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Zhang YN, Shi HY, Shen WQ, Shi JH, Zhu YP, Xu YH, Wu HL. Effect of varying cuff sizes with identical inner diameter on endotracheal intubation in critically ill adults: A sealed tracheal controlled trial. Medicine (Baltimore) 2024; 103:e38326. [PMID: 38875381 PMCID: PMC11175911 DOI: 10.1097/md.0000000000038326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND The present study aims to determine the impact of different cuff diameters on the cuff pressure of endotracheal tubes (ETTs) when the trachea is adequately sealed. METHODS In the present single-center clinical trial, adult patients who underwent cardiothoracic surgery were assigned to use ETTs from 2 brands (GME and GZW). The primary endpoint comprised of the following: cuff diameter, inner diameter of the ETT, manufacturer, and the number of subjects with tracheal leakage when the cuff pressure was 30 cm H2O. RESULTS A total of 298 patients were assigned into 2 groups, based on the 2 distinct brands of ETTs: experimental group (n = 122, GME brand) and control group (n = 176, GZW brand). There were no significant differences in baseline characteristics. However, the cuff diameter was significantly smaller in the control group, when compared to the experimental group (P = .001), and the incidence of tracheal leakage was significantly higher in the control group (P = .001). Furthermore, the GME brand ETT had a significantly larger cuff diameter, when compared to the GZW brand ETT. CONCLUSION The cuff size would mismatch the tracheal area in clinical practice. Therefore, chest computed tomography is recommended to routinely evaluate the tracheal cross-sectional area during anesthesia, in order to ensure the appropriate cuff size selection.
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Affiliation(s)
- Yan-Nan Zhang
- Nursing Department, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Hai-Yan Shi
- Nursing Department, The People's Hospital of Rugao, and Affiliated Rugao Hospital of Nantong University, Nantong City, Jiangsu, China
| | - Wang-Qin Shen
- Nursing Department, Nantong Third People's Hospital, Nantong, Jiangsu, China
| | - Jia-Hai Shi
- Department of Cardiothoracic Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yan-Ping Zhu
- Intensive Care Unit, Southeast University Affiliated Zhong Da Hospital, Nanjing, Jiangsu, China
| | - Yang-Hui Xu
- Nursing Department, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Hong-Lei Wu
- Nursing Department, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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Levi D, Hoogendoorn J, Samuels S, Maguire L, Troncoso R, Gunn S, Katz M, VanDillen C, Miller SA, Falk JL, Katz SH, Papa L. The i-gel ® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID-19 pandemic. J Am Coll Emerg Physicians Open 2024; 5:e13150. [PMID: 38576603 PMCID: PMC10992989 DOI: 10.1002/emp2.13150] [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: 08/29/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024] Open
Abstract
Objective Unlike randomized controlled trials, practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID-19 pandemic-driven shift from endotracheal intubation (ETI) to the i-gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first-pass success and timing to successful airway placement between ETI and the i-gel® SGA under extenuating circumstances. Methods This pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non-trauma-related conditions. Data from EMS records were extracted over 2 years, 12 months pre-pandemic, and 12 months post-pandemic. During the pre-COVID-19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post-pandemic paramedics were mandated to utilize i-gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group). Results There were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First-pass success was significantly higher with SGA 96% (92%-99%) than ETI 68% (57%-78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first-pass success was significantly shorter in the SGA group (5.9 min [5.1-6.7 min]) than in the ETI group (8.3 min [6.9-9.6 min]), as was time to overall successful placement at 6.0 min (5.1-6.8 min) versus 9.6 min (8.2-11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator-free days between the groups were not statistically different between the groups. Conclusion In this natural experiment, the SGA performed significantly better than ETI in first-pass airway device placement success and was significantly faster in achieving first-pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.
