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Wani TM, Siddique AY, Khan WN, Rehman S, Tram NK, Tobias JD. Endotracheal tube cuff position in relationship to the walls of the trachea: A retrospective computed tomography-based analysis. Saudi J Anaesth 2024; 18:346-351. [PMID: 39149725 PMCID: PMC11323902 DOI: 10.4103/sja.sja_36_24] [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: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 08/17/2024] Open
Abstract
Background The use of cuffed endotracheal tubes (ETTs) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods The study included patients ranging in age from 1 month to 10 years who underwent neck and chest CT imaging that required general anesthesia and endotracheal intubation. The location of the ETT and of the cuff within the airway was determined from axial CT images at three levels (proximal, middle, and distal). Anatomical orientations were tabulated, and percent chances of each orientation were determined for the ETT and the cuff. Results The study cohort included 42 patients ranging in age from 1 to 114 months. An ETT with a polyvinylchloride cuff was used in 24 patients, and an ETT with a polyurethane cuff was used in 18 patients. The ETT was located near the posterior wall of the trachea in approximately 24-38% of patients, being most likely to be centrally located at the proximal end and at its mid-portion. The middle part of the cuff was most likely to be positioned in the mid-portion of the trachea but tended to skew anteriorly at both the proximal and distal ends. Conclusion This is the first study using CT imaging to identify the uniformity of cuff inflation within the trachea in children. With commonly used cuffed ETTs, cuff inflation and the final position of ETT cuff within the tracheal lumen were not uniform. Future investigations are needed to determine the reasons for this asymmetry and its clinical implications.
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Affiliation(s)
- Tariq M. Wani
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | | | - Wajahat N. Khan
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Saif Rehman
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Nguyen K. Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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Sarhan K, Walaa R, Hasanin A, Elgohary M, Alkonaiesy R, Nawwar K, Elsonbaty M, Elsonbaty A. Cuffed versus uncuffed endotracheal tubes in neonates undergoing noncardiac surgeries: A randomized controlled trial. Paediatr Anaesth 2024. [PMID: 38922733 DOI: 10.1111/pan.14953] [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: 03/23/2024] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The efficacy and safety of cuffed endotracheal tubes (ETTs) in neonates are still unclear, this study aimed to assess the efficacy of cuffed versus uncuffed ETTs in neonate undergoing noncardiac surgeries. METHODS Neonates scheduled for noncardiac surgeries were randomized into two groups according to the type of airway device during general anesthesia: cuffed ETT group (n = 60) and the uncuffed ETT group (n = 60). The primary outcome was the incidence of ETT exchange to find the appropriate ETT. Other outcomes included: duration of intubation, lung ultrasound score, and incidence of postoperative complications (croup, wheezes, hypoxia, etc.). RESULTS The frequency of ETT exchange was lower in the cuffed ETT group compared to the uncuffed one {1 (1.7%) vs. 28 (46.7%), p = .0001; relative risk [95% confidence interval]: 0.54 [0.43-0.69]}. Postoperative adverse events were comparable between both groups except for significantly higher post extubation croup in the uncuffed ETT group compared to the cuffed ETT {10 (16.7%) vs. 3(5%), p value = .04, relative risk (95% confidence interval): 1.14 (1-1.29)}. CONCLUSION In full term neonates undergoing noncardiac surgeries, the use of cuffed ETT was associated with less need to tracheal tube exchange and less incidence of postoperative croup, without increasing the postoperative respiratory complications compared to uncuffed ETT.
