyngeal airway compared to facemask on carbon dioxide clearance in emergency adults: a prospective randomized non-blinded clinical trial. Eur J Trauma Emerg Surg 2024; 50:1051-1061. [PMID: 38148421 PMCID: PMC11249433 DOI: 10.1007/s00068-023-02418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Before tracheal intubation, it is essential to provide sufficient oxygen reserve for emergency patients with full stomachs. Recent studies have demonstrated that high-flow nasal oxygen (HFNO) effectively pre-oxygenates and prolongs apneic oxygenation during tracheal intubation. Despite its effectiveness, the use of HFNO remains controversial due to concerns regarding carbon dioxide clearance. The air leakage and unknown upper airway obstruction during HFNO therapy cause reduced oxygen flow above the vocal cords, possibly weaken the carbon dioxide clearance. METHODS Patients requiring emergency surgery who had fasted < 8 h and not drunk < 2 h were randomly assigned to the high-flow group, who received 100% oxygen at 30-60 L/min through nasopharyngeal airway (NPA), or the mask group, who received 100% oxygen at 8 L/min. PaO2 and PaCO2 were measured immediately before pre-oxygenation (T0), anesthesia induction (T1), tracheal intubation (T2), and mechanical ventilation (T3). The gastric antrum's cross-sectional area (CSA) was measured using ultrasound technology at T0, T1, and T3. Details of complications, including hypoxemia, reflux, nasopharyngeal bleeding, postoperative pulmonary infection, postoperative nausea and vomiting (PONV), and postoperative nasopharyngeal pain, were recorded. The primary outcomes were PaCO2 measured at T1, T2, and T3. The secondary outcomes included PaO2 at T1, T2, and T3, CSA at T1 and T3, and complications happened during this trial. RESULTS Pre-oxygenation was administered by high-flow oxygen through NPA (n = 58) or facemask (n = 57) to 115 patients. The mean (SD) PaCO2 was 32.3 (6.7) mmHg in the high-flow group and 34.6 (5.2) mmHg in the mask group (P = 0.045) at T1, 45.0 (5.5) mmHg and 49.4 (4.6) mmHg (P < 0.001) at T2, and 47.9 (5.1) mmHg and 52.9 (4.6) mmHg (P < 0.001) at T3, respectively. The median ([IQR] [range]) PaO2 in the high-flow and mask groups was 404.5 (329.1-458.1 [159.8-552.9]) mmHg and 358.9 (274.0-413.3 [129.0-539.1]) mmHg (P = 0.007) at T1, 343.0 (251.6-428.7 [73.9-522.1]) mmHg and 258.3 (162.5-347.5 [56.0-481.0]) mmHg (P < 0.001) at T2, and 333.5 (229.9-411.4 [60.5-492.4]) mmHg and 149.8 (87.0-246.6 [51.2-447.5]) mmHg (P < 0.001) at T3, respectively. The CSA in the high-flow and mask groups was 371.9 (287.4-557.9 [129.0-991.2]) mm2 and 386.8 (292.0-537.3 [88.3-1651.7]) mm2 at T1 (P = 0.920) and 452.6 (343.7-618.4 [161.6-988.1]) mm2 and 385.6 (306.3-562.0 [105.5-922.9]) mm2 at T3 (P = 0.173), respectively. The number (proportion) of complications in the high-flow and mask groups is shown below: hypoxemia: 1 (1.7%) vs. 9 (15.8%, P = 0.019); reflux: 0 (0%) vs. 0 (0%); nasopharyngeal bleeding: 1 (1.7%) vs. 0 (0%, P = 1.000); pulmonary infection: 4 (6.9%) vs. 3 (5.3%, P = 1.000); PONV: 4 (6.9%) vs. 4 (7.0%, P = 1.000), and nasopharyngeal pain: 0 (0%) vs. 0 (0%). CONCLUSIONS Compared to facemasks, pre-oxygenation with high-flow oxygen through NPA offers improved carbon dioxide clearance and enhanced oxygenation prior to tracheal intubation in patients undergoing emergency surgery, while the risk of gastric inflation had not been ruled out. TRIAL REGISTRATION This trial was registered prospectively at the Chinese Clinical Research Registry on 26/4/2022 (Registration number: ChiCTR2200059192).
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Affiliation(s)
- Jie Li
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, 314001, Zhejiang Province, China
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China
| | - Bin Liu
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Jiaxing, 314001, Zhejiang Province, China
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China
| | - Qing-He Zhou
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China
| | - Hua-Dong Ni
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China
| | - Ming-Juan Liu
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China
| | - Kang Deng
- Department of Anesthesiology and Pain Research Center, The First Hospital of Jiaxing or The Affiliated Hospital of Jiaxing University, Jiaxing, 314001, Zhejiang Province, China.
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Massoth C, Wenk M. [The Myth about the Laryngeal Mask]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:325-327. [PMID: 38759687 DOI: 10.1055/a-2199-4692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Peak pressures ≥ 20 mbar are not a contraindication for laryngeal masks. The oropharyngeal leak pressure of a laryngeal mask does not correspond to the pressure at which oesophagogastric air leakage occurs. Setting a peak pressure limit of 20 cm H2O on the respirator can lead to critical situations because the tidal volume may then remain too low. A good alternative is to use a pressure alarm limit. The use of laryngeal masks does not preclude the use of PEEP and/or relaxation.
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Seol T, Kim H, Chang JE, Kang Y, Hwang JY. Effect of paratracheal pressure on the effectiveness of mask ventilation in obese anesthetized patients: a randomized, cross-over study. J Clin Monit Comput 2024; 38:31-36. [PMID: 37418060 DOI: 10.1007/s10877-023-01048-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/18/2023] [Indexed: 07/08/2023]
Abstract
Paratracheal pressure has been recently suggested to compress and occlude the upper esophagus at the lower left paratracheal region to prevent gastric regurgitation alternative to cricoid pressure. It also prevents gastric insufflation. The aim of this randomized cross-over study was to investigate the effectiveness of paratracheal pressure on mask ventilation in obese anesthetized paralyzed patients. After the induction of anesthesia, two-handed mask ventilation was initiated in a volume-controlled mode with a tidal volume of 8 mL kg‒1 based on ideal body weight (IBW), a respiratory rate of 12 breaths min- 1, and positive end-expiratory pressure of 10 cmH2O. Expiratory tidal volume and peak inspiratory pressure were recorded alternately with or without the application of 30 Newtons (approximately 3.06 kg) paratracheal pressure during a total of 16 successive breaths over 80 s. Association of patient characteristics with the effectiveness of paratracheal pressure on mask ventilation, defined as the difference in expiratory tidal volume between the presence or absence of paratracheal pressure were evaluated. In 48 obese anesthetized paralyzed patients, expiratory tidal volume was significantly higher with the application of paratracheal pressure than without paratracheal pressure [496.8 (74.1) mL kg- 1 of IBW vs. 403.8 (58.4) mL kg- 1 of IBW, respectively; P < 0.001]. Peak inspiratory pressure was also significantly higher with the application of paratracheal pressure compared to that with no paratracheal pressure [21.4 (1.2) cmH2O vs. 18.9 (1.6) cmH2O, respectively; P < 0.001]. No significant association was observed between patient characteristics and the effectiveness of paratracheal pressure on mask ventilation. Hypoxemia did not occur in any of the patients during mask ventilation with or without paratracheal pressure. The application of paratracheal pressure significantly increased both the expiratory tidal volume and peak inspiratory pressure during face-mask ventilation with a volume-controlled mode in obese anesthetized paralyzed patients. Gastric insufflation was not evaluated in this study during mask ventilation with or without paratracheal pressure.
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Affiliation(s)
- Taikyung Seol
- Department of Anesthesiology and Pain Medicine, Sheikh Khalifa Specialty Hospital, RAK, Ras al Khaimah, United Arab Emirates
| | - Hyerim Kim
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramaero 5-gil, Dongjakgu, Seoul, 07061, Republic of Korea
- Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jee-Eun Chang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramaero 5-gil, Dongjakgu, Seoul, 07061, Republic of Korea
- Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Yeonsoo Kang
- Department of Anesthesiology & Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Boramaero 5-gil, Dongjakgu, Seoul, 07061, Republic of Korea.
- Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.
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Broc A, Morin F, Schmit H, Taillantou-Candau M, Vuillermoz A, Drouet A, Hutin A, Polard L, Lamhaut L, Brisset U, Charbonney E, Delisle S, Beloncle F, Richard JC, Savary D. Performances and limits of Bag-Valve-Device for pre-oxygenation and manual ventilation: A comparative bench and cadaver study. Resuscitation 2024; 194:109999. [PMID: 37838142 DOI: 10.1016/j.resuscitation.2023.109999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Bag-Valve-Device (BVD) is the most frequently used device for pre-oxygenation and ventilation during cardiopulmonary resuscitation (CPR). A minimal expired fraction of oxygen (FeO2) above 0.85 is recommended during pre-oxygenation while insufflated volume (VTi) should be reduced during manual ventilation. The objective was to compare the performances of different BVD in simulated conditions. METHODS Nine BVD were evaluated during pre-oxygenation: spontaneous breathing patients were simulated on a test lung (mild and severe conditions). FeO2 was measured with and without positive end-expiratory pressure (PEEP). CO2 rebreathing was evaluated. Then, manual ventilation was performed by 36 caregivers (n = 36) from three hospitals on a specific manikin; same procedure was repeated by 3 caregivers (n = 3) on two human cadavers with three of the nine BVD: In non-CPR scenario and during mechanical CPR with Interrupted Chest Compressions strategy (30:2). RESULTS Pre-oxygenation: FeO2 was lower than 0.85 for three BVD in severe condition and for two BVD in mild condition. FeO2 was higher than 0.85 in eight of nine BVD with an additional PEEP valve (PEEP 5 cmH2O). One BVD induced CO2 rebreathing. Manual ventilation: For non-CPR manual ventilation, mean VTi was within the predefined lung protective range (4-8 mL/kg PBW) for all BVD on the bench. For CPR manual ventilation, mean VTi was above the range for three BVD on the bench. Similar results were observed on cadavers. CONCLUSIONS Several BVD did not reach the FeO2 required during pre-oxygenation. Manual ventilation was significantly less protective in three BVD. These observations are related to the different BVD working principles.
