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Toyota Y, Kondo T, Narasaki S, Miyoshi H, Tsutsumi YM. Prevention of Oxygen Desaturation in a Patient With Previous Experience of Severe Hypoxia in Modified Electroconvulsive Therapy by Transnasal Humidified Rapid-Insufflation Ventilator Exchange: A Case Report. Cureus 2024; 16:e60564. [PMID: 38887347 PMCID: PMC11181234 DOI: 10.7759/cureus.60564] [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: 05/17/2024] [Indexed: 06/20/2024] Open
Abstract
Transnasal humidified rapid-insufflation ventilator exchange (THRIVE) has been reported to have better efficacy during anesthesia induction compared to conventional mask ventilation, including improved oxygenation and prolonged safe apnea time. This study reports on the effectiveness of the THRIVE system during modified electroconvulsive therapy (mECT) for a patient experiencing severe hypoxia. A 78-year-old female patient with bipolar disorder received maintenance mECT every four weeks. She previously experienced a significant hypoxic event, with oxygen saturation (SpO2) dropping to 50% following electrical stimulation. In response, we employed the THRIVE system, designed to deliver high-flow, 100% oxygen, thereby extending apnea tolerance. The implementation of THRIVE ensured a stable oxygen supply, maintaining oxygen saturation levels above 95% throughout the mECT procedure. THRIVE is useful for treating hypoxia that occurs due to the unavoidable lack of ventilation during mECT.
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Affiliation(s)
- Yukari Toyota
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, JPN
| | - Takashi Kondo
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, JPN
| | - Soshi Narasaki
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, JPN
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, JPN
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, JPN
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2
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Hohenstein C, Merz S, Eppler F, Arslan V, Ayvaci BM, Ünlü L. Emergency airway management: an EUSEM statement with regard to the guidelines of the Society of Critical Care Medicine. Eur J Emerg Med 2024; 31:83-85. [PMID: 38100641 PMCID: PMC10901228 DOI: 10.1097/mej.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Christian Hohenstein
- Department of Emergency Medicine, Zentralklinik Bad Berka, University of Marburg, Faculty of Medicine, Bad Berka
| | - Sabine Merz
- Red Cross Villingen-Schwenningen, Villingen-Schwenningen
| | - Fabian Eppler
- Faculty of Medicine, University of Mainz, Mainz, Germany
| | - Volkan Arslan
- Department of Emergency Medicine, Hacettepe University Medicine Faculty, Ankara
| | - Bariş Murat Ayvaci
- Department of Emergency Medicine, University of Health Sciences Prof. Dr. Cemil Taşcioğlu City Hospital, Istanbul, Turkey
| | - Luca Ünlü
- Faculty of Medicine, Karl-Landsteiner University of Health Sciences, Krems a.d. Donau, Austria
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3
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Ananthapadmanabhan S, Kudpaje A, Raju D, Smith M, Riffat F, Novakovic D, Stokan M, Palme CE. Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review. Indian J Otolaryngol Head Neck Surg 2024; 76:1921-1930. [PMID: 38566676 PMCID: PMC10982204 DOI: 10.1007/s12070-023-04445-2] [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: 11/01/2023] [Accepted: 12/13/2023] [Indexed: 04/04/2024] Open
Abstract
High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.
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Affiliation(s)
| | - Akshay Kudpaje
- Department of Head and Neck Surgical Oncology, Cytecare Cancer Hospital, Bangalore, Karnataka India
| | - Dinesh Raju
- Department of Anaesthesia, Critical Care, and Pain, Cytecare Cancer Hospital, Bangalore, Karnataka India
| | - Mark Smith
- Department of Otolaryngology, Westmead Hospital, Westmead, NSW 2145 Australia
- Chris O’Brien Lifehouse, Camperdown, NSW Australia
| | - Faruque Riffat
- Department of Otolaryngology, Westmead Hospital, Westmead, NSW 2145 Australia
- Chris O’Brien Lifehouse, Camperdown, NSW Australia
| | - Daniel Novakovic
- Chris O’Brien Lifehouse, Camperdown, NSW Australia
- The Canterbury Hospital, Campsie, NSW Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW Australia
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Latona A, Pellatt R, Wedgwood D, Keijzers G, Grant S. Ventilator-assisted preoxygenation in an aeromedical retrieval setting. Emerg Med Australas 2024. [PMID: 38504443 DOI: 10.1111/1742-6723.14404] [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: 10/23/2023] [Revised: 01/13/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting. METHODS Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2 ). RESULTS VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events. CONCLUSION VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.
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Affiliation(s)
- Akmez Latona
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Pellatt
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - David Wedgwood
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Department of Anaesthesiology, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Steven Grant
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Sax L, Sharma S, Benedict J, Guy K, Mandybur I, Bittner M, Sinacori J, Rubinstein B. Comparison of Hemodynamics in Jet Ventilation vs. Intermittent Apnea for Airway Stenosis Surgery. Laryngoscope 2024; 134:1343-1348. [PMID: 37724978 DOI: 10.1002/lary.31045] [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: 03/05/2023] [Revised: 07/23/2023] [Accepted: 08/22/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE The objective of this study is to assess the impact of two different ventilation techniques, jet ventilation and apneic anesthesia with intermittent ventilation (AAIV), on patient hemodynamics and operative time during endoscopic laryngotracheal stenosis surgery. METHODS Retrospective chart review of patients who underwent airway dilation for laryngotracheal stenosis by a single surgeon at a single institution from October 1, 2000 through January 2, 2020. Logistic regression, Mann-Whitney U tests and chi square analysis were used to determine statistical significance. RESULTS A total of 157 patients, 43 (27.4%) male and 114 (72.6%) female, and 605 total encounters were included for analysis. There were no significant differences in hemodynamic outcomes when comparing the AAIV and jet ventilation groups. Specifically, there was no significant difference in either peak end-tidal CO2 or nadir O2 saturation between the AAIV and jet ventilation groups (p = 0.4016) and (p = 0.1357), respectively. The patients in the AAIV group had a significantly higher median BMI 32.93 (27.40-39.40) compared with 28.80 (24.1-32.65) (p = 0.0001). Although not necessarily clinically significant, patients with higher BMI had lower median O2 nadirs (97.8%) than non-obese patients (99.2%) (p < 0.0001). The median total procedure time was equivalent when comparing the two ventilation techniques. CONCLUSION AAIV is a safe method of ventilation for patients undergoing endoscopic laryngotracheal stenosis surgery with no significant differences in patient hemodynamics or procedure time when compared with jet ventilation. AAIV was the preferred method of ventilation for obese patients undergoing endoscopic laryngotracheal stenosis surgery. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1343-1348, 2024.
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Affiliation(s)
- Leah Sax
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Shaan Sharma
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Jacob Benedict
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Kevin Guy
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Ian Mandybur
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | | | - John Sinacori
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Benjamin Rubinstein
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
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6
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Del Santo T, DI Filippo A, Romagnoli S. Rapid sequence induction of anesthesia: works in progress and steps forward with focus to oxygenation and monitoring techniques. Minerva Anestesiol 2024; 90:181-190. [PMID: 37851418 DOI: 10.23736/s0375-9393.23.17569-9] [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: 10/19/2023]
Abstract
The description of the main scientifically consolidated innovations in recent years on Rapid Sequence Induction have been the subject of this narrative review. Data sources were PubMed, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicaTrials.gov, searched up to March 21st, 2023; rapid sequence induction and anesthesia were used as key word for the research. In recent years at least three significant innovations which have improved the procedure: firstly the possibility of using drugs which rapidly reverse the action of the myorelaxants and which have made it possible to give up the use of succinylcholine, replaced by rocuronium; secondly, the possibility of using much more effective pre-oxygenation methods than in the past, also through apneic oxygenation techniques which allow longer apnea time, and finally new monitoring systems much more effective than pulse oximetry in identifying and predicting periprocedural hypoxemia and indicating the need for ventilation in patients at risk of hypoxemia and preventing it. The description of three main scientifically consolidated innovations in recent years, in pharmacology, oxygen method of administration and monitoring, have been the subject of this narrative review.