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Affiliation(s)
- Khaled Sarhan
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Rana Walaa
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Ahmed Hasanin
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Manal Elgohary
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Ramy Alkonaiesy
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Kareem Nawwar
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Mohamed Elsonbaty
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Ahmad Elsonbaty
- Department of Anaesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
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Veder LL, Joosten KFM, Timmerman MK, Pullens B. Factors associated with laryngeal injury after intubation in children: a systematic review. Eur Arch Otorhinolaryngol 2024; 281:2833-2847. [PMID: 38329528 PMCID: PMC11065910 DOI: 10.1007/s00405-024-08458-7] [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: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this study is to evaluate all potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population. METHODS A systematic literature search was conducted in Medline, Embase, Cochrane, web of science and Google scholar up to 20th of March 2023. We included all unique articles focusing on factors possibly associated with intubation-injury in pediatric patients. Two independent reviewers determined which articles were relevant by coming to a consensus, quality of evidence was rated using GRADE criteria. All articles were critically appraised according to the PRISMA guidelines. The articles were categorized in four outcome measures: post-extubation stridor, post-extubation upper airway obstruction (UAO) necessitating treatment, laryngeal injury found at laryngoscopy and a diagnosed laryngotracheal stenosis (LTS). RESULTS A total of 24 articles with a total of 15.520 patients were included. The incidence of post-extubation stridor varied between 1.0 and 30.3%, of post-extubation UAO necessitating treatment between 1.2 and 39.6%, of laryngeal injury found at laryngoscopy between 34.9 to 97.0% and of a diagnosed LTS between 0 and 11.1%. Although the literature is limited and quality of evidence very low, the level of sedation and gastro-esophageal reflux are the only confirmed associated factors with post-extubation laryngeal injury. The relation with age, weight, gender, duration of intubation, multiple intubations, traumatic intubation, tube size, absence of air leak and infection remain unresolved. The remaining factors are not associated with intubation injury. CONCLUSION We clarify the role of the potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population.
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Affiliation(s)
- L L Veder
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
| | - K F M Joosten
- Department of Pediatrics, Intensive Care Unit, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M K Timmerman
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - B Pullens
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
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Kamaladevi RK, Mishra SK, Rudingwa P, Mohapatra DP, Badhe AS, Senthilnathan M. Comparison of preformed microcuff and preformed uncuffed endotracheal tubes in pediatric cleft palate surgery-A randomized controlled trial. Paediatr Anaesth 2024; 34:340-346. [PMID: 38189558 DOI: 10.1111/pan.14837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND AND AIMS Airway management in children with oral cleft surgery carries unique challenges, concerning the proximity of the surgical site and the tracheal tube. We hypothesized that using a Microcuff oral RAE tube would reduce tube exchange and migration rate. We aimed to compare the performance of Microsoft and uncuffed oral performed tracheal tubes in children undergoing cleft palate surgeries regarding the rate of tracheal tube exchange, endobronchial intubation, and ventilatory parameters. METHODS One hundred children scheduled for cleft palate surgery were randomized into two groups. In the uncuffed group (n = 50), the tracheal tube was selected using the Modified Coles formula, and in the Microcuff (n = 50) group, the manufacturer's recommendations were followed. Intraoperatively, we compared the primary outcome of tube exchange using the chi-square test. The leak pressure and ventilatory parameters after head extension and mouth gag application were measured in both groups. RESULTS The tracheal tube exchange rate was significantly lower in the Microcuff group (0/50) than in uncuffed (19/50) preformed tubes (0 vs. 38% respectively; p <.001). The uncuffed and Microcuff tracheal tube were comparable concerning ventilation parameters and leak pressure of finally placed tubes (17.78 ± 3.95 vs. 19.26 ± 3.81 cm H2 O respectively, with a mean difference (95% CI) of -1.48 (-0.01-2.98); p-value =0.059. Cuff pressure did not vary significantly during the initial hour, and the incidence of postoperative airway morbidity between uncuffed and Microcuff tube was comparable, 5/50 (10%) versus 7/50 (14%) with risk ratio (95% CI) of 0.71(0.24-2.1), p value .49. CONCLUSION Microcuff oral preformed tubes performed better than uncuffed tubes regarding tube exchange during cleft palate surgery.