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Affiliation(s)
- A Broc
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Med(2)Lab, Air Liquide Medical Systems, Antony, France
| | - F Morin
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Emergency Department, Angers University Hospital, Angers, France
| | - H Schmit
- Emergency Department, Annecy Genevois Hospital, Annecy, France
| | - M Taillantou-Candau
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France
| | - A Vuillermoz
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France
| | - A Drouet
- SISA Centre Médical de Soins Immédiats ANNECY SEYNOD 74, Annecy, France
| | - A Hutin
- SAMU of Paris, Necker-Enfants Malades Hospital, Paris, France
| | - L Polard
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Med(2)Lab, Air Liquide Medical Systems, Antony, France
| | - L Lamhaut
- SAMU of Paris, Necker-Enfants Malades Hospital, Paris, France
| | - U Brisset
- Emergency Department, Angers University Hospital, Angers, France
| | - E Charbonney
- Hospital Center of University of Montréal, Montreal, QC H2X 0C1, Canada; Anatomy Department, University of Québec at Trois-Rivières, Trois-Rivières, Canada
| | - S Delisle
- Department of Family and Emergency Medicine, FCCM University of Montréal, Montreal, QC, Canada
| | - F Beloncle
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France
| | - J C Richard
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Med(2)Lab, Air Liquide Medical Systems, Antony, France; Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France.
| | - D Savary
- Ventilation Laboratory (Vent'Lab), Medical Intensive Care Unit (ICU), Angers University Hospital, Angers, France; Emergency Department, Angers University Hospital, Angers, France
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Jarzebowski ML, Kadar R. Pro: The Best Method to Preoxygenate the Physiologically Difficult Airway Is Noninvasive Ventilation. J Cardiothorac Vasc Anesth 2023; 37:2668-2670. [PMID: 37210327 DOI: 10.1053/j.jvca.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/25/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Mary L Jarzebowski
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI; Veterans Affairs Ann Arbor Healthcare System, Department of Anesthesiology, Ann Arbor, MI.
| | - Rachel Kadar
- Department of Anesthesiology, Northwestern University, Chicago, IL
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Naito H, Hanafusa H, Hongo T, Yumoto T, Yorifuji T, Weissman A, Rittenberger JC, Guyette FX, Fujishima M, Maeyama H, Nakao A. Effect of stomach inflation during cardiopulmonary resuscitation on return of spontaneous circulation in out-of-hospital cardiac arrest patients: A retrospective observational study. Resuscitation 2023; 193:109994. [PMID: 37813147 DOI: 10.1016/j.resuscitation.2023.109994] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Gastric inflation caused by excessive ventilation is a common complication of cardiopulmonary resuscitation. Gastric inflation may further compromise ventilation via increases in intrathoracic pressure, leading to decreased venous return and cardiac output, which may impair out-of-hospital cardiac arrest (OHCA) outcomes. The purpose of this study was to measure the gastric volume of OHCA patients using computed tomography (CT) scan images and evaluate the effect of gastric inflation on return of spontaneous circulation (ROSC). METHODS In this single-center, retrospective, observational study, CT scan was conducted after ROSC or immediately after death. Total gastric volume was measured. Primary outcome was ROSC. Achievement of ROSC was compared in the gastric distention group and the no gastric distention group; gastric distension was defined as total gastric volume in the ≥75th percentile. Additionally, factors associated with gastric distention were examined. RESULTS A total of 446 cases were enrolled in the study; 120 cases (27%) achieved ROSC. The median gastric volume was 400 ml for all OHCA subjects; 1068 ml in gastric distention group vs. 287 ml in no gastric distention group. There was no difference in ROSC between the groups (27/112 [24.1%] vs. 93/334 [27.8%], p = 0.440). Gastric distention did not have a significant impact, even after adjustments (adjusted odds ratio 0.73, 95% confidence interval [0.42-1.29]). Increased gastric volume was associated with longer emergency medical service activity time. CONCLUSIONS We observed a median gastric volume of 400 ml in patients after OHCA resuscitation. In our setting, gastric distention did not prevent ROSC.
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Affiliation(s)
- Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan.
| | - Hiroaki Hanafusa
- Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan; Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Gift Foundation SAISEIKAI, Utsunomiya Hospital, Tochigi, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | | | - Hiroki Maeyama
- Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan
| | - Astunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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9
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Edmark L, Englund EK, Jonsson AS, Zilic AT, Cajander P, Östberg E. Pressure-controlled versus manual facemask ventilation for anaesthetic induction in adults: A randomised controlled non-inferiority trial. Acta Anaesthesiol Scand 2023; 67:1356-1362. [PMID: 37476919 DOI: 10.1111/aas.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Pressure-controlled face mask ventilation (PC-FMV) with positive end-expiratory pressure (PEEP) after apnoea following induction of general anaesthesia prolongs safe apnoea time and reduces atelectasis formation. However, depending on the set inspiratory pressure, a delayed confirmation of a patent airway might occur. We hypothesised that by lowering the peak inspiratory pressure (PIP) when using PC-FMV with PEEP, confirmation of a patent airway would not be delayed as studied by the first return of CO2 , compared with manual face mask ventilation (Manual FMV). METHODS This was a single-centre, randomised controlled non-inferiority trial. Seventy adult patients scheduled for elective day-case surgery under general anaesthesia with body mass index between 18.5 and 29.9 kg m-2 , American Society of Anesthesiologists (ASA) classes I-III, and without anticipated difficult FMV, were included. Before the start of pre-oxygenation and induction of general anaesthesia, participants were randomly allocated to receive ventilation with either PC-FMV with PEEP, at a PIP of 11 and a PEEP of 6 cmH2 O or Manual FMV, with the adjustable pressure-limiting valve set at 11 cmH2 O. The primary outcome variable was the number of ventilatory attempts needed until confirmation of a patent airway, defined as the return of at least 1.3 kPa CO2 . RESULTS The return of ≥1.3 kPa CO2 on the capnography curve was observed after mean ± SD, 3.6 ± 4.2 and 2.5 ± 1.9 ventilatory attempts/breaths with PC-FMV with PEEP and Manual FMV, respectively. The difference in means (1.1 ventilatory attempts/breaths) had a 99% CI of -1.0 to 3.1, within the accepted upper margin of four breaths for non-inferiority. CONCLUSION Following induction of general anaesthesia, PC-FMV with PEEP was used without delaying a patent airway as confirmed with capnography, if moderate pressures were used.
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Affiliation(s)
- Lennart Edmark
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Emma-Karin Englund
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
| | | | | | - Per Cajander
- Department of Anaesthesia and Intensive Care, Örebro University Hospital, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Erland Östberg
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
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10
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Ward PA, Athanassoglou V, McNarry AF. Safe use of high flow nasal oxygen in apnoeic patients for laryngotracheal surgery: Adapting practice as technology evolves. Eur J Anaesthesiol 2023; 40:801-804. [PMID: 37789752 DOI: 10.1097/eja.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Affiliation(s)
- Patrick A Ward
- From St John's Hospital, NHS Lothian, Livingston (PAW, AFM), Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford (VA), and Western General Hospital, NHS Lothian, Edinburgh, UK (AFM)
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11
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Jung YK, Kim CL, Jeong MA, Sung JM, Lee KG, Kim NY, Kang L, Lim H. Gastric insufflation and surgical view according to mask ventilation method for laparoscopic cholecystectomy: a randomized controlled study. BMC Anesthesiol 2023; 23:321. [PMID: 37730575 PMCID: PMC10510126 DOI: 10.1186/s12871-023-02269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Proper mask ventilation is important to prevent air inflow into the stomach during induction of general anesthesia, and it is difficult to send airflow only through the trachea without gastric inflation. Changes in gastric insufflation according to mask ventilation during anesthesia induction were compared. METHODS In this prospective, randomized, single-blind study, 230 patients were analyzed to a facemask-ventilated group (Ventilation group) or no-ventilation group (Apnea group) during anesthesia induction. After loss of consciousness, pressure-controlled ventilation at an inspiratory pressure of 15 cmH2O was performed for two minutes with a two-handed mask-hold technique for Ventilation group. For Apnea group, only the facemask was fitted to the face for one minute with no ventilation. Next, endotracheal intubation was performed. The gastric cross-sectional area (CSA, cm2) was measured using ultrasound before and after induction. After pneumoperitoneum with carbon dioxide, gastric insufflation of the surgical view was graded by the surgeon for each group. RESULTS Increase of postinduction antral CSA on ultrasound were not significantly different between Ventilation group and Apnea group (0.04 ± 0.3 and 0.02 ± 0.28, p-value = 0.225). Additionally, there were no significant differences between the two groups in surgical grade according to surgeon's judgement. CONCLUSIONS Pressure-controlled ventilation at an inspiratory pressure of 15 cmH2O for two minutes did not increase gastric antral CSA and insufflation of stomach by laparoscopic view. TRIAL REGISTRATION http://cris.nih.go.kr (KCT0003620) on 13/3/2019.
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Affiliation(s)
- Yun Kyung Jung
- Department of Surgery, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Cho Long Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea
| | - Mi Ae Jeong
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea
| | - Jeong Min Sung
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea
| | - Kyeong Geun Lee
- Department of Surgery, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Na Yeon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea
| | - Leekyeong Kang
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea
| | - Hyunyoung Lim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seoungdong-gu, 04763, Seoul, Republic of Korea.