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Affiliation(s)
- Tommaso Del Santo
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Stefano Romagnoli
- Department of Health Sciences, University of Florence, Florence, Italy
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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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Cırıl MF, Akarca M, Unal Akoglu E, Cimilli Ozturk T, Onur Ö. High-Flow Nasal Cannula versus Bag Valve Mask for Preoxygenation during Rapid Sequence Intubation in the Emergency Department: A Single-Center, Prospective, Randomized Controlled Trial. Prehosp Disaster Med 2024; 39:45-51. [PMID: 38108139 DOI: 10.1017/s1049023x23006684] [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] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Hypoxia is a frequently reported complication during the intubation procedure in the emergency department (ED) and may cause bad outcomes. Therefore, oxygenation plays an important role in emergency airway management. The efficacy of oxygenation with high-flow nasal cannula (HFNC) in the ED has been studied, though the evidence is limited. The study aim was to compare two methods of preoxygenation in patients undergoing rapid sequence intubation (RSI) in the ED: (1) HFNC and (2) bag-valve mask (BVM) oxygenation. METHODS This is a single-center, prospective, randomized controlled trial (RCT) in adult ED patients requiring RSI. Patients were randomized to receive preoxygenation with either HFNC or BVM. While HFNC therapy was continued during the intubation procedure, BVM oxygenation was interrupted for laryngoscopy. The primary outcome was the lowest peripheral oxygen saturation (SpO2) level during intubation. Secondary outcomes were incidence of desaturation (SpO2<90%) and severe hypoxemia (SpO2<80%) throughout the procedure, intubation time, rate of failed intubation, and 30-day survival rates. RESULTS A total of 135 patients were randomized into two groups (HFNC n = 68; BVM n = 67). The median lowest SpO2 value measured during intubation was 96% (88.8%-99.0%) in the HFNC group and 92% (86.0%-97.5%) in the BVM group (P = .161). During the intubation procedure, severe hypoxemia occurred in 13.2% (n = 9) of patients in the HFNC group and 8.9% (n = 6) in the BVM group, while mild hypoxemia was observed in 35.8% (n = 24) of the BVM group and 26.5% (n = 18) of the HFNC group. However, there was no statistically significant difference between the groups in terms of hypoxemia development (P = .429 and P = .241, respectively). No significant difference was reported in the rate of failed intubation between the groups. Thirty-day mortality was observed in 73.1% of the BVM group and 57.4% of the HFNC group, with a borderline statistically significant difference (difference 15.7; 95% CI of the difference: -0.4 to 30.7; P = .054). CONCLUSION The use of HFNC for preoxygenation, when compared to standard care with BVM oxygenation, did not improve the lowest SpO2 levels during intubation. Also, the use of HFNC during intubation did not provide benefits in reducing the incidence of severe hypoxemia. However, the 30-day survival rates were slightly better in the HFNC group compared to the BVM group.
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Affiliation(s)
- Muhammed Fatih Cırıl
- Sancaktepe Sehit Prof Ilhan Varank Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Mustafa Akarca
- Tokat Erbaa State Hospital Emergency Department, Tokat, Turkey
| | - Ebru Unal Akoglu
- Fatih Sultan Mehmet Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Tuba Cimilli Ozturk
- Fatih Sultan Mehmet Education and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Özge Onur
- Marmara University School of Medicine, Istanbul, Turkey
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9
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White LD, Vlok RA, Thang CY, Tian DH, Melhuish TM. Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments. Cochrane Database Syst Rev 2023; 8:CD013558. [PMID: 37531462 PMCID: PMC10419336 DOI: 10.1002/14651858.cd013558.pub2] [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] [Indexed: 08/04/2023]
Abstract
BACKGROUND Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality. OBJECTIVES To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8. MORTALITY We used GRADE to assess certainty of evidence. MAIN RESULTS We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence). AUTHORS' CONCLUSIONS There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.
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Affiliation(s)
- Leigh D White
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, Australia
| | - Ruan A Vlok
- Intensive Care Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Christopher Yc Thang
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, Australia
| | | | - Thomas M Melhuish
- Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
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10
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Palisch AC. Airway Management of the Cardiac Arrest Victim. Emerg Med Clin North Am 2023; 41:543-558. [PMID: 37391249 DOI: 10.1016/j.emc.2023.03.007] [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: 07/02/2023]
Abstract
Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have traditionally been guided by expert and consensus opinion informed by observational data. In the last 5 years, recent studies, including several randomized controlled trials (RCTs), have provided additional clarity to help guide airway management. This article will review both current data and guidelines for airway management in cardiac arrest, a stepwise approach to airway management, the utility of various airway adjuncts, and best practices for oxygenation and ventilation in the peri-arrest period.
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Affiliation(s)
- Anthony Chase Palisch
- Department of Emergency Medicine, Vanderbilt University, 1211 Medical Center Drive, Nashville, TN 37232, USA.
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11
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Karlupia D, Garg K, Jain R, Grewal A. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction. Cureus 2023; 15:e43063. [PMID: 37680406 PMCID: PMC10481628 DOI: 10.7759/cureus.43063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries. MATERIALS AND METHODS Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed. RESULTS No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05). CONCLUSION We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.
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Affiliation(s)
- Diksha Karlupia
- Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Kamakshi Garg
- Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Richa Jain
- Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Anju Grewal
- Anaesthesiology, All India Institute of Medical Sciences, Bathinda, Bathinda, IND
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12
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Fonternel T, van Rooyen H, Joubert G, Turton E. Evaluating the Usability of a 3D-Printed Video Laryngoscope for Tracheal Intubation of a Manikin. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:157-165. [PMID: 37346781 PMCID: PMC10281522 DOI: 10.2147/mder.s405833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/14/2023] [Indexed: 06/23/2023] Open
Abstract
Background Compared to direct laryngoscopy, videolaryngoscopy (VL) can provide improved laryngeal and glottic view, higher intubation success rates in patients with a known or predicted difficult airway and reduced incidence of laryngeal/airway trauma. However, the cost and availability of these devices handicap its use in resource-restricted facilities. The objective was to design and manufacture a novel VL using additive manufacturing (AM) and evaluate its usability on an intubation manikin by comparing it to one of the most common video laryngoscopes used in clinical practice, the CMAC®, by measuring the time to first pass of the endotracheal tube as the main outcome. Methods A randomised cross-over study was performed with 36 anaesthetists attempting tracheal intubation of a manikin. The novel 3D-printed hyperangulated VL blade was compared to a CMAC® VL (D-blade). Participants had no prior experience or training with the novel device. The participants included consultants, registrars/trainees and medical officers in the Department of Anaesthesiology at the University of the Free State (UFS) in South Africa. Results The CMAC® had a statistically shorter time to first pass (median 13.8 seconds) compared to the 3D-printed model (median 19.0 seconds) (95% confidence interval [CI] 1.0-6.2; P=0.0013). No failed attempts occurred with either device. Conclusion Intubation times were faster with the CMAC® than with the novel device. However, with a comparable intubation success rate, 3D printing technology potentially can improve access to video laryngoscopy. Further design improvements, validation of materials and manufacturing processes are required before 3D-printed laryngoscope blades can be used in human subjects.