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Affiliation(s)
- Daniel Levi
- Department of Emergency MedicineMemorial Hospital WestPembroke PinesFloridaUSA
| | - Joris Hoogendoorn
- Department of Emergency MedicineMemorial Hospital WestPembroke PinesFloridaUSA
| | - Shenae Samuels
- Department of Emergency MedicineMemorial Hospital WestPembroke PinesFloridaUSA
| | - Lindsay Maguire
- Department of Emergency MedicineOrlando Health Orlando Regional Medical CenterOrlandoFloridaUSA
| | - Ruben Troncoso
- Pembroke Pines Fire Rescue DepartmentPembroke PinesFloridaUSA
| | - Scott Gunn
- Pembroke Pines Fire Rescue DepartmentPembroke PinesFloridaUSA
| | | | - Christine VanDillen
- Department of Emergency MedicineOrlando Health Orlando Regional Medical CenterOrlandoFloridaUSA
| | - Susan A. Miller
- Department of Emergency MedicineOrlando Health Orlando Regional Medical CenterOrlandoFloridaUSA
| | - Jay L. Falk
- Department of Emergency MedicineOrlando Health Orlando Regional Medical CenterOrlandoFloridaUSA
| | - Steven H. Katz
- Department of Emergency MedicineMemorial Hospital WestPembroke PinesFloridaUSA
| | - Linda Papa
- Department of Emergency MedicineOrlando Health Orlando Regional Medical CenterOrlandoFloridaUSA
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Ladde JG, Miller S, Chin K, Feffer C, Gulenay G, Kepple K, Hunter C, Thundiyil JG, Papa L. End-tidal carbon dioxide measured at emergency department triage outperforms standard triage vital signs in predicting in-hospital mortality and intensive care unit admission. Acad Emerg Med 2023; 30:832-841. [PMID: 36802204 DOI: 10.1111/acem.14703] [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: 12/08/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVES This study assessed the ability of end-tidal carbon dioxide (ETCO2 ) in predicting in-hospital mortality and intensive care unit (ICU) admission compared to standard vital signs at ED triage as well as comparing to measures of metabolic acidosis. METHODS This prospective study enrolled adult patients presenting to the ED of a tertiary care Level I trauma center over 30 months. Patients had standard vital signs measured along with exhaled ETCO2 at triage. Outcome measures included in-hospital mortality; ICU admission; and correlations with lactate, sodium bicarbonate (HCO3 ), and anion gap. RESULTS There were 1136 patients enrolled and 1091 patients with outcome data available. There were 26 (2.4%) patients who did not survive to hospital discharge. Mean ETCO2 levels were 34 (33-34) in survivors and 22 (18-26) nonsurvivors (p < 0.001). The area under the curve (AUC) for predicting in-hospital mortality for ETCO2 was 0.82 (0.72-0.91). In comparison the AUC for temperature was 0.55 (0.42-0.68), respiratory rate (RR) 0.59 (0.46-0.73), systolic blood pressure (SBP) 0.77 (0.67-0.86), diastolic blood pressure (DBP) 0.70 (0.59-0.81), heart rate (HR) 0.76 (0.66-0.85), and oxygen saturation (SpO2 ) 0.53 (0.40-0.67). There were 64 (6%) patients admitted to the ICU, and the ETCO2 AUC for predicting ICU admission was 0.75 (0.67-0.80). In comparison the AUC for temperature was 0.51, RR 0.56, SBP 0.64, DBP 0.63, HR 0.66, and SpO2 0.53. Correlations between expired ETCO2 and serum lactate, anion gap, and HCO3 were rho = -0.25 (p < 0.001), rho = -0.20 (p < 0.001), and rho = 0.330 (p < 0.001), respectively. CONCLUSIONS ETCO2 was a better predictor of in-hospital mortality and ICU admission than the standard vital signs at ED triage. ETCO2 correlated significantly with measures of metabolic acidosis.
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Affiliation(s)
- Jay G Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Stacie Miller
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Kevin Chin
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Cole Feffer
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - George Gulenay
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Kirsten Kepple
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Christopher Hunter
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Josef G Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
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Sakles JC, Ross C, Kovacs G. Preventing unrecognized esophageal intubation in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12951. [PMID: 37128296 PMCID: PMC10148380 DOI: 10.1002/emp2.12951] [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: 02/04/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 05/03/2023] Open
Abstract
Tracheal intubation is a commonly performed procedure on critically ill patients in the emergency department. It is associated with many serious complications, one of the most dangerous being unrecognized esophageal intubation, which can result in anoxic brain injury, cardiac arrest, or death. It is the responsibility of the emergency physician to do everything possible to avoid this devastating complication. Preventing unrecognized esophageal intubation requires a two-pronged approach. First, the inadvertent placement of intended tracheal tubes into the esophagus must be reduced as much as is humanly possible. This can be achieved with the routine use of video laryngoscopes for emergency department intubations. Numerous studies have demonstrated that use of video laryngoscopes can significantly reduce the occurrence of esophageal intubation, presumably by providing an improved view of the larynx. Second, if an esophageal intubation inadvertently occurs, it must be rapidly identified and appropriately addressed. The cornerstone of rapid identification is the use of continuous waveform capnography to detect exhaled carbon dioxide. Capnography has been shown to be the most accurate method to determine tube placement after intubation. Standard clinical examinations, for example, auscultation of breath sounds, visualization of chest excursion, and observation of condensation in the tube, have all been demonstrated in studies to be unreliable and thus should not be used to exclude esophageal intubation. Recently, the Project for Universal Management of Airways, an international collaborative of airway experts from anesthesiology, critical care and emergency medicine, published evidence-based guidelines to specifically address the issue of preventing unrecognized esophageal intubation. These guidelines, which have received endorsement from several prominent airway societies, including the Society for Airway Management, the Difficult Airway Society, and the European Airway Management Society, will be briefly discussed in this review.