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12
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Ding Y, Huang T, Ge Y, Gao J, Zhang Y. Effect of trans-nasal humidified rapid insufflation ventilatory exchange on reflux and microaspiration in patients undergoing laparoscopic cholecystectomy during induction of general anesthesia: a randomized controlled trial. Front Med (Lausanne) 2023; 10:1212646. [PMID: 37746088 PMCID: PMC10512709 DOI: 10.3389/fmed.2023.1212646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Background Reflux aspiration is a rare but serious complication during induction of anesthesia. The primary aim of this study is to compare the incidence of reflux and microaspiration in patients undergoing laparoscopic cholecystectomy during induction of general anesthesia using either a facemask or trans-nasal humidified rapid insufflation ventilatory exchange. Methods We conducted a single-center, randomized, controlled trial. Thirty patients were allocated to either a facemask or a trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) group. Pre-oxygenation for 5 min with a facemask or THRIVE, positive pressure ventilation for 2 min or THRIVE for 2 min after anesthesia induction was followed. Before endotracheal intubation, the secretion above and below the glottis was collected to measure pepsin content and analyze blood gas. The ELISA assay for supra- and subglottic human pepsin content was used to detect the presence of reflux and microaspiration. The primary outcome was the incidence of reflux and microaspiration. Secondary outcomes were apnea time, PaO2 before tracheal intubation, and the end-expiratory carbon dioxide partial pressure. Results Patients in the THRIVE group had a significantly longer apnea time (379.55 ± 94.12 s) compared to patients in the facemask group (172.96 ± 58.87 s; p < 0.001). There were no differences observed in PaO2 between the groups. A significant difference in gastric insufflation, reflux, and microaspiration was observed between the groups. Gastric insufflation was 6.9% in the THRIVE group vs. 28.57% kPa in the facemask group (p = 0.041); reflux was 10.34% in the THRIVE group vs. 32.14% kPa in the facemask group (p = 0.044); and microaspiration was 0% in the THRIVE group vs. 17.86% kPa in the facemask group (p = 0.023). Conclusion The application of THRIVE during induction of general anesthesia reduced the incidence of reflux and microaspiration while ensuring oxygenation and prolonged apnea time in laparoscopic cholecystectomy patients. THRIVE may be an optimal way to administer oxygen during the induction of general anesthesia in laparoscopic cholecystectomy patients. Clinical trial registration Chinese Clinical Trial Registry, No: ChiCTR2100054086, https://www.chictr.org.cn/indexEN.html.
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Affiliation(s)
| | | | | | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Yang Zhang
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
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13
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Rajendran P, Karim HMR, Panda CK, Neema PK, Dey S. Preintubation Machine-Delivered Pressure Support Ventilation With Positive End-Expiratory Pressure Versus Manual Bag-Mask Ventilation for Oxygenation in Overweight and Obese Patients: A Randomized, Pilot Study. Cureus 2023; 15:e45185. [PMID: 37842344 PMCID: PMC10575795 DOI: 10.7759/cureus.45185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Noninvasive positive pressure ventilation (NIPPV) maintains mean airway pressures well, and its usability for preoxygenation is well described. Anesthesia machine-delivered NIPPV-based preoxygenation has recently been evaluated against the traditional manual bag-mask ventilation (BMV). The efficiency of such a technique over the traditional one is yet to be established well. The present study evaluated the feasibility of machine-delivered preoxygenation using pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and compared the effectiveness with BMV. METHODS Thirty overweight and obese adults belonging to the American Society of Anesthesiologist's physical status I-II were randomized to receive PSV+PEEP or BMV for preintubation preoxygenation targeted to a fraction of expired oxygen (FeO2) of 85% and 90% or for a maximum period of five minutes, whichever came first. Postintubation, the patient was observed for the time taken until 1% desaturation without ventilation. Arterial blood gases, respiratory variables, FeO2 achieved, and different times were collected and compared. RESULTS The baseline characteristics and arterial blood gases were similar between the two groups. The PSV+PEEP group had consistent and favorable tidal volume and airway pressure delivery. The difference in time to reach a FeO2 of 85% between the two groups was not statistically different. Only two patients achieved a FeO2 of 90% in the PSV+PEEP group versus none in the BMV group. However, partial pressure of oxygen at 1% desaturation (217.42±109.47 versus 138.073±71.319 mmHg, p 0.0259) was higher in the PSV+PEEP group. Similarly, the time until 1% desaturation was significantly prolonged in the PSV+PEEP group (206.6±76.952 versus 140.466±54.245 seconds, p 0.0111). CONCLUSION The present pilot study findings indicate that preintubation machine-delivered PSV+PEEP-based preoxygenation is feasible and might be more effective than traditional BMV in overweight and obese patients.
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Affiliation(s)
| | - Habib Md R Karim
- Anesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
| | - Chinmaya K Panda
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Praveen K Neema
- Cardiac Anaesthesiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, IND
| | - Samarjit Dey
- Anaesthesiology, All India Institute of Medical Sciences, Mangalagiri, Mangalagiri, IND
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14
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Park JJ, Seong H, Huh H, Kwak JS, Park H, Yoon SZ, Cho JE. Comparison between pressure-controlled and manual ventilation during anesthetic induction in patients with expected difficult airway: A prospective randomized controlled trial. Medicine (Baltimore) 2023; 102:e35007. [PMID: 37653750 PMCID: PMC10470681 DOI: 10.1097/md.0000000000035007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Gastric insufflation can cause gastric regurgitation, which may be exacerbated in patients who are expected to have difficult airways. The purpose of this study was to investigate the difference in respiratory parameters and the frequency of gastric insufflation according to the ventilation mode during the anesthestic induction on patients who were predicted to have difficult facemask ventilation. METHODS A total of eighty patients with expected airway difficulties were included. Patient were allocated to 2 groups (n = 40 each). In the manual ventilation group, ventilation was performed by putting a mask on the patient's face with 1-hand and adjusting the pressure limiting valve to 15 cm H2O. In the pressure-controlled ventilation group, a mask was held in place using 2-handed jaw-thrust maneuver. The pressure-controlled ventilation was applied and peak inspiration pressure was adjusted to achieve a tidal volume of 6 to 8 mL/kg. The primary outcome was the difference of the peak airway pressure between 2 groups every 30 seconds for 120 seconds duration of mask ventilation. We also evaluated respiratory variables including peak airway pressure, End-tidal carbon dioxide and also gastric insufflation using ultrasonography. RESULTS The pressure-controlled ventilation group demonstrated lower peak airway pressure than the manual ventilation group (P = .005). End-tidal carbon dioxide was higher in the pressure-controlled ventilation group (P = .012). The incidence of gastric insufflation assessed by real-time ultrasonography of the gastric antrum was higher in the manual ventilation group than in the pressure-controlled ventilation group [3 (7.5%) vs 17 (42.5%), risk ratio (95% confidence interval): 0.06 to 0.56, P = .003]. CONCLUSIONS Pressure-controlled ventilation during facemask ventilation in patients who were expected to have difficult airways showed a lower gastric insufflation rate with low peak airway pressure compared to manual ventilation.
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Affiliation(s)
- Jeong Jun Park
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyunyoung Seong
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyub Huh
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ji Soo Kwak
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Heechan Park
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung Zhoo Yoon
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jang Eun Cho
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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15
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Zhou X, Huang X, Zhou Z, Xu Q, Mei A, Mazomba LX, Sun J. Effect of transnasal humidified rapid-insufflation ventilatory exchange on gastric insufflation during anaesthesia induction: A randomised controlled trial and multivariate analysis. Eur J Anaesthesiol 2023; 40:521-528. [PMID: 37171113 DOI: 10.1097/eja.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Mask ventilation during anaesthesia induction is generally used to provide adequate oxygenation but improper mask ventilation can result in gastric insufflation. It has been reported that oxygen administered by transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) during anaesthesia induction can maintain oxygenation but its effect on gastric insufflation is unknown. OBJECTIVES The primary aim of this study was to evaluate whether THRIVE provided adequate oxygenation without gastric insufflation. The secondary aim was to explore the change in cross-sectional area of the antrum (CSAa) during anaesthesia induction. Other potential risk factors of gastric insufflation were also explored. DESIGN A prospective, randomised, double-blind study. SETTING Single centre, Department of Anaesthesiology, 1 st Affiliated Hospital, Wenzhou Medical University, China, from May 2022 to September 2022. PATIENTS A total of 210 patients (age >18 years, ASA classification I to III) scheduled to undergo general anaesthesia were enrolled. INTERVENTIONS For induction of general anaesthesia, patients were randomised into two groups: THRIVE and pressure-controlled facemask ventilation (PCFV). The THRIVE group received high-flow nasal oxygen with no additional ventilation. The PCFV group had pressure-controlled positive pressure ventilation from the anaesthesia machine via a tight fitting facemask. Gastric insufflation was detected using real-time ultrasonography. The CSAa was measured from ultrasonography images obtained before anaesthesia induction and at 0, 1, 2 and 3 min after loss of consciousness. MAIN OUTCOME MEASURES The incidence of gastric insufflation during the period from loss of consciousness until intubation. RESULTS The THRIVE group had a lower incidence of gastric insufflation during anaesthesia induction than the PCFV group (13.0 vs. 35.3%, odds ratio (OR) = 0.27, 95% confidence interval (CI), 0.14 to 0.56, P < 0.001). Increase in the CSA after anaesthesia induction was significantly correlated with gastric insufflation (OR = 5.35, 95% CI, 2.90 to 9.89, P < 0.001). Multivariate logistic regression analysis showed that advancing age (OR = 1.04, 95% CI, 1.01 to 1.07), obstructive sleep apnoea syndrome (OR = 2.43, 95% CI, 1.24 to 4.76), higher Mallampati score (OR = 2.66, 95% CI, 1.21 to 5.85) and PCFV (OR = 4.78, 95% CI, 2.06 to 11.06) were important independent risk factors for gastric insufflation. CONCLUSION During anaesthesia induction, the THRIVE technique provided adequate oxygenation with a reduced incidence of gastric insufflation. PCFV, advancing age, obstructive sleep apnoea syndrome and the Mallampati score were found to be independent risk factors for gastric insufflation during anaesthesia induction. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR200059555.