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Affiliation(s)
- Theodorus Fonternel
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | | | - Gina Joubert
- Department of Biostatistics, School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Edwin Turton
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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George S, Gibbons K, Williams T, Humphreys S, Gelbart B, Le Marsney R, Craig S, Tingay D, Chavan A, Schibler A. Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a statistical analysis plan for a randomised controlled trial. Trials 2023; 24:369. [PMID: 37259146 DOI: 10.1186/s13063-023-07330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
The placement of an endotracheal tube for children with acute or critical illness is a low-frequency and high-risk procedure, associated with high rates of first-attempt failure and adverse events, including hypoxaemia. To reduce the frequency of these adverse events, the provision of oxygen to the patient during the apnoeic phase of intubation has been proposed as a method to prolong the time available for the operator to insert the endotracheal tube, prior to the onset of hypoxaemia. However, there are limited data from randomised controlled trials to validate the efficacy of this technique in children. The technique known as transnasal humidified rapid insufflation ventilatory exchange (THRIVE) uses high oxygen flow rates (approximately 2 L/kg/min) delivered through nasal cannulae during apnoea. It has been shown to at least double the amount of time available for safe intubation in healthy children undergoing elective surgery. The technique and its application in real time have not previously been studied in acutely ill or injured children presenting to the emergency department or admitted to an intensive care unit. The Kids THRIVE trial is a multicentre, international, randomised controlled trial (RCT) in children less than 16 years old undergoing emergent intubation in either the intensive care unit or emergency department of participating hospitals. Participants will be randomised to receive either the THRIVE intervention or standard care (no apnoeic oxygenation) during their intubation. The primary objective of the trial is to determine if the use of THRIVE reduces the frequency of oxygen desaturation and increases the frequency of first-attempt success without hypoxaemia in emergent intubation of children compared with standard practice. The secondary objectives of the study are to assess the impact of the use of THRIVE on the rate of adverse events, length of mechanical ventilation and length of stay in intensive care. In this paper, we describe the detailed statistical analysis plan as an update of the previously published protocol.
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine, Children's Critical Care, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, Australia.
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia.
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Southport, Australia.
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Tara Williams
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
- Division of Critical Care Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | - Susan Humphreys
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
- Division of Critical Care Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Renate Le Marsney
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Simon Craig
- Paediatric Emergency Department, Monash Medical Centre, Monash Emergency Research Collaborative, Monash Health, Clayton, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - David Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Neonatology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, Townsville University Hospital, Townsville, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Brisbane, Australia
- Critical Care Research Group, St Andrew's War Memorial Hospital, Brisbane, Australia
- Wesley Medical Research, Auchenflower, Queensland, Australia
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14
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Breitkopf M, Wihler C, Walther A. [Prehospital emergency anesthesia in adults : Current recommendations for performing prehospital emergency anesthesia based on the recommendations for prehospital emergency anesthesia in adults]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01026-7. [PMID: 37219565 DOI: 10.1007/s00063-023-01026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 05/24/2023]
Abstract
The frequency of prehospital emergency anesthesia in Germany is around 2-3% of all emergency medical missions. The Association of the Scientific Medical Societies of Germany (AWMF) has published guidelines for the implementation of a prehospital emergency anesthesia. The purpose of this article is to highlight important aspects from these guidelines and to present the implementation and special features for specific patient groups. A case study is intended to illustrate that the preclinical setting can provide various facets that make a certain amount of experience and expertise indispensable. The article emphasizes that clear standard situations are not always present and that there are some challenges in the preclinical setting. Therefore, mastering the content of prehospital emergency anesthesia and the manual skills of induction of anesthesia are essential and obligatory for the emergency team.
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Affiliation(s)
- Martin Breitkopf
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.
| | - Christoph Wihler
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - Andreas Walther
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
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15
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Robinson AE, Pearson AM, Bunting AJ, Kennedy HJ, Prekker ME, Reardon RF, Jones GA, Simpson NS, Kummer TM, Babcock CP, Driver BE. A Practical Solution for Preoxygenation in the Prehospital Setting: A Nonrebreather Mask with Flush Rate Oxygen. PREHOSP EMERG CARE 2023; 28:215-220. [PMID: 37171895 DOI: 10.1080/10903127.2023.2213761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Prehospital clinicians need a practical means of providing adequate preoxygenation prior to intubation. A bag-valve-mask (BVM) can be used for preoxygenation in perfect conditions but is likely to fail in emergency settings. For this reason, many airway experts have moved away from using BVM for preoxygenation and instead suggest using a nonrebreather (NRB) mask with flush rate oxygen.Literature on preoxygenation has suggested that a NRB mask delivering flush rate oxygen (on a 15 L/min O2 regulator, maximum flow, ∼50 L/min) is noninferior to BVM at 15 L/min held with a tight seal. However, in the prehospital setting, where emergency airway management success varies, preoxygenation techniques have not been deeply explored. Our study seeks to determine whether preoxygenation can be optimally performed with NRB at flush rate oxygen. METHODS We performed a crossover trial using healthy volunteers. Subjects underwent 3-min trials of preoxygenation with NRB mask at 25 L/min oxygen delivered from a portable tank, NRB at flush rate oxygen from a portable tank, NRB with flush rate oxygen from an onboard ambulance tank, and BVM with flush rate oxygen from an onboard ambulance tank. The primary outcome was the fraction of expired oxygen (FeO2). We compared the FeO2 of the BVM-flush to other study groups, using a noninferiority margin of 10%. RESULTS We enrolled 30 subjects. Mean FeO2 values for NRB-25, NRB-flush ambulance, NRB-flush portable, and BVM-flush were 63% (95% confidence interval [CI] 58-68%), 74% (95%, CI 70-78%), 78% (95%, CI 74-83%), and 80% (95%, CI 75-84%), respectively. FeO2 values for NRB-flush on both portable tank and ambulance oxygen were noninferior to BVM-flush on the ambulance oxygen system (FeO2 differences of 1%, 95% CI -3% to 6%; and 6%, 95% CI 1-10%). FeO2 for the NRB-25 group was inferior to BVM-flush (FeO2 difference 16%, 95% CI 12-21%). CONCLUSIONS Among healthy volunteers, flush rate preoxygenation using NRB masks is noninferior to BVM using either a portable oxygen tank or ambulance oxygen. This is significant because preoxygenation using NRB masks with flush rate oxygen presents a simpler alternative to the use of BVMs. Preoxygenation using NRB masks at 25 L/min from a portable tank is inferior to BVM at flush rate.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Alec J Bunting
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | | | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregg A Jones
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy M Kummer
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Corey P Babcock
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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16
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Park S, Kim SY, Kim MS, Park WK, Byon HJ, Kim HJ. Comparison of preoxygenation efficiency measured by the oxygen reserve index between high-flow nasal oxygenation and facemask ventilation: a randomised controlled trial. BMC Anesthesiol 2023; 23:159. [PMID: 37161369 PMCID: PMC10169184 DOI: 10.1186/s12871-023-02126-9] [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: 03/07/2022] [Accepted: 05/05/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND High-flow nasal oxygenation and the oxygen reserve index (ORI), which is a non-invasive and innovative modality that reflects the arterial oxygen content, are used in general anaesthesia. This study compares the preoxygenation efficiency (measured by the ORI) of high-flow nasal oxygenation and facemask ventilation during the induction process. METHODS This single-centre, two-group, randomised controlled trial included 197 patients aged ≥ 20 years who underwent orotracheal intubation for general anaesthesia for elective surgery. The patients were randomly allocated to receive preoxygenation via facemask ventilation or high-flow nasal oxygenation. The ORI was measured and compared between both groups. RESULTS The ORI increased during preoxygenation in all patients. At 1 min of preoxygenation, the ORI was significantly higher in the high-flow nasal oxygenation group (0.34 ± 0.33) than in the facemask ventilation group (0.21 ± 0.28; P = 0.003). The highest ORI was not significantly different between the two groups (0.68 ± 0.25 in the high-flow nasal oxygenation group vs. 0.70 ± 0.28 in the facemask ventilation group; P = 0.505). CONCLUSIONS High-flow nasal oxygenation results in an oxygenation status similar to that provided by facemask ventilation during the induction process of general anaesthesia; therefore, high-flow nasal oxygenation is a feasible preoxygenation method. TRIAL REGISTRATION Clinicaltrials.gov (NCT04291339).