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Affiliation(s)
- Rithu Krishna Kamaladevi
- Department of Anaesthesia and Critical Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Kumar Mishra
- Department of Anaesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Priya Rudingwa
- Department of Anaesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Devi Prasad Mohapatra
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ashok Shankar Badhe
- Department of Anaesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Muthapillai Senthilnathan
- Department of Anaesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Lewis D, Khalsa DD, Cummings A, Schneider J, Shah S. Factors Associated With Post-Extubation Stridor in Infants Intubated in the Pediatric ICU. J Intensive Care Med 2024; 39:336-340. [PMID: 37787175 DOI: 10.1177/08850666231204208] [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: 10/04/2023]
Abstract
BACKGROUND Post-extubation stridor (PES) is a common problem in the pediatric intensive care unit (PICU) and is associated with extubation failure, longer length of stay, and increased mortality. Infants represent a large proportion of PICU admissions and are at higher risk for PES, making identification and mitigation of factors associated with PES important in this age group. RESEARCH QUESTION What factors are associated with PES in infants (age less than 1 year) intubated in the PICU? STUDY DESIGN & METHODS The primary outcome was PES as defined by the need for racemic epinephrine within 6 h of extubation. Secondary outcomes were heliox administration and reintubation. Statistical analyses were performed with Fisher's exact test for univariate analyses and multivariate logistic regression. RESULTS 518 patient charts were retrospectively reviewed. 24.1% of patients developed PES. Duration of mechanical ventilation greater than 48 h was associated with increased risk of PES (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.13-2.71, P = .01), as was nonelective intubation (OR = 2.92, 95% CI 1.91-4.46, P < .01). The presence of a cuff, gastroesophageal reflux disease, prematurity, and known upper airway abnormality had no association with PES. 4.0 endotracheal tubes (ETTs) had an increased association with PES compared to 3.5 ETTs (OR = 1.96, 95% CI 1.18-3.27, P < .01). There was no difference in risk of PES between 3.5 and 3.0 ETTs. INTERPRETATION In infants intubated in the PICU, mechanical ventilation greater than 48 h and nonelective intubation were associated with PES. 4.0 ETTs were associated with higher risk of PES compared to 3.5 ETTs. These findings may help providers in ETT selection and to identify infants that may be at increased risk of PES.
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Affiliation(s)
- Deirdre Lewis
- Department of Pediatrics, Division of Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Dev Darshan Khalsa
- Department of Pediatrics, Division of Critical Care Medicine, Mattel Children's Hospital, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Alexandra Cummings
- Department of Pediatrics, Division of Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - James Schneider
- Department of Pediatrics, Division of Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Sareen Shah
- Department of Pediatrics, Division of Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
- Department of Pediatrics, Division of Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Jiang B, Wang Y, He X, Zhang L, Fu S. Meta-analysis of the influence of tracheal intubation with cuff and without cuff on the incidence of total wound complications in ICU intubation patients. Int Wound J 2024; 21:e14741. [PMID: 38414304 PMCID: PMC10899797 DOI: 10.1111/iwj.14741] [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: 01/03/2024] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 02/29/2024] Open
Abstract
At present, it is still controversial whether patients in intensive care unit (ICU) use tracheal intubation with or without cuff. This paper evaluates the effect of tracheal intubation with and without cuff on overall complication rate of patients with intubation in ICU. The database of PubMed, Embase, Conchrane Library and Web of Science was searched by computer, and the clinical research on intubation with and without cuff in ICU was collected. The time range was from the database establishment to November 2023. Literature was independently screened, information was extracted, and quality was assessed by two researchers. Finally, there were nine studies included, with 11 068 patients (7391 in cuff group and 3677 in non-cuff group). The results showed that the overall complication rate of cuff group was significantly lower than that of non-cuff group, and that of cuff group (RR = 0.53, p < 0.01). In addition, compared with the non-cuff group, the cuff group had a lower number of tracheal intubation changes [RR = 0.05, p < 0.01] and a lower incidence of aspiration pneumonia (RR = 0.45, p = 0.01). Compared with the non-cuff group, the cuff group had a higher incidence of oral mucosal ulcers and pharyngitis (RR = 1.99, p = 0.04), while the cuff group had a lower incidence of laryngeal edema (RR = 0.39, p < 0.01). In ICU intubation patients, the use of cuffs reduces overall complication rate in comparison to patients without cuffs. Therefore, patients with intubation in ICU can recommend tracheal intubation with cuff.