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Affiliation(s)
- Xiaotian Zhou
- From the Department of Anaesthesiology (XZ, XH, ZZ, LXM, JS), Operating Room Nursing Department (QX) and Post Anaesthesia Care Unit Nursing (AM), 1st affiliated hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
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16
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Lim KS, Nielsen JR, Piekarski F, Gerth AM, Zhong G. What airway management information do anaesthetic charts prompt for? An audit of charts from 132 hospitals across Australia and New Zealand. Anaesth Intensive Care 2023; 51:43-50. [PMID: 36217287 DOI: 10.1177/0310057x221099033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Anaesthetists can make safer airway plans if they know which airway techniques worked previously and which ones did not. Anaesthetic charts do not always capture this information, however, and guidelines from the Australian and New Zealand College of Anaesthetists do not specify what details on airway management they should include. To assess how anaesthetic charts support airway documentation, we audited the airway management section of blank charts from 132 hospitals accredited for training by the Australian and New Zealand College of Anaesthetists. We evaluated charts for the presence of 17 clinically important data fields describing tracheal intubation, supraglottic airway use and bag-mask ventilation. Our audit revealed that data fields on anaesthetic charts focus more on tracheal intubation than bag-mask ventilation or supraglottic airway use. Nearly all charts (99%) had prompts for intubation and most had prompts for both operator technique and patient outcome. For supraglottic airway use, 95% of charts had at least one data field, but few had prompts for difficulty or outcome. For bag-mask ventilation, 58% of charts had a data field for difficulty but most of these were subjective; few (1.5%) included any outcome measures. Data fields describing bag-mask ventilation and supraglottic airway use were also inconsistent. In summary, data fields on Australian and New Zealand anaesthetic charts focus on tracheal intubation with consistent prompts for both operator method and outcome. The inclusion of fields for outcome and difficulty of bag-mask ventilation and supraglottic airway use could help clinicians make better records of airway management.
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Affiliation(s)
- Kar-Soon Lim
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - James R Nielsen
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Alice M Gerth
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - George Zhong
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia
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17
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He G, Ma L, Tian K, Cao Y, Qin Z. Effect of facemask oxygenation with and without positive pressure ventilation on gastric volume during anesthesia induction in patients undergoing laparoscopic cholecystectomy or partial hepatectomy: a randomized controlled trial. BMC Anesthesiol 2022; 22:412. [PMID: 36581835 PMCID: PMC9801608 DOI: 10.1186/s12871-022-01958-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Studies focusing on the relationship between gastric volume and facemask oxygenation without ventilation during apnea in anesthesia induction are scarce. This study compared the change in gastric volume during apnea in anesthesia induction using facemask ventilation and facemask oxygenation without ventilation in adults undergoing laparoscopic surgery. METHODS In this prospective, randomized, double-blinded trial, 70 adults undergoing laparoscopic surgery under general anesthesia were divided into two groups to receive facemask oxygenation with and without ventilation for 60 seconds after loss of consciousness. Before anesthesia induction and after endotracheal intubation, the gastric antral cross-sectional area was measured with ultrasound imaging. Arterial blood gases were tested at baseline (T1), after preoxygenation (T2), after loss of consciousness (T3), and before and after endotracheal intubation (T4 and T5, respectively). RESULTS Sixty patients were included (ventilation n = 30; non ventilation n = 30, 10 patients were excluded). The median [IQR] change of gastric antral cross-sectional area in ventilation group was significantly higher than in non ventilation group (0.83 [0.20 to 1.54] vs. 0.10 [- 0.11 to 0.56] cm2, P = 0.001). At T4 and T5, the PaO2 in ventilation group was significantly higher than in non ventilation group (T4: 391.83 ± 61.53 vs. 336.23 ± 74.99 mmHg, P < 0.01; T5: 364.00 ± 58.65 vs. 297.13 ± 86.95 mmHg, P < 0.01), while the PaCO2 in non ventilation group was significantly higher (T4: 46.57 ± 5.78 vs. 37.27 ± 6.10 mmHg, P < 0.01; T5: 48.77 ± 6.59 vs. 42.63 ± 6.03 mmHg, P < 0.01) and the pH value in non ventilation group was significantly lower (T4: 7.35 ± 0.029 vs 7.42 ± 0.047, P < 0.01; T5: 7.34 ± 0.033 vs 7.39 ± 0.044, P < 0.01). At T4, the HCO3- in non ventilation group was significantly higher (25.79 ± 2.36 vs. 23.98 ± 2.18 mmol l- 1, P < 0.01). CONCLUSIONS During apnoea, the increase in gastric volume was milder in patients undergoing facemask oxygenation without ventilation than with positive pressure ventilation. TRIAL REGISTRATION ChiCTR2100054193, 10/12/2021, Title: "Effect of positive pressure and non-positive pressure ventilation on gastric volume during induction of general anesthesia in laparoscopic surgery: a randomized controlled trial". Website: https://www.chictr.ogr.cn .
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Affiliation(s)
- Guangting He
- grid.284723.80000 0000 8877 7471Department of Anesthesiology, NanFang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515 People’s Republic of China
| | - Liyun Ma
- grid.284723.80000 0000 8877 7471Department of Anesthesiology, NanFang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515 People’s Republic of China
| | - Ke Tian
- grid.284723.80000 0000 8877 7471Department of Anesthesiology, NanFang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515 People’s Republic of China
| | - Yuqi Cao
- grid.284723.80000 0000 8877 7471Department of Anesthesiology, NanFang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515 People’s Republic of China
| | - Zaisheng Qin
- grid.284723.80000 0000 8877 7471Department of Anesthesiology, NanFang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515 People’s Republic of China
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Kim EH, Cho SA, Kang P, Song IS, Ji SH, Jang YE, Lee JH, Kim JT, Kim HS. Ultrasound-guided esophageal compression during mask ventilation in small children: a prospective observational study. BMC Anesthesiol 2022; 22:257. [PMID: 35971064 PMCID: PMC9377106 DOI: 10.1186/s12871-022-01803-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/08/2022] [Indexed: 11/12/2022] Open
Abstract
Background The use of cricoid compression to prevent insufflation remains controversial, and its use in children is limited. This study aimed to examine the effect of real-time ultrasound-guided esophageal compression on the prevention of gastric insufflation. Method This prospective observational study was conducted with fifty children aged < 2 years undergoing general anesthesia. Patients were excluded if they were at an increased risk for gastric regurgitation or pulmonary aspiration. Following anesthetic induction under spontaneous breathing, ultrasound-guided esophageal compression was performed during pressure-controlled face-mask ventilation using a gradual increase in peak inspiratory pressure from 10 to 24 cm H2O to determine the pressure at which gastric insufflation occurred. The primary outcome was the incidence of gastric insufflation during anesthetic induction with variable peak inspiratory pressure after real-time ultrasound-guided esophageal compression was applied. Results Data from a total of 42 patients were analyzed. Gastric insufflation was observed in 2 (4.7%) patients. All patients except one had their esophagus on the left side of the trachea. Applying ultrasound-guided esophageal compression did not affect the percentage of glottic opening scores (P = 0.220). Conclusions The use of real-time ultrasound-guided esophageal compression pressure can aid preventing gastric insufflation during face-mask ventilation in children less than 2 years old. Trial registration Clinicaltrials.gov identifier: NCT04645043. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01803-5.
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Affiliation(s)
- Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Sung-Ae Cho
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon, 35365, Republic of Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - In-Sun Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul, 03080, Republic of Korea.
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Gunasekaran A, Govindaraj K, Gupta SL, Vinayagam S, Mishra SK. Comparison of Gastric Insufflation Volume Between Ambu AuraGain and ProSeal Laryngeal Mask Airway Using Ultrasonography in Patients Undergoing General Anesthesia: A Randomized Controlled Trial. Cureus 2022; 14:e27888. [PMID: 36110490 PMCID: PMC9464011 DOI: 10.7759/cureus.27888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Ambu AuraGain and ProSeal laryngeal mask airway are second-generation supraglottic airway devices (SADs) with added advantage of gastric drain and better oropharyngeal sealing pressure. The primary objective was to study the difference in the gastric insufflation volume between Ambu AuraGain and ProSeal LMA in patients undergoing general anesthesia. Methods: This randomized controlled trial involving 120 adult patients scheduled under general anesthesia were randomized into either Ambu AuraGain or LMA ProSeal group. Gastric cross-sectional area was measured using ultrasonography at baseline, after mask ventilation, and at the end of surgery. Gastric volume was calculated from the measured cross-sectional area. Oropharyngeal sealing pressure, peak airway pressure, and postoperative complications were noted. Statistical analysis was done using SPSS version 22 (Armonk, NY: IBM Corp.) and p < 0.05 was considered statistically significant. Results: Demographic profile of the study groups was comparable. There was a significant difference in gastric volume between the groups at the end of surgery with 5.91 ml (±9.68 ml) in Ambu AuraGain group and 12.28 ml (±13.05 ml) in the LMA ProSeal group (p = 0.001). Similarly, there was a difference in volume between baseline and at the end of the surgery within the groups also (Ambu AuraGain group, p=0.0012; LMA ProSeal group, p=0.0015, respectively). Though the oropharyngeal sealing pressure and peak airway pressures were comparable, increased incidence of postoperative complications was observed with LMA ProSeal. Conclusion: Thus, Ambu AuraGain resulted in a lower gastric insufflation volume than LMA ProSeal with lesser incidence of postoperative complications.
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Evaluation of adequacy of ventilation and gastric insufflation at three levels of inspiratory pressure for facemask ventilation during induction of anaesthesia: A randomised controlled trial. Anaesth Crit Care Pain Med 2022; 41:101132. [PMID: 35901954 DOI: 10.1016/j.accpm.2022.101132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND In this study, we aimed to compare three inspiratory pressures during face-mask ventilation in paralysed patients regarding the subsequent incidence of gastric insufflation and the adequacy of lung ventilation. METHODS In this randomised controlled trial, we included adult patients undergoing elective surgery under general anaesthesia. The patients were randomly allocated to receive positive inspiratory pressure (PIP) of 10, 15, or 20 cmH2O during pressure-controlled mask ventilation. Antral cross-sectional area (CSA) was assessed by ultrasound at baseline before mask ventilation and after endotracheal intubation and gastric insufflation was defined as increased CSA after endotracheal intubation > 30% of the baseline measurement. The primary outcome was the incidence of gastric insufflation. Other outcomes included the tidal volume, and the incidence of adequate ventilation (tidal volume of 6-10 mL/kg predicted body weight). RESULTS We analysed data from 36 patients in each group. The number of patients with gastric insufflation was lowest in the PIP 10 group (0/36 [0%]) in comparison with PIP 15 (2/36 [19%] and PIP 20 36/36 [100%] groups (P-values of 0.019 and < 0.001, respectively). The probability of adequate ventilation at any time point was the highest in PIP 10, followed by PIP 15, and was the lowest in the PIP 20 group. CONCLUSION An inspiratory pressure of 10 cmH2O in paralysed patients provided the least risk of gastric insufflation with adequate ventilation during induction of general anaesthesia compared to inspiratory pressure of 15- and 20 cmH2O.