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Affiliation(s)
- Sujung Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Wyun Kon Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo-Jin Byon
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyun Joo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea.
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17
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Turner JS, Hunter BR, Haseltine ID, Motzkus CA, DeLuna HM, Cooper DD, Ellender TJ, Sarmiento EJ, Menard LM, Kirschner JM. Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis. Emerg Med J 2023; 40:293-299. [PMID: 35393346 DOI: 10.1136/emermed-2021-211968] [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: 08/25/2021] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.
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Affiliation(s)
- Joseph S Turner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian D Haseltine
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christine A Motzkus
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hannah M DeLuna
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura M Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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18
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Urquhart CS, Airlie M. Airway trauma. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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19
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Präklinische Notfallnarkose beim Erwachsenen. Notf Rett Med 2023. [DOI: 10.1007/s10049-022-01116-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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20
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Rosboch GL, Cortese G, Neitzert L, Brazzi L. Towards a universal, holistic, evidence-based consensus on difficult airway management: the new American Society of Anesthesiologists guidelines. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1182. [PMID: 36467366 PMCID: PMC9708469 DOI: 10.21037/atm-22-4271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/21/2022] [Indexed: 08/30/2023]
Affiliation(s)
- Giulio Luca Rosboch
- Department of Anesthesia and Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Gerardo Cortese
- Department of Anesthesia and Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Luca Neitzert
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia and Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
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21
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West J, Levine R, Raggi J, Nguyen DT, Oliver M, Caputo N, Sakles J. Time to Renitrogenation After Maximal Denitrogenation in Healthy Volunteers in the Supine and Sitting Positions. West J Emerg Med 2022; 23:926-930. [DOI: 10.5811/westjem.2022.5.55378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/28/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: Prior to intubation, preoxygenation is performed to denitrogenate the lungs and create an oxygen reservoir. After oxygen is removed, it is unclear whether renitrogenation after preoxygenation occurs faster in the supine vs the sitting position.
Methods: We enrolled 80 healthy volunteers who underwent two preoxygenation and loss of preoxygenation procedures (one while supine and one while sitting) via bag-valve-mask ventilation with spontaneous breathing. End-tidal oxygen (ETO2) measurements were recorded as fraction of expired oxygen prior to preoxygenation, at the time of adequate preoxygenation (ETO2 >85%), and then every five seconds after the oxygen was removed until the ETO2 values reached their recorded baseline.
Results: The mean ETO2 at completion of preoxygenation was 86% (95% confidence interval 85-88%). Volunteers in both the supine and upright position lost >50% of their denitrogenation in less than 60 seconds. Within 25 seconds, all subjects had an ETO2 of <70%. Complete renitrogenation, defined as return to baseline ETO2, occurred in less than 160 seconds for all volunteers.
Conclusion: Preoxygenation loss, or renitrogenation, occurred rapidly after oxygen removal and was not different in the supine and sitting positions. After maximal denitrogenation in healthy volunteers, renitrogenation occurred rapidly after oxygen removal and was not different in the supine and sitting positions.
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Affiliation(s)
- Jason West
- NYC Health + Hospitals
- Lincoln, Department of Emergency Medicine, Bronx, New York
| | - Rykiel Levine
- NYC Health + Hospitals
- Lincoln, Department of Emergency Medicine, Bronx, New York
| | - Jason Raggi
- NYC Health + Hospitals
- Lincoln, Department of Emergency Medicine, Bronx, New York
| | - Du-Thuyen Nguyen
- Royal Prince Alfred Hospital, Sydney, Department of Emergency Medicine, New South Wales, Australia
| | - Matthew Oliver
- Royal Prince Alfred Hospital, Sydney, Department of Emergency Medicine, New South Wales, Australia; RPA Green Light Institute for Emergency Care, Sydney, New South Wales, Australia
| | - Nicholas Caputo
- NYC Health + Hospitals
- Lincoln, Department of Emergency Medicine, Bronx, New York
| | - John Sakles
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
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22
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Morton S, Dawson J, Wareham G, Broomhead R, Sherren P. The Prehospital Emergency Anaesthetic in 2022. Air Med J 2022; 41:530-535. [PMID: 36494168 DOI: 10.1016/j.amj.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.
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Affiliation(s)
- Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Department of Surgery, Imperial College, London, United Kingdom
| | - Jonathan Dawson
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Gaynor Wareham
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Robert Broomhead
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Peter Sherren
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
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Non-invasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2022; 22:306. [PMID: 36180822 PMCID: PMC9524013 DOI: 10.1186/s12871-022-01842-y] [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: 01/06/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background and objectives Preoxygenation is crucial for providing sufficient oxygen reservoir to a patient before intubation and enables the extension of the period between breathing termination and critical desaturation (safe apnoea time). Conventionally, face mask ventilation is used for preoxygenation. Non-invasive ventilation is a new preoxygenation method. The study objective was to compare the outcomes of non-invasive ventilation and face mask ventilation for preoxygenation. Method PubMed, Embase, Cochrane Library, and the ClinicalTrials.gov registry were searched for eligible studies published from database inception to September 2021. Individual effect sizes were standardized, and a meta-analysis was conducted using random effects models to calculate the pooled effect size. Inclusion criteria were randomised controlled trials of comparing the outcomes of non-invasive ventilation or face mask ventilation for preoxygenation in patients scheduled for surgeries. The primary outcome was safe apnea time, and the secondary outcomes were post-operative complications, number of patients who achieved the expired O2 fraction (FeO2) after 3 min of preoxygenation, minimal SpO2 during tracheal intubation, partial pressure of oxygen in the arterial blood (PaO2) and partial pressure of carbon dioxide (PaCO2) after preoxygenation, and PaO2 and PaCO2 after tracheal intubation. Results 13 trials were eligible for inclusion in this study. Significant differences were observed in safe apnoea time, number of patients who achieved FeO2 90% after preoxygenation for 3 min, and PaO2 and PaCO2 after preoxygenation and tracheal intubation. Only in the non-obese subgroup, no significant difference was observed in safe apnoea time (mean difference: 125.38, 95% confidence interval: − 12.26 to 263.03). Conclusion Non-invasive ventilation appeared to be more effective than conventional methods for preoxygenation. We recommend non-invasive ventilation based on our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01842-y.