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Affiliation(s)
- John C. Sakles
- Department of Emergency MedicineUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Christopher Ross
- Department of Emergency MedicineMercy Health Javon Bea HospitalRockfordIllinoisUSA
| | - George Kovacs
- Department of Emergency MedicineDalhousie UniversityHalifaxNova ScotiaCanada
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Baker PA, O'Sullivan EP, Aziz MF. Unrecognised oesophageal intubation: time for action. Br J Anaesth 2022; 129:836-840. [PMID: 36192220 DOI: 10.1016/j.bja.2022.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/02/2022] Open
Abstract
Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error. Unrecognised oesophageal intubation can occur in any patient of any age whenever intubation occurs regardless of the seniority or experience of the airway practitioner or others involved in the patient's airway management. The tragic fact is that it continues to happen despite improvements in monitoring, airway devices, and medical education. We review these improvements with strategies to eliminate this problem.
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Affiliation(s)
- Paul A Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand; Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.
| | - Ellen P O'Sullivan
- Department of Anaesthesia and Intensive Care Medicine, St James's Hospital, Dublin, Ireland
| | - Michael F Aziz
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Maissan I, van Lieshout E, de Jong T, van Vledder M, Houmes RJ, Hartog DD, Stolker RJ. The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in The Netherlands: a retrospective observational study. Eur J Trauma Emerg Surg 2022; 48:4205-4213. [PMID: 35362731 PMCID: PMC9532291 DOI: 10.1007/s00068-022-01962-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/15/2022] [Indexed: 12/01/2022]
Abstract
Purpose The first-pass success rate for endotracheal intubation (ETI) depends on provider experience and exposure. We hypothesize that video laryngoscopy (VL) improves first-pass and overall ETI success rates in low and intermediate experienced airway providers and prevents from unrecognized oesophageal intubations in prehospital settings. Methods In this study 3632 patients were included. In all cases, an ambulance nurse, HEMS nurse, or HEMS physician performed prehospital ETI using direct Laryngoscopy (DL) or VL. Results First-pass ETI success rates for ambulance nurses with DL were 45.5% (391/859) and with VL 64.8% (125/193). For HEMS nurses first-pass success rates were 57.6% (34/59) and 77.2% (125/162) respectively. For HEMS physicians these successes were 85.9% (790/920) and 86.9% (1251/1439). The overall success rate for ambulance nurses with DL was 58.4% (502/859) and 77.2% (149/193) with VL. HEMS nurses successes were 72.9% (43/59) and 87.0% (141/162), respectively. HEMS physician successes were 98.7% (908/920) and 99.0% (1425/1439), respectively. The incidence of unrecognized intubations in the oesophagus before HEMS arrival in traumatic circulatory arrest (TCA) was 30.6% with DL and 37.5% with VL. In medical cardiac arrest cases the incidence was 20% with DL and 0% with VL. Conclusion First-pass and overall ETI success rates for ambulance and HEMS nurses are better with VL. The used device does not affect success rates of HEMS physicians. VL resulted in less unrecognized oesophageal intubations in medical cardiac arrests. In TCA cases VL resulted in more oesophageal intubations when performed by ambulance nurses before HEMS arrival.
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Affiliation(s)
- Iscander Maissan
- Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Esther van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Timo de Jong
- Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark van Vledder
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert Jan Houmes
- Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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Carlson JN, Colella MR, Daya MR, J De Maio V, Nawrocki P, Nikolla DA, Bosson N. Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:54-63. [PMID: 35001831 DOI: 10.1080/10903127.2021.1971349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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 out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends:Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA.Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest.EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation.Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.
