Critical Care Airway Management

Upper airway angle and glottic height: a prospective cohort to evaluate two new features for airway prediction

BACKGROUND

Predicting difficult direct laryngoscopies remains challenging and improvements are needed in preoperative airway assessment. We conceived two new tests (the upper airway angle and the glottic height) and assessed their association with difficult direct laryngoscopies as well as their predictive performance.

METHODS

A prospective cohort was conducted with 211 patients undergoing general anesthesia for surgical procedures. We assessed the association between difficult laryngoscopies and modified Mallampati Test (MMT), Upper Lip Bite Test (ULBT), Mandibular Length (ML), Neck Circumference (NC), Mouth Opening (MO), Sternomental Distance (SMD), Thyromental Distance (TMD), Upper Airway Angle (UAA), and Glottic Height (GH). We also estimated their predictive values.

RESULTS

Difficult laryngoscopy was presented by 12 patients (5.7%). Six tests were significantly associated with difficult laryngoscopies and their area under the ROC curve, and 95% CIs were as follows: UAA = 88.82 (81.86-95.78); GH = 86.43 (72.67-100); ML = 83.75 (72.77-94.74); NC = 79.17 (64.98-93.36); MO = 65.58 (45.13-86.02); and MMT = 77.89 (68.37-87.41).

CONCLUSION

We have found two new features (the UAA and the GH) to be significantly associated with the occurrence of difficult direct laryngoscopies. They also presented the best predictive performance amongst the nine evaluated tests in our cohort of patients. We cannot ensure, however, these tests to be superior to other regularly used bedside tests based on our estimated 95% CIs.

Emergencies in obese patients: a narrative review

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

Establishment of evidence-based nursing review indicators for airway management of adult critical patients and analysis of obstacle factors

AIM

To select and obtain relevant evidence of airway management in adult critically ill patients at home and abroad, formulate clinical quality review indicators based on evidence and analyse obstacle factors and promoting factors in evidence-based nursing practice. To promote standardized ICU airway management evidence-based nursing practice to provide the basis.

DESIGN

Obstacle factor analysis.

METHODS

Take the Joanna Briggs Institute (JBI) evidence-based healthcare model as theoretical guidance, establish evidence-based problems, form a team, systematically search for literature, evaluate quality and summarize evidence, establish quality review indicators and review methods, analyse obstacles and facilitating factors based on the review results and formulate corresponding action strategies.

RESULTS

According to the 29 best evidences, 21 review indicators were developed. Through the results of clinical quality review, the main barriers to evidence-based practice were analysed: the lack of nurse training and relevant evidence-based knowledge at the practitioner level, the lack of standardized procedures for airway management and the lack of materials at the system level.

CONCLUSION

There is a big gap between airway management evidence and clinical practice in critically ill adult patients. Therefore, improvement measures should be formulated for obstacle factors to promote effective transformation of evidence into clinical practice.

Is Mallampati classification a good screening test? A prospective cohort evaluating the predictive values of Mallampati test at different thresholds

BACKGROUND

There is currently some discussion over the actual usefulness of performing preoperative upper airway assessment to predict difficult airways. In this field, modified Mallampati test (MMT) is a widespread tool used for prediction of difficult airways showing only a feeble predictive performance as a diagnostic test. We therefore aimed at evaluating if MMT test would perform better when used as a screening test rather than diagnostic.

METHODS

An accuracy prospective study was conducted with 570 patients undergoing general anesthesia for surgical procedures. We collected preoperatively data on sex, age, weight, height, body mass index (BMI), ASA physical status, and MMT. The main outcome was difficult laryngoscopy defined as Cormack and Lahane classes 3 or 4. Bivariate analyses were performed to build three different predictive models with their ROC curves.

RESULTS

Difficult laryngoscopy was reported in 36 patients (6.32%). Sex, ASA physical status, and MMT were associated with difficult laryngoscopy, while body mass index (BMI) was not. The MMT cut-off with the highest odds ratio was the class II, which also presented significantly higher sensitivity (94.44%). The balanced accuracy was 67.11% (95% CI: 62.78-71.44%) for the cut-off of class II and 71.68% (95% CI: 63.83-79.54) for the class III.

CONCLUSION

MMT seems to be more clinically useful when the class II is employed as the threshold for possible difficult laryngoscopies. At this cut-off, MMT shows the considerable highest sensitivity plus the highest odds ratio, prioritizing thus the anticipation of difficult laryngoscopies.

The critical care literature 2019

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments across the United States has steadily increased. From 2006 to 2014, emergency department (ED) visits for critically ill patients increased approximately 80%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the ICU remain in the ED for more than 6 h. Prolonged ED wait times for critically ill patients to be transferred to the ICU is associated with increased hospital, 30-day, and 90-day mortality. It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2019 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to emergency medicine. The following topics are covered: sepsis, rapid sequence intubation, mechanical ventilation, neurocritical care, post-cardiac arrest care, and ED-based ICUs.

Donning and doffing of personal protective equipment protocol and key points of nursing care for patients with COVID-19 in ICU

Coronavirus pandemic is the most important public health event in the world currently. Patients with coronavirus disease 2019 (COVID-19) in a critical state are at risk of progressing rapidly into many serve complications; they require a high level of care from ICU nurses. How to avoid the virus to infect health care worker is also a critical issue. Based on the summarized experience of Chinese health workers, literature review and clinical practice, this article introduced donning and doffing of personal protective equipment (PPE) protocol and some keypoints of nursing critical care in patients with coronavirus disease 2019 (COVID-19): caring of patients requiring intubation and ventilation, venous thromboembolism (VTE) prevention, caring of patients on ECMO, caring for patients requiring enteral nutrition, psychological support and nursing management of COVID-19 ICU. This article introduced a useful protocol of donning and doffing personal protective equipment to protect health care workers, and provided key points for the ICU nurses how to take care of COVID-19 patients.

Simulation Training for Critical Care Airway Management: Assessing Translation to Clinical Practice Using a Small Video-Recording Device

BACKGROUND

Critical care airway management (CCAM) is a key skill for critical care physicians. Simulation-based training (SBT) may be an effective modality in training intensivists in CCAM.

RESEARCH QUESTION

Is SBT of critical care fellows an effective means of providing training in CCAM, in particular in urgent endotracheal intubation?

STUDY DESIGN AND METHODS

Thirteen first-year pulmonary critical care medicine (PCCM) fellows at an academic training program underwent SBT with a computerized patient simulator (CPS) in their first month of fellowship training. At the end of the training period, the fellows underwent video-based scoring using a 46-item checklist (of which 40 points could be scored) while performing a complete CCAM sequence on the CPS. They were then tested, using video-based scoring on their first real-life CCAM. Maintenance of skill at CCAM was assessed during the fellows' second and third year of training, using the same scoring method.

RESULTS

For the first-year fellows, the score on the CPS was 38.3 ± 0.75 SD out of a maximum score of 40. The score on their first real-life patient CCAM was 39.0 ± 0.81 SD (P = .003 for equivalence; 95% CI for difference between real-life patient CCAM and CPS scores, 0.011-1.373). Sixteen second- and third-year fellows were tested at a real-life CCAM event later in their fellowship to examine for maintenance of skill. The mean maintenance of skill score of this group was 38.7 ± 1.14 SD.

INTERPRETATION

Skill acquired through SBT of critical care fellows for CCAM transfers effectively to the real-life patient care arena. Second- and third-year fellows who had initially received SBT maintained skill at CCAM.