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Madhav A, Parate LH, Govindswamy S. Comparison of Effectiveness of CE Technique and Jaw Thrust Technique for Mask Ventilation on Apneic Anesthetized Adults: A Randomized Controlled Trial. Anesth Essays Res 2022; 16:386-391. [PMID: 36620104 PMCID: PMC9813989 DOI: 10.4103/aer.aer_110_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 12/13/2022] Open
Abstract
Background The two most common techniques for mask ventilation are CE and jaw thrust (JT) technique. However, few studies have validated their efficiency in terms of tidal volume (TV). Aims This study aimed to compare the effectiveness of the CE technique and JT technique during pressure-controlled ventilation (PCV) by the mean of returned TV on apneic anesthetized adults. Design This was a prospective, randomized cross over study. Settings This study was conducted in a tertiary care hospital. Methods Ethical Committee approval from our institution was taken (ss-1/EC 049/2017) and was registered in Clinical Trials Registry of India (CTRI/2018/04/012958). Sixty-five American Society of Anesthesiologists Physical Status classes I and II adult patients were enrolled in the study. After induction and muscle relaxation, mask ventilation was performed with CE and JT technique on PCV mode (Pinsp 15 cm H2O, respiratory rate 15) for 1 min each. The mean of returned TV of last 12 breaths, gastric insufflation, audible mask leak, and operator comfort in each technique were compared. Statistical Analysis Statistical software namely IBM SPSS 22.0 and R environment version 3.2.2 (IBM Corp. SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA) were used for data analysis. Microsoft Excel was used to generate graphs and tables. Data were expressed as mean ± standard deviation for continuous variables and number (%) for categorical variables. Student's t-test (two tailed, independent) was used to find the significance of the study parameters on a continuous scale. Chi-square/Fisher's exact test was used to find the significance of the study parameters on a categorical scale between two or more groups. Results There was a significant increase in mean TV generated by JT technique over CE technique (591.46 ± 140.27 mL vs. 544.59 ± 159.08 mL; P < 0.001). Gastric insufflation (12.9% vs. 14.5%) and mask leak (11.3% vs. 38.7%) were more in CE technique. Operator comfort (79% vs. 19.4%) was more in JT technique. Conclusion A two-handed JT technique is more effective than a one-handed CE technique for mask ventilation in apneic anesthetized adults.
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Affiliation(s)
- Akshara Madhav
- Department of Anaesthesiology and Pain Relief, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Leena Harshad Parate
- Department of Anaesthesiology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Suresh Govindswamy
- Department of Anaesthesiology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
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Lee MK, Kim KN, Jeong MA, Kim SY, Oh MS, Kwon BS. Facemask ventilation and vocal cord angle following neuromuscular blockade: a prospective observational study . Anaesthesia 2022; 77:1010-1017. [PMID: 35727620 DOI: 10.1111/anae.15786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
Numerous studies support the idea that neuromuscular blockade facilitates facemask ventilation after induction of anaesthesia. Although improved airway patency or pulmonary compliance and a resolution of laryngospasm have been suggested as possible causes, the exact mechanism remains unclear. We aimed to assess whether neuromuscular blockade improves facemask ventilation and to clarify whether this phenomenon is associated with the vocal cord angle. This prospective observational study included patients aged between 20 and 65 years scheduled for elective surgery under general anaesthesia. After induction of anaesthesia, patients' lungs were ventilated with pressure-controlled ventilation using a facemask. During facemask ventilation, a flexible bronchoscope was inserted through a self-sealing diaphragm at the elbow connector attached to the facemask and breathing circuit and positioned to allow a continuous view of the vocal cords. The mean tidal volume and vocal cord angle were measured before and after administration of neuromuscular blocking drugs. Of 108 patients, 100 completed the study. Mean (SD) tidal volume ((11.0 (3.9) ml.kg-1 vs. 13.6 (2.6) ml.kg-1 ; p < 0.001) and mean (SD) vocal cord angle (17° (10°) vs. 26° (5°); p < 0.001) increased significantly after neuromuscular blockade. The proportional increase in mean tidal volume after neuromuscular blockade was positively correlated with vocal cord angle (Spearman's ρ = 0.803; p < 0.001). In conclusion, neuromuscular blockade facilitated facemask ventilation, and the improvement was correlated with further opening of the vocal cords.
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Affiliation(s)
- M K Lee
- Department of Anaesthesiology and Pain Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - K N Kim
- Department of Anaesthesiology and Pain Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - M A Jeong
- Department of Anaesthesiology and Pain Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - S Y Kim
- Department of Anaesthesiology and Pain Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - M S Oh
- College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - B S Kwon
- Department of Anaesthesiology and Pain Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
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Mask ventilation in the obese: Can we ignore positive end-expiratory pressure? Eur J Anaesthesiol 2022; 39:184. [PMID: 34980857 DOI: 10.1097/eja.0000000000001583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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W Lyng J, Guyette FX, Levy M, Bosson N. Prehospital Manual Ventilation: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:23-31. [PMID: 35001826 DOI: 10.1080/10903127.2021.1981506] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. Several strategies and adjunct technologies can increase the effectiveness of manual ventilation. NAEMSP recommends:All EMS clinicians must be proficient in bag-valve-mask ventilation.BVM ventilation should be performed using a two-person technique whenever feasible.EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Facemask ventilation. BJA Educ 2022; 22:5-11. [PMID: 34992795 PMCID: PMC8703149 DOI: 10.1016/j.bjae.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
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Min KJ, Rabinowitz AL, Hess CJ. Is It Time to Abandon Routine Mask Ventilation Before Intubation? Anesth Analg 2021; 133:1353-1357. [PMID: 34673727 DOI: 10.1213/ane.0000000000005723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Cary J Hess
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hur M, Lee K, Min SK, Kim JY. Left paratracheal pressure versus cricoid pressure for successful laryngeal mask airway insertion in adult patients: a randomized, non-inferiority trial. Minerva Anestesiol 2021; 87:1183-1190. [PMID: 34337919 DOI: 10.23736/s0375-9393.21.15779-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cricoid pressure (CP) is used to prevent pulmonary aspiration of regurgitated gastric contents and gastric insufflation during positive-pressure ventilation. However, CP impedes the successful insertion of laryngeal mask airway (LMA). Left paratracheal pressure (LPP), a manoeuvre of applying backward digital force at the lower left paratracheal level, was recently introduced as an alternative to CP. We assessed whether LPP is non-inferior to CP in successful LMA insertion on the first attempt in adult patients undergoing general anaesthesia. METHODS In this non-inferiority randomized controlled trial, 108 patients undergoing general anaesthesia were randomly allocated to receive either LPP or CP during LMA insertion. The primary outcome was the success rate of LMA insertion on the first attempt. The margin of non-inferiority was defined as 15%. RESULTS The success rate of LMA insertion on the first attempt was 68.5% (37/54) in the LPP group and 51.9% (28/54) in the CP group (P=0.077) with between-group difference of 16.7% (two-sided 95% CI, -1.9% to 35.2%). Time for successful device insertion was comparable in the two groups (P=0.355), whereas LMA insertion was easier in the LPP group than in the CP group (P=0.001). There was no significant difference between the two groups for change in antral cross-sectional area measured before and after mask ventilation (P=0.081). No serious complication was evident in any group. CONCLUSIONS This randomized clinical trial demonstrated the non-inferiority of LPP over CP in the success rate of LMA insertion on the first attempt in adult patients undergoing general anaesthesia.
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Affiliation(s)
- Min Hur
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyuhyeok Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang K Min
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jong Y Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea -
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Chang JE, Seol T, Hwang JY. Body position and the effectiveness of mask ventilation in anaesthetised paralysed obese patients: A randomised cross-over study. Eur J Anaesthesiol 2021; 38:825-830. [PMID: 33600105 DOI: 10.1097/eja.0000000000001473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Airway management is more challenging in the obese. Compared with the supine position, the sitting position can decrease the collapsibility of the upper airway and improve respiratory mechanics. OBJECTIVE The aim of this study was to evaluate the 25° semisitting position on the effectiveness of mask ventilation in anaesthetised paralysed obese patients. DESIGN A randomised, cross-over study. SETTING Medical centre managed by a university tertiary hospital. PATIENTS Thirty-eight obese adults scheduled for general anaesthesia. METHODS After anaesthesia and paralysis, two-handed mask ventilation was performed in the supine and 25° semi-sitting positions with a cross-over, in a randomised order. During mask ventilation, mechanical ventilation was delivered with a pressure-controlled mode with a peak inspiratory pressure of 15 cmH2O, a respiratory rate of 15 bpm, and no positive end-expiratory pressure. Ventilatory outcomes were based upon lean body weight. MAIN OUTCOMES Exhaled tidal volume (ml kg-1), respiratory minute volume (ml kg-1 min-1), and the occurrence of inadequate ventilation, defined as an exhaled tidal volume less than 4 ml kg-1, or absence of end-tidal CO2 recording. RESULTS Exhaled tidal volume (mean ± SD) in the 25° semi-sitting position was higher than in the supine position, 9.3 ± 2.7 vs. 7.6 ± 2.4 ml kg-1; P less than 0.001. Respiratory minute volume was improved in the 25° semisitting position compared with that in the supine position, 139.6 ± 40.7 vs. 113.4 ± 35.7 ml kg-1 min-1; P less than 0.001. CONCLUSION The 25° semisitting position improved mask ventilation compared with the supine position in anaesthetised paralysed obese patients. TRIAL REGISTRY NUMBER ClinicalTrials.gov (NCT03996161).