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Geng W, Chen C, Chen Y, Yu X, Huang S. Role of modified nasopharyngeal oxygen therapy in apnoeic oxygenation under general anaesthesia: a single-centre, randomized controlled clinical study. Sci Rep 2022; 12:16325. [PMID: 36175532 PMCID: PMC9522846 DOI: 10.1038/s41598-022-20717-3] [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] [Received: 02/24/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022] Open
Abstract
Apnoeic oxygenation is not only important for patients who cannot be intubated/ventilated, but also can be routinely employed when planning to secure the airway.We aimed to compare safe apnoea times between patients receiving modified nasopharyngeal oxygen therapy and those receiving high-flow nasal oxygen therapy (HFNO) following the induction of general anaesthesia.This was a single-centre, randomized controlled clinical study. Eighty-four female patients undergoing elective laparoscopic gynaecological surgery under general anaesthesia were randomly assigned to the high-flow nasal oxygen therapy group (Group HFNO) or the modified nasopharyngeal oxygen therapy group (Group Naso). A Kaplan-Meier survival curve was used to describe the apnoeic oxygenation time.The safe apnoea time of the patients in the Group Naso was higher than that of the patients in the Group HFNO (20 (19.3 to 20.0) vs. 16.5 (12.9 to 20) minutes, P < 0.05). The incidence of SpO2 < 95% in the Group Naso was lower than that in the Group HFNO; hazard ratio 0.3 (95% confidence interval 0.2 to 0.6, P < 0.0001). Modified nasopharyngeal oxygen therapy which uses far less oxygen than HFNO is a convenient and effective method of apnoeic oxygenation in normal female patients.Trial registration: https://www.chictr.org.cn , ChiCTR2000039433; date of registration: 28/10/2020.
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Affiliation(s)
- Weilian Geng
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, China
| | - Changxing Chen
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yaobing Chen
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, China
| | - Xinhua Yu
- The Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Shaoqiang Huang
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, China.
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Changes in lung volume estimated by electrical impedance tomography during apnea and high-flow nasal oxygenation: A single-center randomized controlled trial. PLoS One 2022; 17:e0273120. [PMID: 36170281 PMCID: PMC9518885 DOI: 10.1371/journal.pone.0273120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Previous studies concerning humidified, heated high-flow nasal oxygen delivered in spontaneously breathing patients postulated an increase in functional residual capacity as one of its physiological effects. It is unclear wheter this is also true for patients under general anesthesia.
Methodology
The sincle-center noninferiority trial was registered at ClinicalTrials.gov (NCT NCT03478774). This secondary outcome analysis shows estimated differences in lung volume changes using electrical impedance tomography between different flow rates of 100% oxygen in apneic, anesthetized and paralyzed adults prior to intubation. One hundred and twenty five patients were randomized to five groups with different flow rates of 100% oxygen: i) minimal-flow: 0.25 l.min-1 via endotracheal tube; ii) low-flow: 2 l.min-1 + continuous jaw thrust; iii) medium-flow: 10 l.min-1 + continuous jaw thrust; iv) high-flow: 70l.min-1 + continuous jaw thrust; and v) control: 70 l.min-1 + continuous video-laryngoscopy. After standardized anesthesia induction with non-depolarizing neuromuscular blockade, the 15-minute apnea period and oxygen delivery was started according to the randomized flow rate. Continuous electrical impedance tomography measurements were performed during the 15-minute apnea period. Total change in lung impedance (an estimate of changes in lung volume) over the 15-minute apnea period and times to 25%, 50% and 75% of total impedance change were calculated.
Results
One hundred and twenty five patients completed the original study. Six patients did not complete the 15-minute apnea period. Due to maloperation, malfunction and artefacts additional 54 measurements had to be excluded, resulting in 65 patients included into this secondary outcome analysis. We found no differences between groups with respect to decrease in lung impedance or curve progression over the observation period.
Conclusions
Different flow rates of humidified 100% oxygen during apnea result in comparable decreases in lung volumes. The demonstrated increase in functional residual capacity during spontaneous breathing with high-flow nasal oxygenation could not be replicated during apnea under general anesthesia with neuromuscular blockade.
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Ramos M, Tau Anzoategui S. Preoxygenation: from hardcore physiology to the operating room. J Anesth 2022; 36:770-781. [PMID: 36136165 DOI: 10.1007/s00540-022-03105-z] [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: 02/01/2022] [Accepted: 09/08/2022] [Indexed: 10/14/2022]
Abstract
If we define the human body by the mass of the elements that compose it, we could say that we are oxygen and other elements. Oxygen, in addition to being fundamental in our composition, is an element that we constantly need to support cellular respiration and, therefore, life. Interestingly, despite its importance, humans have not developed mechanisms that allow us to store it and, therefore, we are unable to sustain life if we are deprived of ventilation, even for brief periods. Accordingly, the ability to induce the cessation of ventilation in a patient must be accompanied by different technical and non-technical skills that allow the patient's safety to be maintained in this highly vulnerable state. Through the use of basic mathematical tools and comparative physiology, we hereby propose to review the physiological foundations of preoxygenation to understand the reasons behind the clinical recommendations in this field.
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Affiliation(s)
- Matias Ramos
- Department of Anesthesiology, Hospital de Clínicas "José de San Martín", Buenos Aires, Argentina.
| | - Santiago Tau Anzoategui
- Department of Anesthesiology, Hospital de Clínicas "José de San Martín", Buenos Aires, Argentina
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Airway Management during Massive Gastric Regurgitation Using VieScope or Macintosh Laryngoscope-A Randomized, Controlled Simulation Trial. J Clin Med 2022; 11:jcm11185363. [PMID: 36143008 PMCID: PMC9503399 DOI: 10.3390/jcm11185363] [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: 08/17/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
In this model of massive gastric aspiration, we compared two different laryngoscopes (VieScope and Macintosh) in a randomized, controlled simulation study. The primary endpoint was time to intubation; the secondary endpoints were intubation success (i.e., tracheal tube position) and amount of pulmonary aspiration. Thirty-four anesthetists performed endotracheal intubation using VieScope and Macintosh laryngoscopy in a randomized order on an airway manikin simulating massive regurgitation of gastric fluid. The primary endpoint “time until intubation” could be achieved significantly faster (mean −12.4 s [95% confidence intervals (CI) −19.7 s; −7.3 s]) with Macintosh compared to VieScope (p < 0.001). Concerning “correct tube position”, no statistical difference was found between the devices (p = 1.0). The mean time to first ventilation was −11.1 s [95% CI −18.3 s; −5.3 s] when using Macintosh (p = 0.001). The mean volume of aspirated gastric fluid was lower in the Macintosh group: −90.0 mL [95% CI −235.0 mL; −27.5 mL] (p = 0.011). Data from this simulation study suggest that in a model of massive gastric regurgitation, airway management can be achieved faster and with less gastric aspiration when using a Macintosh laryngoscope compared to a VieScope laryngoscope.