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Affiliation(s)
- Bingyu Jiang
- Third People's Hospital of Gansu ProvinceLanzhouChina
| | - Yupeng Wang
- Third People's Hospital of Gansu ProvinceLanzhouChina
| | - Xiaoyan He
- Third People's Hospital of Gansu ProvinceLanzhouChina
| | - Lele Zhang
- Third People's Hospital of Gansu ProvinceLanzhouChina
| | - Shangpeng Fu
- Third People's Hospital of Gansu ProvinceLanzhouChina
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7
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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8
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [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: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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Sun Y, Zhao H, Ma Y, An Y. Commentary: Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis. Front Med (Lausanne) 2023; 10:1289321. [PMID: 38046411 PMCID: PMC10690941 DOI: 10.3389/fmed.2023.1289321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Yao Sun
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Ye Ma
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
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10
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Miyazaki Y, Taniguchi Y, Miyazaki C, Allen E, Yoshimoto F. Negative pressure pulmonary edema in a 2-month-old infant after general anesthesia: a case report. JA Clin Rep 2023; 9:79. [PMID: 37966588 PMCID: PMC10651558 DOI: 10.1186/s40981-023-00670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Yusuke Miyazaki
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yoshie Taniguchi
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Chika Miyazaki
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Elissa Allen
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumina Yoshimoto
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
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11
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Chou CH, Tsai CL, Lin KL, Wu SC, Chiang MH, Huang HW, Hung KC. A new formula to predict the size and insertion depth of cuffed nasotracheal tube in children receiving dental surgery: a retrospective study. Sci Rep 2023; 13:12585. [PMID: 37537321 PMCID: PMC10400640 DOI: 10.1038/s41598-023-39793-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023] Open
Abstract
This retrospective study aimed to develop a new formula for selecting the appropriate size and determining the depth of the cuffed nasotracheal intubation (NTI) for a cuffed endotracheal tube (cETT) in pediatric patients undergoing dental surgery. In addition, the clinical data on cETT (i.e., the size and depth of insertion) was compared with those calculated with age-based formulas to evaluate their correlation. A total number of 684 patients who received NTI were enrolled (healthy group, n = 607; special-need group, n = 77). The ETT size used in real-world scenarios was smaller (i.e., about 0.5 and 0.94 mm) than the age-based formula, while the ETT depth was greater (i.e., about 1.5 cm) than the age-based formula in both groups. In the healthy group, age, gender, and body weight were identified as predictors of ETT size and depth through multiple linear regression analysis, while only age and body weight were predictors in the special-needs group. New formulas were developed based on these findings, with ETT size = 3.98 + 0.052 × age + 0.048 × gender (male = 1, female = 0) + 0.023 × body weight (kg) and ETT depth = 15.1 + 0.43 × age + 0.300 × gender (male = 1, female = 0) + 0.007 × body weight (kg). The new formula could be useful for both healthy and special-need pediatric populations undergoing dental procedures.
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Affiliation(s)
- Chen-Hung Chou
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Ling Tsai
- Department of Pediatric Dentistry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kai-Lieh Lin
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Min-Hsien Chiang
- Department of Anesthesiology, Shin Huey Shin Hospital, Kaohsiung, Taiwan
| | - Hui-Wen Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, 804, Taiwan.
- Department of Anesthesiology, Chi Mei Medical Center, No. 901, ChungHwa Road, YungKung District, Tainan, 71004, Taiwan.