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Affiliation(s)
- Jee-Eun Chang
- From the Department of Anaesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul (J-EC, J-YH), College of Medicine, Kangwon University, Chuncheon, Republic of Korea (J-EC), Department of Anaesthesiology & Pain Medicine, Sheikh Khalifa Specialty Hospital, RAK, United Arab Emirates (TS) and College of Medicine, Seoul National University, Seoul, Republic of Korea (TS, J-YH)
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Ahn JH, Park J, Ryu KH, Jo JS, Kang RA, Ko JS, Hahm TS, Jeong JS. Utility of ultrasound evaluation of I-Gel ® placement in children: An observational study. Paediatr Anaesth 2021; 31:902-910. [PMID: 34031951 DOI: 10.1111/pan.14224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ultrasound is not widely used to evaluate optimal supraglottic airway positioning even though it could potentially be used to identify and correct problem areas. AIMS We evaluated a new ultrasound scoring method to identify the position of the supraglottic airway and detect the location of air leaks during ventilation in pediatric patients. METHODS Using a prospective observational study design, we enrolled 90 pediatric patients of ASA physical status I-III scheduled for elective surgery under general anesthesia. After anesthesia induction, patients were assigned to a noncorrection group or a correction group after their first ultrasound evaluation. Noncorrection group comprised patients with tolerable I-Gel positioning based on ultrasound evaluation and no problems with clinical parameters, while the correction group comprised patients with I-Gel mispositioning based on ultrasound. RESULTS After the first ultrasound evaluation, 61 patients did not need I-Gel correction (noncorrection group), while 29 patients needed I-Gel correction (correction group) and underwent a second ultrasound evaluation. Airway sealing pressure and total ultrasound score showed a negative correlation (r = -.845, p < .001). The area under the receiver operating curve for total ultrasound score was 0.97 (95% confidence interval, 0.94-0.99; p < .001). In the correction group, ultrasound score and ventilation parameters improved after correction based on ultrasound evaluation. CONCLUSIONS Ultrasound scores were negatively correlated with airway sealing pressure in pediatric patients. Ultrasound evaluation is useful for detecting misplacement of the I-Gel and can be a useful tool for correction.
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Affiliation(s)
- Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jiyeon Park
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University, Incheon, Korea
| | - Kyoung Ho Ryu
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Seong Jo
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryung A Kang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
BACKGROUND Rapid sequence induction (RSI) is a standard procedure, which should be implemented in all patients with a risk of aspiration/regurgitation during anaesthesia induction. OBJECTIVE The primary aim was to evaluate clinical practice in RSI, both in adult and paediatric populations. DESIGN Online survey. SETTINGS A total of 56 countries. PARTICIPANTS Members of the European Society of Anaesthesiology. MAIN OUTCOME MEASURES The aim was to identify and describe the actual clinical practice of RSI related to general anaesthesia. RESULTS From the 1921 respondents, 76.5% (n=1469) were qualified anaesthesiologists. When anaesthetising adults, the majority (61.7%, n=1081) of the respondents preoxygenated patients with 100% O2 for 3 min and 65.9% (n=1155) administered opioids during RSI. The Sellick manoeuvre was used by 38.5% (n=675) and was not used by 37.4% (n=656) of respondents. First-line medications for a haemodynamically stable adult patient were propofol (90.6%, n=1571) and suxamethonium (56.0%, n=932). Manual ventilation (inspiratory pressure <12 cmH2O) was used in 35.5% (n=622) of respondents. In the majority of paediatric patients, 3 min of preoxygenation (56.6%, n=817) and opioids (54.9%, n=797) were administered. The Sellick manoeuvre and manual ventilation (inspiratory pressure <12 cmH2O) in children were used by 23.5% (n=340) and 35.9% (n=517) of respondents, respectively. First-line induction drugs for a haemodynamically stable child were propofol (82.8%, n=1153) and rocuronium (54.7%, n=741). CONCLUSION We found significant heterogeneity in the daily clinical practice of RSI. For patient safety, our findings emphasise the need for international RSI guidelines. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03694860
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Sud A, Athanassoglou V, Anderson EM, Scott S. A comparison of gastric gas volumes measured by computed tomography after high-flow nasal oxygen therapy or conventional facemask ventilation . Anaesthesia 2021; 76:1184-1189. [PMID: 33651914 DOI: 10.1111/anae.15433] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2021] [Indexed: 12/21/2022]
Abstract
High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm3 in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm3 in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U = 1136, p = 0.432, n1 = n2 = 50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.
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Affiliation(s)
- A Sud
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - E M Anderson
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Scott
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Hell J, Pohl H, Spaeth J, Baar W, Buerkle H, Schumann S, Schmutz A. Incidence of gastric insufflation at high compared with low laryngeal mask cuff pressure: A randomised controlled cross-over trial. Eur J Anaesthesiol 2021; 38:146-156. [PMID: 32740320 DOI: 10.1097/eja.0000000000001269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The success of ventilation with a laryngeal mask depends crucially on the seal between the mask and the periglottic tissue. Increasing the laryngeal mask's cuff volume is known to reduce oral air leakage but may lead to gastric insufflation. OBJECTIVE We hypothesised that a lower cuff pressure would result in less gastric insufflation. We sought to compare gastric insufflation with laryngeal mask cuff pressures of 20 cmH2O (CP20) and 60 cmH2O (CP60) during increasing peak airway pressures in a randomised controlled double-blind cross-over study. We also evaluated the incidence of gastric insufflation at the recommended peak airway pressure of 20 cmH2O or less and during both intermittent positive airway pressure and continuous positive airway pressure. METHODS After obtaining ethics approval and written informed consent, 184 patients ventilated via laryngeal mask received a stepwise increase in peak airway pressure from 15 to 30 cmH2O with CP20 and CP60 in turn. Gastric insufflation was determined via real-time ultrasound and measurement of the cross-sectional area of the gastric antrum. The primary endpoint was the incidence of gastric insufflation at the different laryngeal mask cuff pressures. RESULTS Data from 164 patients were analysed. Gastric insufflation occurred less frequently at CP20 compared with CP60 (P < 0.0001). Gastric insufflation was detected in 35% of cases with CP20 and in 48% with CP60 at a peak airway pressure of 20 cmH2O or less. Gastric insufflation occurred more often during continuous than during intermittent positive airway pressures (P < 0.01). CONCLUSION A laryngeal mask cuff pressure of 20 cmH2O may reduce the risk of gastric insufflation during mechanical ventilation. Surprisingly, peak airway pressure of 20 cmH2O or less may already induce significant gastric insufflation. Continuous positive airway pressure should be avoided due to an increased risk of gastric insufflation. CLINICAL TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (DRKS00010583) https://www.drks.de.
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Affiliation(s)
- Johannes Hell
- From the Department of Anesthesiology and Critical Care, Medical Center (JH, HP, JS, WB, HB, SS, AS) and Faculty of Medicine, University of Freiburg, Freiburg, Germany (JH, HP, JS, WB, HB, SS, AS)
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Li Z, Yuan X, Deng W. Real-Time Ultrasound Detection of Left Paratracheal Esophagus on Air Entry into the Gastric Antrum in the Induction Period of General Anesthesia: A Prospective, Randomized Study. Ther Clin Risk Manag 2021; 17:103-109. [PMID: 33542632 PMCID: PMC7850980 DOI: 10.2147/tcrm.s284322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/11/2021] [Indexed: 11/26/2022] Open
Abstract
Background Positive-pressure ventilation (PPV) delivered via a facemask during anesthesia induction can result in gastric content being inhaled into the lungs. We hypothesized that the real-time ultrasound left paratracheal esophagus monitoring could more effectively reduce air entry into the stomach than real-time ultrasound monitoring of the gastric antrum (GA). Methods Patients were divided into two groups: study (S; n=30) and control (C; n=30) groups. During the induction of general anesthesia, mask ventilation adopts a pressure control mode. The initial ventilation pressure of both groups was 15 cmH2O. Before anesthesia induction, an ultrasonic probe was used to monitor the cross-sectional area (CSA) of the GA and the presence of gas in the stomach. During and after anesthesia induction, group S used a high-frequency ultrasound probe to observe the entry of air from the left paratracheal esophagus into the GA. The ventilation pressure was gradually reduced over time until no esophageal air was found. In group C, the ventilatory pressure was set maintained at 15 cmH2O and the CSA of the GA and air intake were monitored using an ultrasonic probe. Results Before and after PPV, the CSA of the GA in group S decreased (P<0.001), whereas the CSA in group C increased (P=0.002). The GA CSA in group C after PPV was larger than in group S after PPV (P=0.002). The proportion of patients who experienced intragastric air intake in group S (23.3%) was significantly lower than that in group C (66.7) (P=0.001). Conclusion Compared with ultrasound monitoring of the GA, real-time ultrasound detection of LPEOAE into the GA during anesthesia induction was more effective, more sensitive, significantly reduced the prevalence of intragastric air intake, and provided sufficient tidal volume and oxygen for patients.
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Affiliation(s)
- Zhengping Li
- Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Xiaozhong Yuan
- Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Wei Deng
- Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
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Hayashi R, Maeda S, Hideki T, Higuchi H, Miyawaki T. Pulmonary Aspiration During Induction of General Anesthesia. Anesth Prog 2021; 67:214-218. [PMID: 33393603 DOI: 10.2344/anpr-67-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/03/2020] [Indexed: 11/11/2022] Open
Abstract
Perioperative pulmonary aspiration of gastric contents can induce complications of varying severity, including aspiration pneumonitis or pneumonia, which may be lethal. A 34-year-old man with no significant medical history presented to Okayama University Hospital for extraction of the third molars and incisive canal cystectomy under general anesthesia. He experienced pulmonary aspiration of clear stomach fluid during mask ventilation after induction. After aspiration occurred, the patient was immediately intubated, and suctioning was performed through the endotracheal tube (ETT). An anteroposterior (AP) chest radiograph was obtained that demonstrated atelectasis in the left lower lobe, in addition to increased peak airway pressures being noted, although SpO2 remained at 96% to 99% at an FiO2 of 1.0. The decision was made to proceed, and the scheduled procedures were completed in approximately 2 hours. A repeat AP chest radiograph obtained at the end of the operation revealed improvement of the atelectasis, and no residual atelectasis was observed on the next day. Although the patient reported following standard preoperative fasting instructions (no fluids for 2 hours preoperatively), more than 50 mL of clear fluid remained in his stomach. Because vomiting can occur despite following NPO guidelines, the need for continued vigilance by anesthesia providers and proper timely management is reinforced.