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Gavrilovska-Brzanov A, Shosholcheva M, Kartalov A, Jovanovski-Srceva M, Brzanov N, Kuzamanovska B. Medium-Flow Oxygenation Through Facial Mask and Nasal Cannula in a Limited Resource Setting. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2022; 43:101-109. [PMID: 35843919 DOI: 10.2478/prilozi-2022-0023] [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] [Indexed: 06/15/2023]
Abstract
Introduction: In centers with limited resources, a high flow nasal cannula is not available, thus we assess if preoxygenation with 15L flow of O2 available from anesthesia machines can prolong the safety period of induction of anesthesia before intubation and provide more time for securing the airway. Moreover, we compared the preoxygenation with standard 6L vs. 15L O2 through a facemask or a nasal cannula. Material and methods: Patients were allocated into four groups. Group I patients were preoxygenated with a nasal cannula on 6L of oxygen, patients in group II were preoxygenated with a nasal cannula on 15L of oxygen, patients in group III were preoxygenated with a facemask on 6L of oxygen, and patients in group IV were preoxygenated with a facemask on 15L of oxygen. The primary endpoint was time to desaturation and intubation. The secondary endpoints were PaO2, PaCO2, Sat% and ETCO2. Results: The groups with 15L preoxygenation had a statistically significant prolonged time to desaturation and intubation. Patients allocated to group II have a statistically significant greater PaO2 and lesser ETCO2 compered with group I. However, between patients in group III and IV there is a difference only in PaCO2, and although this effect is significant, both groups have values within the normal range. Conclusion: In centers with limited resources, preoxygenation with the maximum available oxygen flow from anesthesia machines (15L/min) are useful. This prolongs the safety period for securing the airway. We suggest the use of the maximum available amount of oxygen flow from anesthesia machines in clinical settings.
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Affiliation(s)
- Aleksandra Gavrilovska-Brzanov
- University Clinic for Traumatology, Orthopedic Disease, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, RN Macedonia
| | - Mirjana Shosholcheva
- University Clinic for General Surgery "St. NaumOhridski" Faculty of Medicine, University "Ss. Cyril and Methodius", Skopje, RN Macedonia
| | - Andrijan Kartalov
- University Clinic for Traumatology, Orthopedic Disease, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, RN Macedonia
| | - Marija Jovanovski-Srceva
- University Clinic for Traumatology, Orthopedic Disease, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, RN Macedonia
| | - Nikola Brzanov
- University Clinic for Traumatology, Orthopedic Disease, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, RN Macedonia
| | - Biljana Kuzamanovska
- University Clinic for Traumatology, Orthopedic Disease, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, RN Macedonia
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Kim EH, Ji SH, Lee JH, Kim JT, Jang YE, Kwon SK, Kim HS. Use of high-flow nasal oxygen in spontaneously breathing pediatric patients undergoing tubeless airway surgery: A prospective observational study. Medicine (Baltimore) 2022; 101:e29520. [PMID: 35801795 PMCID: PMC9259177 DOI: 10.1097/md.0000000000029520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The use of high-flow nasal oxygen is gaining popularity in apneic and spontaneously breathing adult patients during anesthesia. This prospective observational study evaluated the effect of high-flow nasal oxygen in maintaining adequate oxygenation and ventilation in spontaneously breathing pediatric patients with dynamic airway obstruction, undergoing tubeless airway surgery. Oxygenation was provided via an age-appropriate, high-flow nasal cannula at a flow rate of 2 L kg-1 min-1. Propofol and remifentanil were used to maintain anesthesia while preserving spontaneous respiration. We sought to determine the incidence and risk factors of rescue ventilation. Rescue ventilation with a face mask was performed when the pulse oximetry oxygen saturation was <90% or transcutaneous carbon dioxide was >80 mm Hg. In total, 27 patients were included in the final analysis. Median (interquartile range) of pulse oximetry and transcutaneous carbon dioxide were 100% (99%-100%) and 58.4 mm Hg (51.4-70.3 mm Hg), respectively. Altogether, 9 (33.3%) patients needed rescue ventilation during anesthesia. Of these, 7 patients (25.9%) developed oxygen desaturation (<90%) and 2 patients (7.4%) developed hypercarbia. Patients who required rescue ventilation were significantly younger (8.2 vs 28.8 months, P = .02) and required a longer anesthesia time (55.7 vs 41.0 minutes, P = .04) than those who did not. In conclusion, High-flow nasal oxygen is an alternative technique to maintain oxygenation in children undergoing airway surgeries. However, younger age and longer anesthesia time are significant risk factors leading to the requirement of rescue ventilation in these patients. Further studies with large sample size are required for clinical application of these techniques.
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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, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seong-Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- * Correspondence: Hee-Soo Kim, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea (e-mail: )
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Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department. Emerg Med Clin North Am 2022; 40:539-563. [DOI: 10.1016/j.emc.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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31
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Dunn D. Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice. AORN J 2022; 115:423-436. [PMID: 35476194 DOI: 10.1002/aorn.13666] [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: 12/10/2020] [Revised: 04/15/2021] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Abstract
The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask-ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse's role as an assistant to the anesthesia professional when applying cricoid pressure.
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Midega TD, Chaves RCDF, Ashihara C, Alencar RM, Queiroz VNF, Zelezoglo GR, Vilanova LCDS, Olivato GB, Cordioli RL, Bravim BDA, Corrêa TD. Ketamine use in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2022; 34:287-294. [PMID: 35946660 DOI: 10.5935/0103-507x.20220027-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
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Affiliation(s)
- Thais Dias Midega
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Carolina Ashihara
- Departamento de Anestesiologia, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Roger Monteiro Alencar
- Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | | | | | | | - Ricardo Luiz Cordioli
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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The Aerosol-Generating Effect Among Noninvasive Positive Pressure Ventilation, High-Flow Nasal Cannula, Nonrebreather Mask, Nasal Cannula, and Ventilator-Assisted Preoxygenation. Ann Emerg Med 2022; 80:22-34. [DOI: 10.1016/j.annemergmed.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/23/2022]
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Chua MT, Ng WM, Lu Q, Low MJW, Punyadasa A, Cove ME, Yau YW, Khan FA, Kuan WS. Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (the Pre-AeRATE trial): A multicentre randomised controlled trial. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:149-160. [PMID: 35373238 DOI: 10.47102/annals-acadmedsg.2021407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation for preoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNC oxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO2) during rapid sequence intubation (RSI) in ED patients compared to usual care. METHODS This was a multicentre, open-label, randomised controlled trial in adult ED patients requiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at 60L/min) group or control (non-rebreather mask for preoxygenation and nasal prongs of at least 15L/min oxygen flow for apnoeic oxygenation) group. Primary outcome was lowest SpO2 during the first intubation attempt. Secondary outcomes included incidence of SpO2 falling below 90% and safe apnoea time. RESULTS One hundred and ninety patients were included, with 97 in the intervention and 93 in the control group. Median lowest SpO2 during the first intubation attempt was 100% in both groups. Incidence of SpO2 falling below 90% was lower in the intervention group (15.5%) compared to the control group (22.6%) (adjusted relative risk=0.68, 95% confidence interval [CI] 0.37-1.25). Post hoc quantile regression analysis showed that the first quartile of lowest SpO2 during the first intubation attempt was greater by 5.46% (95% CI 1.48-9.45%, P=0.007) in the intervention group. CONCLUSION Use of HFNC for preoxygenation and apnoeic oxygenation, when compared to usual care, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.