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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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Farrokhi M, Yarmohammadi B, Mangouri A, Hekmatnia Y, Bahramvand Y, Kiani M, Nasrollahi E, Nazari-Sabet M, Manoochehri-Arash N, Khurshid M, Mosalanejad S, Hajizadeh V, Amani-Beni R, Moallem M, Farahmandsadr M. Screening Performance Characteristics of Ultrasonography in Confirmation of Endotracheal Intubation; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e68. [PMID: 34870234 PMCID: PMC8628646 DOI: 10.22037/aaem.v9i1.1360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Recent studies have suggested that point-of-care ultrasonography can be used for confirming the placement of endotracheal tube. This systematic review and meta-analysis aimed to investigate the sensitivity and specificity of ultrasonography for confirming endotracheal tube placement. Methods: In this meta-analysis, systematic search of the previous published papers investigating the diagnostic accuracy of ultrasonography for confirmation of endotracheal tube placement was performed. Seven electronic databases, including PubMed, Scopus, Google Scholar, EBSCO, EMBASE, Web of Science, and Cochrane Database were searched up to July 2021, for all relevant articles published in English on this topic. Meta-DiSc version 1.4 software was used for statistical analysis. Results: The estimated pooled sensitivity and specificity of ultrasonography for confirmation of endotracheal tube location were 0.98 (95% CI: 0.98–0.99) and 0.94 (95% CI 0.91–0.96), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 5.94 (95% CI 4.41–7.98) and 0.03 (95% CI: 0.02-0.04), respectively. The diagnostic odds ratio of ultrasonography was 281.47 and the area under hierarchical summary receiver operating characteristic (HSROC) revealed an appropriate accuracy of 0.98. Conclusion: Ultrasonography has high diagnostic accuracy and can be used as a promising tool for confirmation of endotracheal tube placement, especially in critically ill patients or when capnography is not available, or its result is equivocal.
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Affiliation(s)
| | - Bardia Yarmohammadi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Mangouri
- Department of Vascular and Endovascular Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yasaman Hekmatnia
- Islamic Azad University, Sari Branch, School of Medicine, Sari, Iran
| | - Yaser Bahramvand
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Moein Kiani
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Elham Nasrollahi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Milad Nazari-Sabet
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Niusha Manoochehri-Arash
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maria Khurshid
- Department of Internal Medicine, Berkshire Medical Center, Pittsfield, Massachusetts, USA
| | - Shima Mosalanejad
- Department of Internal Medicine, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Vida Hajizadeh
- School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Amani-Beni
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Moallem
- Department of Emergency Medicine, School of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
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Torres GM, Nascimento ERPD, Hermida PMV, Malfussi LBHD, Galetto SGDS. Care for unplanned extubation prevention: analysis of the validity of an instrument's content. Rev Bras Enferm 2021; 74:e20180998. [PMID: 33567053 DOI: 10.1590/0034-7167-2018-0998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 09/07/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze the validity of a nursing care instrument content for unplanned extubation prevention in Intensive Care Units. METHODS a methodological study carried out with 40 nurses, containing 26 interventions distributed in the components: agitation/delirium/pain management; respiratory device stability; weaning from sedation and spontaneous breathing assessment; human resource management. Content Validity Index, average and universal proportion, and Fleiss' Kappa coefficient were applied. RESULTS Brazilian female experts stood out, with an average age of 44.9 years and a standard deviation of 7.75 years. Two interventions did not reach a valid Content Validation Index (≥0.78), when considering the set of evaluated criteria. A universal agreement of 4.0% was identified among Brazilians and 26.6% among foreigners. CONCLUSIONS the instrument is relevant and represents "unplanned extubation prevention in Intensive Care Units", which can be implemented in Brazil and in Latin countries, in Brazilian and foreign versions.