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12
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Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S61-S75. [PMID: 36661436 DOI: 10.1097/pcc.0000000000003159] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To provide evidence for the Second Pediatric Acute Lung Injury Consensus Conference updated recommendations and consensus statements for clinical practice and future research on invasive mechanical ventilation support of patients with pediatric acute respiratory distress syndrome (PARDS). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included clinical studies of critically ill patients undergoing invasive mechanical ventilation for PARDS, January 2013 to April 2022. In addition, meta-analyses and systematic reviews focused on the adult acute respiratory distress syndrome population were included to explore new relevant concepts (e.g., mechanical power, driving pressure, etc.) still underrepresented in the contemporary pediatric literature. DATA EXTRACTION Title/abstract review, full text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations, good practice statements and research statements. We identified 26 pediatric studies for inclusion and 36 meta-analyses or systematic reviews in adults. We generated 12 recommendations, two research statements, and five good practice statements related to modes of ventilation, tidal volume, ventilation pressures, lung-protective ventilation bundles, driving pressure, mechanical power, recruitment maneuvers, prone positioning, and high-frequency ventilation. Only one recommendation, related to use of positive end-expiratory pressure, is classified as strong, with moderate certainty of evidence. CONCLUSIONS Limited pediatric data exist to make definitive recommendations for the management of invasive mechanical ventilation for patients with PARDS. Ongoing research is needed to better understand how to guide best practices and improve outcomes for patients with PARDS requiring invasive mechanical ventilation.
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13
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Saracoglu A, Saracoglu KT, Sorbello M, Kurdi R, Greif R. A view on pediatric airway management: a cross sectional survey study. Minerva Anestesiol 2022; 88:982-993. [PMID: 35833855 DOI: 10.23736/s0375-9393.22.16445-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
BACKGROUND This survey aimed to investigate routine practices and approaches of clinicians on pediatric airway in anesthesia and intensive care medicine. METHODS A 20-question multiple-choice questionnaire with the possibility to provide open text answers was developed and sent. The survey was sent to the members of European Airway Management Society via a web-based platform. Responses were analyzed thematically. Only the answers from one representative of the pediatric service of each hospital was included into the analysis. RESULTS Among the members, 143 physicians responded the survey, being anesthesiologists (83.2%), intensivists (11.9%), emergency medicine physicians (2.1%), and (2.8%) pain medicine practitioners. A straight blade was preferred by 115 participants (80.4%) in newborns, whereas in infants 86 (60.1%) indicated a curved blade and 55 (38.5%) a straight blade. Uncuffed tracheal tube were preferred by 115 participants (80.4%) in newborns, whereas 24 (16.8%) used cuffed tubes. Approximately 2/3 of the participants (89, 62.2%) reported not to use routinely a cuff manometer in their clinical practice, whereas 54 participants (37.8%) use it routinely in pediatric patients. Direct laryngoscopy for routine pediatric tracheal intubation was reported by 127 participants (88.8%), while 16 (11.2%) reported using videolaryngoscopes routinely. Interestingly, 39 (27.3%) had never performed neither videolaryngoscopy nor flexible bronchoscopy in children. These results were significantly less in hospitals with a dedicated pediatric anesthesiologist. CONCLUSIONS This survey on airway management in pediatric anesthesia revealed that the use of cuffed tubes and the routine monitoring of cuff pressure are rare. In addition, the rate of videolaryngoscopy or flexible optical intubation was low for expected difficult intubation. Our survey highlights the need for properly trained pediatric anesthesiologists working in-line with updated scientific evidence.