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Affiliation(s)
- Mui Teng Chua
- Emergency Medicine Department, National University Hospital, Singapore
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35
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Mushambi M. Facemask or high‐flow nasal oxygenation: time to switch? Anaesthesia 2022; 77:716-717. [DOI: 10.1111/anae.15665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Affiliation(s)
- M. Mushambi
- University Hospitals of Leicester Leicester UK
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Rutt AL, Torp KD, Zimmermann T, Warner P, Hofer R, Charnin JE, Ekbom D. Apneic Technique in Laryngotracheal Surgery. Cureus 2022; 14:e21584. [PMID: 35228942 PMCID: PMC8873441 DOI: 10.7759/cureus.21584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/05/2022] Open
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Baez AA, Qasim Z, Wilcox S, Weir WB, Loeffler P, Golden BM, Schwartz D, Levy M. Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:88-95. [PMID: 35001824 DOI: 10.1080/10903127.2021.1994676] [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] [Indexed: 12/23/2022]
Abstract
Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. Portable mechanical ventilators offer an important strategy for optimizing ventilation and mitigating ventilatory complications.EMS clinicians, including those performing emergency response as well as interfacility transports, should consider using mechanical ventilation after advanced airway insertion.Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices.EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency.Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.
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Reardon RF, Robinson AE, Kornas R, Ho JD, Anzalone B, Carlson J, Levy M, Driver B. Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:96-101. [PMID: 35001821 DOI: 10.1080/10903127.2021.1995552] [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] [Indexed: 10/19/2022]
Abstract
Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.
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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: 6] [Impact Index Per Article: 3.0] [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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Davis DP, Bosson N, Guyette FX, Wolfe A, Bobrow BJ, Olvera D, Walker RG, Levy M. Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:72-79. [PMID: 35001819 DOI: 10.1080/10903127.2021.1992056] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.
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Joachim N, Mathew G, Manjuladevi M, Kothari A. Effect of high fresh gas flow and pattern of breathing on rapid preoxygenation. Indian J Anaesth 2022; 66:213-219. [PMID: 35497700 PMCID: PMC9053897 DOI: 10.4103/ija.ija_340_21] [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] [Received: 04/18/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Preoxygenation is supplementation of 100% oxygen prior to induction of general anaesthesia to increase the body’s oxygen stores. Efficacy of preoxygenation can be increased by optimising fresh gas flow (FGF) rate and pattern of breathing. Methods: Based on pattern of breathing—Tidal Volume Breathing (TVB) or Deep Breathing (DB) and FGF-10 L/min or 15 L/min—100 subjects of the American Society of Anesthesiologists physical status I/II posted for elective surgery were recruited and randomised into four groups: T10 - TVB with 10 L/min; D10 - DB with 10 L/min; T15 - TVB with 15 L/min; and D15 - DB with 15 L/min. A tight-fitting anaesthesia mask along with continuous positive airway pressure of 5 cm of H2O with 20° head-up was used for preoxygenation. The total time taken and the total number of breaths required to achieve end tidal oxygen concentration (EtO2) of 90% were noted. Exhaled tidal volume (Vte), end tidal carbon dioxide, fraction of inspired oxygen, and EtO2 were recorded at each breath. Analysis of variance (ANOVA) was used for inferential statistics and Tukey’s honestly significant difference (HSD) test was used to calculate mean difference in total time and number of breaths amongst the groups. Results: Total time taken was significantly low (P < 0.001) in DB compared to TVB (D10: 70.2 ± 19.91, D15: 68.4 ± 20.27 vs T10: 112.28 ± 47.96, T15: 113.6 ± 48.57 seconds). Number of breaths was significantly high (P < 0.001) in TVB with 22.84 ± 8.73, 23.76 ± 11.64, 10.56 ± 3.69, and 8.32 ± 1.8 in T10, T15, D10 and D15, respectively. Vte was significantly low in TVB (P < 0.001). Conclusion: Rapid preoxygenation can be achieved by DB at high FGF of a minimum of 10 L/min.
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Lauria MJ, Root CW, Gottula AL, Braude DA. Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport. Air Med J 2022; 41:133-140. [PMID: 35248332 DOI: 10.1016/j.amj.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/24/2021] [Accepted: 09/21/2021] [Indexed: 06/14/2023]
Abstract
Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.
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Affiliation(s)
- Michael J Lauria
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Christopher W Root
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Adam L Gottula
- Department of Anesthesiology, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Darren A Braude
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
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George S, Wilson M, Humphreys S, Gibbons K, Long E, Schibler A. Apnoeic oxygenation during paediatric intubation: A systematic review. Front Pediatr 2022; 10:918148. [PMID: 36479287 PMCID: PMC9720125 DOI: 10.3389/fped.2022.918148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This review assesses the effect of apnoeic oxygenation during paediatric intubation on rates of hypoxaemia, successful intubation on the first attempt and other adverse events. DATA SOURCES The databases searched included PubMed, Medline, CINAHL, EMBASE and The Cochrane Library. An electronic search for unpublished studies was also performed. STUDY SELECTION We screened studies that include children undergoing intubation, studies that evaluate the use of apnoeic oxygenation by any method or device with outcomes of hypoxaemia, intubation outcome and adverse events were eligible for inclusion. DATA EXTRACTION Screening, risk of bias, quality of evidence and data extraction was performed by two independent reviewers, with conflicts resolved by a third reviewer where consensus could not be reached. DATA SYNTHESIS From 362 screened studies, fourteen studies (N = 2442) met the eligibility criteria. Randomised controlled trials (N = 482) and studies performed in the operating theatre (N = 835) favoured the use of apnoeic oxygenation with a reduced incidence of hypoxaemia (RR: 0.34, 95% CI: 0.24 to 0.47, p < 0.001, I 2 = 0% and RR: 0.27, 95% CI: 0.11 to 0.68, p = 0.005, I 2 = 68% respectively). Studies in the ED and PICU were of lower methodological quality, displaying heterogeneity in their results and were unsuitable for meta-analysis. Among the studies reporting first attempt intubation success, there were inconsistent effects reported and data were not suitable for meta-analysis. CONCLUSION There is a growing body of evidence to support the use of apnoeic oxygenation during the intubation of children. Further research is required to determine optimal flow rates and delivery technique. The use of humidified high-flow oxygen shows promise as an effective technique based on data in the operating theatre, however its efficacy has not been shown to be superior to low flow oxygen in either the elective anesthetic or emergency intubation situations Systematic Review Registration: This review was prospectively registered in the PROSPERO international register of systematic reviews (Reference: CRD42020170884, registered April 28, 2020).