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12
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Trageser H, Lott C, Epp K, Pirlich N. Subglottic stenosis imitating the carina - a case report of airway mimicry. Anaesth Rep 2021; 9:20-23. [PMID: 33521642 PMCID: PMC7816110 DOI: 10.1002/anr3.12094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/19/2022] Open
Abstract
We present a case of awake tracheal intubation with flexible bronchoscopy which resulted in incorrect tracheal tube placement. The presence of a stenotic subglottic lesion with an appearance similar to the carina led to the tube being positioned with only the tip within the trachea whilst the cuff was located between the vocal cords. A capnography trace was identified before induction of anaesthesia; however, visual confirmation of the carina was undertaken in a rushed manner due to the patient becoming agitated. Once the incorrect tracheal tube placement was identified, the decision was made to wake the patient. Thereafter, a more experienced operator successfully performed awake tracheal intubation with flexible bronchoscopy using a smaller tracheal tube, which easily passed through the subglottic stenosis. This report emphasises the importance of performing the ‘two‐point check’ every time awake tracheal intubation is undertaken: to confirm correct tube placement, both a capnography trace and view of the tracheal lumen including the carina and main bronchi is required. This must be properly performed before induction of anaesthesia; safety should not be compromised by a stressful environment or time pressure.
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Affiliation(s)
- H Trageser
- Department of Anaesthesiology University Medical Centre of the Johannes-Gutenberg University Mainz Mainz Germany
| | - C Lott
- Department of Anaesthesiology University Medical Centre of the Johannes-Gutenberg University Mainz Mainz Germany
| | - K Epp
- Department of Anaesthesiology University Medical Centre of the Johannes-Gutenberg University Mainz Mainz Germany
| | - N Pirlich
- Department of Anaesthesiology University Medical Centre of the Johannes-Gutenberg University Mainz Mainz Germany
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13
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Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2019; 75:509-528. [PMID: 31729018 PMCID: PMC7078877 DOI: 10.1111/anae.14904] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
Abstract
Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - I Hodzovic
- Department of Anaesthesia, Cardiff University School of Medicine, Cardiff, UK.,Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - F Mir
- Department of Anaesthesia, St. George's University Hospital NHS Foundation Trust, London, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
| | - A Patel
- Department of Anaesthesia, Royal National Throat Nose and Ear Hospital and University College London Hospitals NHS Foundation Trust, London, UK
| | - M Stacey
- Department of Anaesthesia, Cardiff and Vale NHS Trust (HEIW), Cardiff, UK
| | - D Vaughan
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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14
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Duhem H, Viglino D, Bellier A, Tanguy S, Descombe V, Boucher F, Chaffanjon P, Debaty G. Cadaver models for cardiac arrest: A systematic review and perspectives. Resuscitation 2019; 143:68-76. [DOI: 10.1016/j.resuscitation.2019.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/09/2019] [Accepted: 08/06/2019] [Indexed: 02/08/2023]
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15
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Mitra A, Gave A, Coolahan K, Nguyen T. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting. World J Emerg Med 2019; 10:210-214. [PMID: 31534594 DOI: 10.5847/wjem.j.1920-8642.2019.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients intubated in the prehospital setting require quick and definitive confirmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no definitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confirmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confirmed with disposable fiberoptic bronchoscopy. METHODS Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, flexible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identified ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of difficulty were measured. RESULTS Residents accurately identified the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very difficult). No tubes were damaged or dislodged. CONCLUSION While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confirmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.
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Affiliation(s)
- Avir Mitra
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine, New Jersey 08043, USA
| | - Asaf Gave
- Department of Surgery Critical Care, Mount Sinai Beth Israel, Icahn School of Medicine, New York 10009, USA
| | - Kelsey Coolahan
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine, New Jersey 08043, USA
| | - Thomas Nguyen
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine, New Jersey 08043, USA
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16
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US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation: Validation and potential impact. Resuscitation 2018; 127:125-131. [DOI: 10.1016/j.resuscitation.2018.01.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 02/04/2023]
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17
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Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, Beilicke A, Stehr SN, Josten C, Wrigge H. Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients. Sci Rep 2018; 8:3976. [PMID: 29507415 PMCID: PMC5838247 DOI: 10.1038/s41598-018-22457-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/23/2018] [Indexed: 11/16/2022] Open
Abstract