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Affiliation(s)
- Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Marmara University Medical School, Istanbul Turkey
| | - Kemal T Saracoglu
- Department of Anesthesiology and Intensive Care, Kartal Dr. Lutfi Kirdar City Hospital, Health Sciences University, Istanbul Turkey -
| | - Massimiliano Sorbello
- Department of Anesthesiology and Intensive Care, AOU Policlinico San Marco, Catania, Italy
| | - Raghad Kurdi
- Department of Anesthesiology and Intensive Care, Marmara University Medical School, Istanbul Turkey
| | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital Inselspital, Bern, Switzerland
- School of Medicine, Sigmund Freud University, Vienna, Austria
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14
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Assefa B, Samuel H, Fentie F, Daniel T, Hika A, Aberra B, Alemu B. Effect of tracheal tube cuff inflation with alkalinized lidocaine versus air on hemodynamic responses during extubation and post-operative airway morbidities in children: prospective observational cohort study, Ethiopia. BMC Anesthesiol 2022; 22:337. [PMID: 36333687 PMCID: PMC9635071 DOI: 10.1186/s12871-022-01868-2] [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: 05/14/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background Endotracheal tube with an inflated cuff was used to manage and maintain the airway during general anesthesia in children. When the lateral pressure exerted by an inflated Endotracheal tube cuff on tracheal mucosa exceeds capillary perfusion pressure, patients may complain of cough, sore throat, and hoarseness in the postoperative period. This study aimed to assess the effect of a tracheal tube cuff filled with alkalinized lidocaine versus air on hemodynamic parameter changes during extubation and post-operative airway morbidity in children. Methods Institutional based observational prospective cohort study was conducted among 56 elective children; aged 3–13 years, who underwent operation under general anesthesia with cuffed endotracheal intubation for greater than one hour by grouping into the air (group1) and alkalinized Lidocaine (group2) at Tikur Anbessa specialized Hospital. Hemodynamic parameters (Heart rate and Blood pressure) and other variables were measured starting from 5 min before extubation to 24th hours after extubation of the endotracheal tube. A Comparison of numerical variables between study group was done with an independent t-test. Data were expressed in terms of mean ± standard deviation. Categorical data were assessed by Chi-square tests. Results Postoperative Sore throat was lower in alkalinized lidocaine group compared to the air group. The mean heart rate at five minutes after extubation was significantly lower in alkalinized lidocaine group (107.29 ± 6.457 beat per minute (bpm)) compared to the air group (122.04 ± 8.809 bpm), with P ≤ 0.001. Systolic blood pressure was also significantly lower in alkalinized lidocaine group (99.64 ± 8.434 millimeters of mercury (mmHg)) compared to the air group (108.21 ± 11.902 mmHg), p = 0.016 at five minutes after extubation. Conclusion Alkalinized lidocaine inflated tracheal tubes have shown improved hemodynamic and laryngotracheal morbidities in children.
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Affiliation(s)
- Biniam Assefa
- grid.7123.70000 0001 1250 5688Department of Anesthesia, College of Medicine and Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia ,Present Address: University Hospital, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
| | - Hirbo Samuel
- grid.7123.70000 0001 1250 5688Department of Anesthesia, College of Medicine and Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fissiha Fentie
- grid.7123.70000 0001 1250 5688Department of Anesthesia, College of Medicine and Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tenbite Daniel
- grid.7123.70000 0001 1250 5688Department of Anesthesia, College of Medicine and Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Hika
- grid.448640.a0000 0004 0514 3385Department of Anesthesia, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Bacha Aberra
- grid.448640.a0000 0004 0514 3385Department of Anesthesia, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Belete Alemu
- grid.192268.60000 0000 8953 2273Department of Anesthesia, College of Health Science, Hawassa University, Hawassa, Ethiopia
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15
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Park S, Shin SW, Kim HJ, Byeon GJ, Yoon JU, Kim EJ, Kim HY. Choice of the correct size of endotracheal tube in pediatric patients. Anesth Pain Med (Seoul) 2022; 17:352-360. [DOI: 10.17085/apm.22215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Selection and insertion of an endotracheal tube (ETT) of appropriate size for airway management during general anesthesia in pediatric patients is very important. A very small ETT increases the risk of inadequate ventilation, air leakage, and aspiration, whereas a very large ETT may cause serious complications including airway damage, post-intubation croup, and, in severe cases, subglottic stenosis. Although the pediatric larynx is conical, the narrowest part, the rima glottidis, is cylindrical in the anteroposterior dimension, regardless of development, and the cricoid ring is slightly elliptical. A cuffed ETT reduces the number of endotracheal intubation attempts, and if cuff pressure can be maintained within a safe range, the risk of airway damage may not be greater than that of an ETT without cuff. The age-based formula suggested by Cole (age/4 + 4) has long been used to select the appropriate ETT size in children. Because age-based formulas in children are not always accurate, various alternative methods for estimating the ETT size have been examined and suggested. Chest radiography, ultrasound, and a three-dimensional airway model can be used to determine the appropriate ETT size; however, there are several limitations.