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Affiliation(s)
- Reina Hayashi
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shigeru Maeda
- Department of Dental Anesthesiology, Okayama University Hospital, Okayama, Japan
| | - Taninishi Hideki
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hitoshi Higuchi
- Department of Dental Anesthesiology, Okayama University Hospital, Okayama, Japan
| | - Takuya Miyawaki
- Department of Dental Anesthesiology and Special Care Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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Jiang W, Shi L, Zhao Q, Zhang W, Xu M, Wang W, Wang X, Bao H, Leng J, Jiang L. [Ultrasound assessment of gastric insufflation in obese patients receiving transnasal humidified rapid-insufflation ventilatory exchange during general anesthesia induction]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1543-1549. [PMID: 33243741 DOI: 10.12122/j.issn.1673-4254.2020.11.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the effect of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) on gastric insufflation during general anesthesia induction in obese patients. METHODS Ninety obese patients (BMI 30-39.9 kg/m2) undergoing laparoscopic cholecystectomy under general anesthesia were randomized into 3 groups (n=30) to receive facemask pre- oxygenation followed by face mask ventilation (FMV) after administration of anesthetics (Group M), oxygenation with THRIVE (Group T), or pre-oxygenation with facemask combined with THRIVE followed continuous oxygenation with both FMV and THRIVE after administration of anesthetics (Group M+T). The patients in the latter two groups received continuous oxygen via THRIVE during tracheal intubation. All the patients received real-time ultrasound monitoring of the gastric antrum, and positive gastric insufflation (GI+) was defined by the presence of comet-tail artifacts. The cross-sectional area of the gastic antrum (CSA-GA) was measured by ultrasound before and after pre-oxygenation and after intubation. The patients' SpO2, PaO2, and PaCO2 at admission (T1), 5 min after pre-oxygenation (T2), 5 min after medication (T3), and immediately after intubation (T4) were recorded, and the incidence of postoperative adverse events was assessed. RESULTS The incidence of gastric insufflation was significantly higher in Group M and Group M+T than in Group T (P < 0.05). The CSA-GA was significantly greater at T4 than at T1 in Group M and Group M+T and in their GI+s ubgroups. The GI+ subgroups in Group M and Group M+ T had significantly larger CSA-GA at T4 than the GI- subgroups (P < 0.05). CSA-GA did not vary significantly during anesthesia induction in Group T (P>0.05). The incidence of grade Ⅰ gastric distension was lower but grade Ⅱ gastric distention was higher in Group M and Group M+T than in Group T (P < 0.05). Group M showed significantly greater variations of PaO2 at T3 and T4 than Group T and Group M+T (P < 0.05). CONCLUSIONS Ultrasound monitoring of the comet tail sign and the changes of CSA-GA in the gastric antrum is feasible and reliable for detecting gastrointestinal airflow, and in obese patients, the application of THRIVE for induction of anesthesia can ensure the oxygenation level without further increasing gastric insufflation.
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Affiliation(s)
- Weiqing Jiang
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Li Shi
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Qian Zhao
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Wenwen Zhang
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Man Xu
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Wanling Wang
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Xiaoliang Wang
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Hongguang Bao
- Department of Anesthesiology, Nanjing Hospital Affiliated to Nanjing Medical University/Nanjing First Hospital, Nanjing 210006, China
| | - Jing Leng
- Department of Pathology, Nanjing Medical University, Nanjing 210029, China
| | - Li Jiang
- The Royal Wolverhampton NHS Trust in UK, Wolverhampton, UK
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Culbreth RE, Gardenhire DS. Manual bag valve mask ventilation performance among respiratory therapists. Heart Lung 2020; 50:471-475. [PMID: 33138977 PMCID: PMC7604178 DOI: 10.1016/j.hrtlng.2020.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND High peak pressures delivered via bag valve mask (BVM) can be dangerous for patients. OBJECTIVE To examine manual ventilation performance among respiratory therapists (RTs) in a simulation model. METHODS Respiratory therapists (n=98) were instructed to ventilate a manikin for 18 breaths. Linear regression was utilized to determine associated predictors with the outcomes: delivered tidal volume, pressure and flow rate. RESULTS Among all participants, the mean ventilation parameters include a tidal volume of 599.70 ml, peak pressure of 26.35 cmH2O, and flow rate of 77.20 l/min. Higher confidence values were positively associated with delivered peak pressure (p=0.01) and flow rate (p=0.008). Those with the most confidence in using the BVM actually delivered higher peak pressures and flow rates compared to those with lower confidence levels. CONCLUSIONS Our results emphasize the urgent need to create an intervention that allows providers to deliver safe and optimal manual ventilation.
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Affiliation(s)
- Rachel E Culbreth
- Department of Respiratory Therapy, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, USA.
| | - Douglas S Gardenhire
- Department of Respiratory Therapy, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, USA
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Tonelli R, Tabbì L, Fantini R, Castaniere I, Gozzi F, Busani S, Nava S, Clini E, Marchioni A. Reply to Tuffet et al. and to Michard and Shelley. Am J Respir Crit Care Med 2020; 202:771-772. [PMID: 32492359 PMCID: PMC7462399 DOI: 10.1164/rccm.202005-1730le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Luca Tabbì
- University of Modena Reggio Emilia Modena, Italy and
| | | | | | - Filippo Gozzi
- University of Modena Reggio Emilia Modena, Italy and
| | | | | | - Enrico Clini
- University of Modena Reggio Emilia Modena, Italy and
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Evaluation of Different Positive End-Expiratory Pressures Using Supreme™ Airway Laryngeal Mask during Minor Surgical Procedures in Children. ACTA ACUST UNITED AC 2020; 56:medicina56100551. [PMID: 33096743 PMCID: PMC7589667 DOI: 10.3390/medicina56100551] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/09/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Abstract
Background and objectives: The laryngeal mask is the method of choice for airway management in children during minor surgical procedures. There is a paucity of data regarding optimal management of mechanical ventilation in these patients. The Supreme™ airway laryngeal mask offers the option to insert a gastric tube to empty the stomach contents of air and/or gastric juice. The aim of this investigation was to evaluate the impact of positive end-expiratory positive pressure (PEEP) levels on ventilation parameters and gastric air insufflation during general anesthesia in children using pressure-controlled ventilation with laryngeal mask. Materials and Methods: An observational trial was carried out in 67 children aged between 1 and 11 years. PEEP levels of 0, 3 and 5 mbar were tested for 5 min in each patient during surgery and compared with ventilation parameters (dynamic compliance (mL/cmH2O), etCO2 (mmHg), peak pressure (mbar), tidal volume (mL), respiratory rate (per minute), FiO2 and gastric air (mL)) were measured at each PEEP. Air was aspirated from the stomach at the start of the sequence of measurements and at the end. Results: Significant differences were observed for the ventilation parameters: dynamic compliance (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001), peak pressure (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001) and tidal volume (PEEP 5 vs. PEEP 3: p = 0.0048, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001). All parameters increased significantly with higher PEEP, with the exception of etCO2 (significant decrease) and respiratory rate (no significant difference). We also showed different values for air quantity in the comparisons between the different PEEP levels (PEEP 5: 2.8 ± 3.9 mL, PEEP 3: 1.8 ± 3.0 mL; PEEP 0: 1.6 ± 2.3 mL) with significant differences between PEEP 5 and PEEP 3 (p = 0.0269) and PEEP 5 and PEEP 0 (p = 0.0209). Conclusions: Our data suggest that ventilation with a PEEP of 5 mbar might be more lung protective in children using the Supreme™ airway laryngeal mask, although gastric air insufflation increased with higher PEEP. We recommend the use of a laryngeal mask with the option of inserting a gastric tube to evacuate potential gastric air.
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Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial. Eur J Anaesthesiol 2020; 36:625-632. [PMID: 31116114 PMCID: PMC6688779 DOI: 10.1097/eja.0000000000001016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation. OBJECTIVE The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures. DESIGN A randomised controlled trial. SETTING Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden. PARTICIPANTS Thirty healthy volunteers. INTERVENTIONS Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction. MAIN OUTCOME MEASURES A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures. RESULTS The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP. CONCLUSION Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02238691.
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Wong P, Lim WY. Response to comments on "Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review". Korean J Anesthesiol 2020; 73:175-176. [PMID: 32106640 PMCID: PMC7113155 DOI: 10.4097/kja.20081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Patrick Wong
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Wan Yen Lim
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
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Tianliang W, Gang S, Guocan Y, Haixing F. Effect of facemask ventilation with different ventilating volumes on gastric insufflation during anesthesia induction in patients undergoing laparoscopic cholecystectomy. Saudi Med J 2020; 40:989-995. [PMID: 31588476 PMCID: PMC6887889 DOI: 10.15537/smj.2019.10.24306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives: To compare the occurrence of gastric insufflation during anesthesia induction in patients undergoing laparoscopic cholecystectomy, using facemask ventilation with different ventilation volumes. Methods: This is a prospective study of 54 patients undergoing laparoscopic cholecystectomy under general anesthesia between January 2018 and June 2018. Facemask ventilation with volume mode controlled at 6 ml/kg (group V6), 8 ml/kg (group V8) or 10 ml/kg (group V10) was applied for 120 seconds (sec) during anesthesia induction. Before facemask ventilation and at 120 sec of facemask ventilation, gastric insufflation was determined by ultrasonography. Gastric insufflation was also evaluated using direct vision of laparoscopy. Respiratory parameters were monitored. Results: The incidence of gastric insufflation in group V10 (55.6%) was significantly higher than that in groups V6 (11.1%) and V8 (16.7%). However, it showed no significant difference between groups V6 and V8. During facemask ventilation for 120 sec, carbon dioxide accumulation trend occurred in group V6, and group V10 exhibited evidence of hyper-ventilation. Group V8 might be considered the best balance between low gastric insufflation and effective lung ventilation. Conclusion: Facemask ventilation with a ventilation volume of 8 ml/kg seems to have adequate preoxygenation and avoid excessive gastric insufflation during anesthesia induction in laparoscopic cholecystectomy.