This study aimes to determine the complication rates, possible risk factors and outcomes of emergency procedures performed during resuscitation of severely injured patients. The medical records of patients with an injury severity score (ISS) >15 admitted to the University Hospital Leipzig from 2010 to 2015 were reviewed. Within the first 24 hours of treatment, 526 patients had an overall mechanical complication rate of 26.2%. Multivariate analysis revealed out-of-hospital airway management (OR 3.140; 95% CI 1.963–5.023; p < 0.001) and ISS (per ISS point: OR 1.024; 95% CI 1.003–1.045; p = 0.027) as independent predictors of any mechanical complications. Airway management complications (13.2%) and central venous catheter complications (11.4%) were associated with ISS >32.5 (p < 0.001) and ISS >33.5 (p = 0.005), respectively. Chest tube complications (15.8%) were associated with out-of-hospital insertion (p = 0.002) and out-of-hospital tracheal intubation (p = 0.033). Arterial line complications (9.4%) were associated with admission serum lactate >4.95 mmol/L (p = 0.001) and base excess <−4.05 mmol/L (p = 0.008). In multivariate analysis, complications were associated with an increased length of stay in the intensive care unit (p = 0.019) but not with 24 hour mortality (p = 0.930). Increasing injury severity may contribute to higher complexity of the individual emergency treatment and is thus associated with higher mechanical complication rates providing potential for further harm.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Johannes K M Fakler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Thilo Busch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - André Beilicke
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian N Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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18
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Sanri E, Akoglu EU, Karacabey S, Verimli U, Akoglu H, Sehirli U, Denizbasi A. Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study. Am J Emerg Med 2018; 36:1943-1946. [PMID: 29477268 DOI: 10.1016/j.ajem.2018.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/18/2018] [Accepted: 02/16/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Confirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber-optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time-consuming, and not always practical. Inexpensive endoscopic USB-cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB-camera. METHODS This study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB-endoscopy. We have prepared a randomized intubation list (n=96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB-endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2cm wide ostium on the proximal trachea. RESULTS In this study, all intubations (n=96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB-camera. Both the sensitivity and specificity of TUS and USB-endoscopy for the CoETP were 100.0%. CONCLUSION The perfect accuracy of TUS and USB-endoscopy, have placed those techniques in a unique position as an alternative in resource-poor situations.
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Affiliation(s)
- Erkman Sanri
- Marmara University Faculty of Medicine, Department of Emergency Medicine, Istanbul, Turkey.
| | - Ebru Unal Akoglu
- Ministry of Health Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Sinan Karacabey
- Marmara University Faculty of Medicine, Department of Emergency Medicine, Istanbul, Turkey
| | - Ural Verimli
- Marmara University Faculty of Medicine, Department of Anatomy, Istanbul, Turkey
| | - Haldun Akoglu
- Marmara University Faculty of Medicine, Department of Emergency Medicine, Istanbul, Turkey
| | - Umit Sehirli
- Marmara University Faculty of Medicine, Department of Anatomy, Istanbul, Turkey.
| | - Arzu Denizbasi
- Marmara University Faculty of Medicine, Department of Emergency Medicine, Istanbul, Turkey
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19
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Gao YX, Song YB, Gu ZJ, Zhang JS, Chen XF, Sun H, Lu Z. Video versus direct laryngoscopy on successful first-pass endotracheal intubation in ICU patients. World J Emerg Med 2018; 9:99-104. [PMID: 29576821 DOI: 10.5847/wjem.j.1920-8642.2018.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Airway management in intensive care unit (ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy (DL) and that by using the video laryngoscopy (VL). METHODS A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success. RESULTS A total of 163 ICU patients underwent intubation during the study period (81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group (67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications (all P>0.05). CONCLUSION Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.
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Affiliation(s)
- Yong-Xia Gao
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan-Bo Song
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ze-Juan Gu
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Song Zhang
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xu-Feng Chen
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Sun
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Lu
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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20
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Was capnographic waveform the gold standard to confirm the endotracheal intubation? We need more proofs. Resuscitation 2017. [DOI: 10.1016/j.resuscitation.2017.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Ladde JG, Brown JF, Roa JV, Hunter C, Ralls GA, Papa L. Reply to Letter: Was capnographic waveform the gold standard to confirm the endotracheal intubation? We need more proof. Resuscitation 2017; 119:e13-e14. [DOI: 10.1016/j.resuscitation.2017.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/16/2022]
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22
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Versteeg J, Jan Noordergraaf G. Deadly business, the usefulness of ETCO2. Resuscitation 2017; 115:A12-A13. [DOI: 10.1016/j.resuscitation.2017.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 10/19/2022]
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23
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Ko YK. Importance of Capnography Monitoring in Critical Ill Patients. Korean J Crit Care Med 2017; 32:79-80. [PMID: 31723620 PMCID: PMC6786740 DOI: 10.4266/kjccm.2017.00101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Young-Kown Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
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