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia.,School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Megan Wilson
- Emergency Department, Tweed Heads Hospital, Tweed Heads, NSW, Australia.,Emergency Department, Lismore Base Hospital, Lismore, NSW, Australia
| | - Susan Humphreys
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia.,Clinical Sciences, Murdoch Children's Research Institute, VIC, Australia.,Department of Critical Care, University of Melbourne, VIC, Australia
| | - Andreas Schibler
- Critical Care Research Group, Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia.,Wesley Medical Research, Auchenflower, QLD, Australia
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Jain K, Jafra A, Sravani MV, Yaddanapudi L, Kumar P. Tracheal intubation practices and adverse events in trauma victims on arrival to trauma triage: A single centre prospective observational study. Indian J Anaesth 2022; 66:180-186. [PMID: 35497704 PMCID: PMC9053886 DOI: 10.4103/ija.ija_919_21] [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] [Received: 10/12/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Trauma is one of the leading causes of global disease burden. Data on airway management in trauma patients from developing countries, particularly India is sparse. Hence, we planned a prospective observational study to assess the airway management practice patterns and associated complications. Methods: The study was conducted in trauma triage of a tertiary care hospital. Data was collected on all tracheal intubations occurring in trauma victims requiring definitive airway control, a detailed proforma including patient details, mode of injury, drugs used, intubation procedure, and complications were filled out for each patient. Results: We observed that the airway in trauma patients was primarily managed by non-anaesthesia speciality residents (426 patients); anaesthesia residents were primarily called for deferred or difficult intubations. The first attempt success rate of intubation by anaesthesia residents was significantly higher than speciality residents (P = 0.0001; 95% CI 9.02-24.66). Non-anaesthesia residents used midazolam in varying doses (3-12 mg) for intubation, whereas, rapid sequence intubation was the most common technique used by anaesthesia residents. Airway injuries were the most frequent complication observed in 32.8% of patients intubated by specialty residents compared to 5.9% of patients intubated by anaesthesia residents. Conclusion: The trauma triage is a high-volume area for frequent tracheal intubations which are manned by non-anaesthesia speciality teams. A number of factors related to the patient, staff, availability of airway equipment and unfavourable surroundings impact airway management and may explain the high incidence of airway complications, such as airway injuries in these trauma victims.
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Vaughan EM, Seitz KP, Janz DR, Russell DW, Dargin J, Vonderhaar DJ, Joffe AM, West JR, Self WH, Rice TW, Semler MW, Casey JD. Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials. J Intensive Care Med 2021; 37:899-907. [PMID: 34898310 DOI: 10.1177/08850666211058646] [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: 11/15/2022]
Abstract
Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.
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Affiliation(s)
- Erin M Vaughan
- 12230Georgetown University School of Medicine, Washington, DC, USA
| | - Kevin P Seitz
- 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - David R Janz
- 473408University Medical Center New Orleans, New Orleans, LA, USA.,12258Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA
| | | | - James Dargin
- 2094Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Derek J Vonderhaar
- 12258Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA.,12309Ochsner Health System New Orleans, New Orleans, LA, USA
| | - Aaron M Joffe
- 228464University of Washington School of Medicine, Seattle, WA, USA
| | | | - Wesley H Self
- 12328Vanderbilt University Medical Center, Nashville, TN, USA.,460460Vanderbilt Institute for Clinical and Translational Research, 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Giani M, Lucchini A, Moretto L, Di Pierro M, Lo Re F, Mancini PG, Palano S, Foti G, Bellani G, Bronco A. Bag valve resuscitator versus Mapleson C circuit during manual ventilation: A bench top study. Intensive Crit Care Nurs 2021; 70:103186. [PMID: 34903466 DOI: 10.1016/j.iccn.2021.103186] [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: 08/09/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Manual ventilation is life saving in critically ill patients. The lack of airway pressure monitoring makes it operator and device dependent. In this bench top-study, we compared a self- inflating bag valve resuscitator and a Mapleson C circuit during manual ventilation performed by critical care nurses under normal and pathologic conditions, with a special focus on delivered positive end expiratory pressure (PEEP). METHODS Three different respiratory patterns (normal, restrictive and obstructive) were reproduced by a breathing simulator. Twenty nurses provided manual ventilation with a specific ventilatory pattern. Airway pressure, tidal volume and respiratory rate were recorded. Absolute value, error (difference between recorded and target values) and variability of PEEP were analysed. RESULTS 3820 breathing traces were analysed. PEEP error was significantly higher with Mapelson C (43.3% vs 5.9% respectively, p < 0.001). This finding was confirmed regardless of operator skill and scenario. PEEP was more variable with Mapelson C (p < 0.05 in all scenarios). Ventilation of obstructive patients with Mapelson C resulted in higher PEEP levels compared to the reference value. Conversely, in the restrictive setting, PEEP was lower. Difference between PEEP and the minimum pressure recorded during the respiratory cycle was significantly higher with Mapelson C (p < 0.05). CONCLUSIONS Manual ventilation with a Mapleson C circuit delivered a less accurate and less stable PEEP level compared to a self-inflating bag valve resuscitator.
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Affiliation(s)
- Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Alberto Lucchini
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy.
| | - Lorenza Moretto
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Michela Di Pierro
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabio Lo Re
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | - Salvatore Palano
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Alfio Bronco
- Department of Emergency and Intensive Care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
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Kim JY, Bae J, Lee KH, Kang L, Kim KN, Jeong MA. High-flow nasal cannula application in an infant patient with laryngomalacia during general anesthesia: A case report. Medicine (Baltimore) 2021; 100:e28102. [PMID: 34889265 PMCID: PMC8663912 DOI: 10.1097/md.0000000000028102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Laryngomalacia is defined as the collapse of supraglottic structures and can cause not only strider but also trigger difficulties with ventilation and endotracheal intubation during anesthesia management. High-flow nasal cannula (HFNC) has been used to manage patients at high risk of hypoxemia in the intensive care unit; however, limited literature information is available for the application of HFNC to infant patients with laryngomalacia during anesthesia practice. PATIENT CONCERNS A 2-month-old male infant was scheduled to undergo surgery for inguinal hernia and undescended testis with general anesthesia. DIAGNOSIS The patient had subcostal retraction while breathing and frequent oxygen desaturation events and was diagnosed laryngomalacia. INTERVENTIONS After the patient was supplied oxygen via HFNC and then given general anesthesia, the initial 2 attempts of endotracheal intubation with a rigid laryngoscope were unsuccessful because the vocal cords were obscured by the epiglottis. A third intubation attempt was performed and successful with a 3.0-sized, uncuffed endotracheal tube within 20 minutes of the initial attempt. OUTCOMES No airway complications emerged and oxygen saturation remained at greater than 98% during general anesthesia. The patient was discharged 5 days after surgery without any adverse side effects. LESSONS Continuous oxygenation via HFNC is a good choice to prevent desaturation during difficult tracheal intubations in infant patients with laryngomalacia. This device is expected to be useful for intubation not only in patients with laryngomalacia, but also in infant patients with a predicted high risk of oxygen desaturation events during general anesthesia.
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Effect of using barrier devices on intubation times and performance—a randomized, prospective, crossover manikin study. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00860-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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49
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Kothari R, Hodgson KA, Davis PG, Thio M, Manley BJ, O'Currain E. Time to desaturation in preterm infants undergoing endotracheal intubation. Arch Dis Child Fetal Neonatal Ed 2021; 106:603-607. [PMID: 33931396 PMCID: PMC8543201 DOI: 10.1136/archdischild-2020-319509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/13/2021] [Accepted: 03/23/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU. METHODS Observational study at The Royal Women's Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks' postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%). RESULTS Seventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26-29) weeks and birth weight 946 (773-1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14-32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24-44) s and to desaturation <60% was 56 (42-68) s. No episodes of bradycardia were seen. CONCLUSIONS This is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation. TRIAL REGISTRATION NUMBER ACTRN12614000709640.
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Affiliation(s)
- Radhika Kothari
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Kate Alison Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Eoin O'Currain
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia,University College Dublin–National University of Ireland, Dublin, Ireland,The National Maternity Hospital, Holles St, Dublin, Ireland
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Patel A, El-Boghdadly K. Facemask or high-flow nasal oxygenation: time to switch? Anaesthesia 2021; 77:7-11. [PMID: 34634137 DOI: 10.1111/anae.15593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 01/13/2023]
Affiliation(s)
- A Patel
- Department of Anaesthesia, University College London Hospitals NHS Foundation Trust, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
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