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Affiliation(s)
- Wu Tianliang
- Department of Anesthesiology, First People's Hospital of Fuyang District, Hangzhou, China. E-mail.
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Rutt AL, Bojaxhi E, Torp KD. Management of Refractory Laryngospasm. J Voice 2020; 35:633-635. [PMID: 31987708 DOI: 10.1016/j.jvoice.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
Laryngospasm has been well described in patients emerging from general anesthesia (GA) and is routinely managed with intermittent positive-pressure mask ventilation, a temporary increase in the depth of anesthesia, or small, titrated amounts of succinylcholine. Patients with severe laryngospasm require reintubation to maintain adequate oxygenation and ventilation. However, reintubation may be only a temporary solution because laryngospasm may recur during re-emergence and re-extubation; thus, anesthesiologists need a comprehensive plan that addresses potential causes of laryngospasm and incorporates continuous positive airway pressure (CPAP) for patients with difficulty emerging from GA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a noninvasive ventilation and oxygenation technique used to provide apneic oxygenation, which also generates CPAP. THRIVE uses a high-flow nasal cannula and is more easily tolerated than CPAP with a tight-fitting mask. To our knowledge, we present the first case of refractory laryngospasm during emergence from GA that was successfully managed with THRIVE.
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Affiliation(s)
- Amy L Rutt
- Department of Otorhinolaryngology/Audiology, Mayo Clinic, Jacksonville, Florida.
| | - Elird Bojaxhi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Klaus D Torp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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Ćwiertnia M, Kawecki M, Ilczak T, Mikulska M, Dutka M, Bobiński R. Comparison of standard and over-the-head method of chest compressions during cardiopulmonary resuscitation - a simulation study. BMC Emerg Med 2019; 19:73. [PMID: 31771511 PMCID: PMC6880354 DOI: 10.1186/s12873-019-0292-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Maintaining highly effective cardiopulmonary resuscitation (CPR) can be particularly difficult when artificial ventilation using a bag-valve-mask device, combined with chest compression have to be carried out by one person. The aim of the study is to compare the quality of CPR conducted by one paramedic using chest compression from the patient’s side with compression conducted from the ‘over-the-head’ position. Methods The subject of the study were two methods of CPR – ‘standard’ (STD) and ‘over-the-head’ (OTH). The STD method consisted of cycles of 30 chest compressions from the patient’s side, and two attempts at artificial ventilation after moving round to behind the patient’s head. In the OTH method, both compressions and ventilations were conducted from behind the patient’s head. Results Both CPR methods were conducted by 38 paramedics working in medical response teams. Statistical analysis was conducted on the data collected, giving the following results: the average time of the interruptions between compression cycles (STD 9.184 s, OTH 7.316 s, p < 0.001); the depth of compression 50–60 mm (STD 50.65%, OTH 60.22%, p < 0.001); the rate of compression 100–120/min. (STD 46.39%, OTH 53.78%, p < 0.001); complete chest wall recoil (STD 84.54%, OTH 91.46%, p < 0.001); correct hand position (STD 99.32%, OTH method 99.66%, p < 0.001). A statistically significant difference was demonstrated in the results to the benefit of the OTH method in the above parameters. The remaining parameters showed no significant differences in comparison to reference values. Conclusions The higher quality of CPR in the simulated research using the OTH method by a single person justifies the use of this method in a wider range of emergency interventions.
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Affiliation(s)
- Michał Ćwiertnia
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland.
| | - Marek Kawecki
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland
| | - Tomasz Ilczak
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland
| | - Monika Mikulska
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland
| | - Mieczysław Dutka
- Department of Biochemistry and Molecular Biology, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland
| | - Rafał Bobiński
- Department of Biochemistry and Molecular Biology, Faculty of Health Sciences, University of Bielsko-Biala, Willowa 2, 43-309, Bielsko-Biala, Poland
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Use of point-of-care ultrasound to assess esophageal insufflation during bag mask ventilation: A case report. Respir Med Case Rep 2019; 28:100928. [PMID: 31516820 PMCID: PMC6733966 DOI: 10.1016/j.rmcr.2019.100928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/25/2019] [Indexed: 01/21/2023] Open
Abstract
Bag-valve-mask ventilation is a basic airway management technique often used in patients with acute respiratory failure. Although highly effective in providing oxygenation and ventilation, this technique has been associated with gastric regurgitation and tracheal aspiration. In this case, the esophagus was visualized with bedside ultrasonography during bag-mask ventilation of an unresponsive and critically ill patient. Images were obtained both with and without cricoid pressure. Additionally, images were obtained during ultrasound-guided probe pressure on the lateral neck. Esophageal insufflation was identified consistently during bag mask ventilation. Cricoid pressure did not prevent esophageal insufflation. Ultrasound-guided probe pressure attenuated esophageal insufflation. This case depicts a unique instance of using a novel method to assess breath delivery during bag mask ventilation of a critically ill patient.
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Zhang Q, Zhou Q, Zhang J, Zhao D. Gentle facemask ventilation during induction of anesthesia. Am J Emerg Med 2019; 38:1137-1140. [PMID: 31685304 DOI: 10.1016/j.ajem.2019.158399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/11/2019] [Accepted: 08/14/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To determine the level of inspiratory pressure minimizing the risk of gastric insufflation while providing adequate pulmonary ventilation. METHODS In this prospective, randomized, double-blind study, patients were allocated to one of the two groups (P10, P15) defined by the inspiratory pressure applied during controlled-pressure ventilation: 10 and 15 cm H2O. Anesthesia was induced using propofol and sufentanil; no neuromuscular-blocking agent was administered. Once loss of eyelash reflex occurred, facemask ventilation was started for a 2-min period. The cross-sectional antral area was measured using ultrasonography before and after facemask ventilation. Respiratory parameters were recorded. RESULTS Forty patients were analyzed. Mean tidal volume was about 7 ml/kg in group P10, and was >11 ml/kg in group P15 in the same period. As indicated by ultrasonography test, the antral area in P15 group was markedly incresed compared with P10 group. CONCLUSION Inspiratory pressure of 10 cm H2O allowed for reduced occurrence of gastric insufflation with proper lung ventilation during induction of anesthesia with sufentanil and propofol in nonparalyzed and nonobese patients.
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Affiliation(s)
- Qingfu Zhang
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Quanhong Zhou
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Junfeng Zhang
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China.
| | - Daqiang Zhao
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China.
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Detection of gastric inflation using transesophageal echocardiography after different level of pressure-controlled mask ventilation: a prospective randomized trial. J Clin Monit Comput 2019; 34:535-540. [PMID: 31256309 DOI: 10.1007/s10877-019-00340-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/17/2019] [Indexed: 02/05/2023]
Abstract
This study aimed to assess the technique of using transesophageal echocardiography (TEE) to detect gastric inflation and to determine the optimal level of inspiratory pressure during face mask ventilation (FMV). In this prospective and randomized trial, seventy-five adults scheduled for cardiac surgery were enrolled to one of the three groups (P12, P15, P20) defined by the applied inspiratory pressure during FMV. After induction, mask ventilation was performed with the corresponding level of pressure-control ventilation for 2 min in each patient. Respiratory and hemodynamic parameters were recorded every 15 s. Arterial blood gases were tested before induction and at the time of intubation. Gastric cross-section area was detected using transesophageal echocardiography after intubation. The gastric cross-section areas were 3.1 ± 0.81, 3.8 ± 1.37 and 4.8 ± 2.29 cm2 respectively. It statistically increased in group P20 compared with group P12 and P15. PaCO2 before intubation statistically increased compared with the baseline in groups P12 and P15, while decreased in group P20. The mean values of PaCO2 equaled to 44.4 mmHg (40-51.5), 42.9 mmHg (34-50.5) and 36.9 mmHg (30.9-46) respectively in three groups. Peak airway pressure of 12-20 cmH2O could provide acceptable sufficient ventilation during mask ventilation, but 20 cmH2O result in higher incidence of gastric inflation. TEE is useful to detect the gastric inflation related to the entry of air into the stomach during pressure-controlled face mask ventilation.Trial Registration Number ChiCTR-IOR-14005325.
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Lee JH, Jung H, Jang YE, Kim EH, Song IK, Kim HS, Kim JT. Manual vs pressure-controlled facemask ventilation during the induction of general anesthesia in children: A prospective randomized controlled study. Paediatr Anaesth 2019; 29:331-337. [PMID: 30714260 DOI: 10.1111/pan.13594] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/21/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Gastric insufflation frequently occurs during facemask ventilation in children. In the present study, we compared the incidence of gastric insufflation between pressure-controlled facemask ventilation and manual facemask ventilation during general anesthesia induction in children. METHODS Children in the pressure-controlled ventilation group (n = 76) received pressure-controlled facemask ventilation at an inspiratory pressure of 13 cm H2 O. In the manual ventilation group (n = 75), facemask ventilation was manually performed by anesthesiologists, who tried to maintain an inspiratory pressure of 13 cm H2 O. The adjustable pressure limiting valve was set at 13 cm H2 O. The incidence of gastric insufflation during 90 seconds after the initiation of ventilation was assessed using epigastric auscultation and gastric ultrasonography. RESULTS The incidence of gastric insufflation was significantly higher in the manual facemask ventilation group than in the pressure-controlled ventilation group (48% vs 12%, respectively; odds ratio 7.78, 95% confidence interval [CI] 3.38-17.9; P < 0.001). The mean peak airway pressure during ventilation was significantly higher in the manual ventilation group than in the pressure-controlled ventilation group (16.1 [3.0] cm H2 O vs 13.0 [0.1] cm H2 O; 95% CI of differences, 2.36-3.71 cm H2 O; P < 0.001). The manual ventilation group exhibited a wide peak airway pressure range (11-26 cm H2 O) and a wide variation of tidal volume (0-7.0 mL/kg) compared with those of the pressure-controlled ventilation group (13-14 cm H2 O and 0.6-16.0 mL/kg, respectively). CONCLUSION At an inspiratory pressure of 13 cm H2 O, pressure-controlled ventilation may be more effective than manual ventilation in preventing gastric insufflation while providing stable ventilation in children.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Haesun Jung
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - In-Kyung Song
- Department of Anaesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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