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16
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Antalová N, Klučka J, Říhová M, Poláčková S, Pokorná A, Štourač P. Ventilator-Associated Pneumonia Prevention in Pediatric Patients: Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101540. [PMID: 36291475 PMCID: PMC9600673 DOI: 10.3390/children9101540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 01/24/2023]
Abstract
Ventilator-associated pneumonia (VAP), one of the most common healthcare-associated infections in intensive care settings, is associated with significant morbidity and mortality. VAP is diagnosed in >10% of patients on mechanical ventilation, incidence rising with number of ventilator days. In recent decades, the pathophysiology of VAP, VAP risk factors and treatment have been extensively studied. In critically ill pediatric patients, mechanical issues such as insufficient tightness of the ventilator circuit (mainly due to historically based preference of uncuffed tubes) and excessive humidity in the circuit are both significant risk factors of VAP development. Protocol-based approaches to critically ill patients on mechanical ventilation, closed suctioning, upper body position, enteral feeding and selective gastric acid suppression medication have a beneficial effect on VAP incidence. In recent decades, cuffed tubes applied to the whole spectrum of critically ill pediatric patients (except neonates <2700 g of weight), together with cuff-oriented nursing care including proper cuff-pressure (<20 cm H2O) management and the use of specialized tracheal tubes with subglottic suction ports combined with close infraglottic tracheal suctioning, have been implemented. The aim of this review was to summarize the current evidence-based knowledge about the pathophysiology, risk factors, diagnosis, treatment and prevention of VAP in clinically oriented settings.
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Affiliation(s)
- Natália Antalová
- Department of Pediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Public Health, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Pediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Correspondence: ; Tel.: +420-532-234-696
| | - Markéta Říhová
- Department of Pediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Silvie Poláčková
- Department of Pediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Andrea Pokorná
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Petr Štourač
- Department of Pediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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17
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Kim Y, Park JE, Kim JH. Plain Radiographic Analysis of Laryngeal Dimensions in Young Children: Normal versus Croup. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101532. [PMID: 36291468 PMCID: PMC9600057 DOI: 10.3390/children9101532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/16/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
Abstract
(1) Background: Contrary to a tenet of the funnel-shaped pediatric larynx with the cricoid level being narrowest, recent studies show the glottis and subglottis as the narrowest levels. To locate the functionally narrowest level of the larynx, we reported normal laryngeal dimensions and their croup-related changes in young children. (2) Methods: We reviewed normal plain neck radiographs recorded for the evaluation of minor trauma or foreign bodies in 504 children aged ≤4 years who visited the emergency department from 2016 through 2021. Using computed tomography-based localization of the glottis, we radiographically defined the subglottis and cricoid. At these levels, we measured diameters and calculated cross-sectional areas (CSAs) on the radiographs. The values were compared to the equivalent values of a 1:1 age-matched population with croup. (3) Results: In the study population (n = 401), the narrowest diameter and CSA were observed in the glottis. In detail, the mean anteroposterior/transverse diameters were 9.8/3.4 mm at the glottis, 8.5/5.6 mm at the subglottis, and 7.4/6.8 mm at the cricoid (p < 0.001), respectively. In the same order, the mean CSAs were 26.5, 38.1, and 40.5 mm2 (p < 0.001). All dimensions were narrower in the croup population (p < 0.001). We found croup-related narrowing, namely reductions in the transverse diameter and CSA that were more severe closer to the glottis (p < 0.001), without differences per level in the anteroposterior diameter. (4) Conclusions: This study confirms the glottis as the narrowest level of the larynx in young children. In addition, level-based differences in croup-related narrowing suggest some point between the glottis and subglottis as the functionally narrowest level.
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Affiliation(s)
- Youngdae Kim
- Departments of Emergency Medicine, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea
| | - Ji-Eun Park
- Departments of Radiology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea
| | - Jung-Heon Kim
- Departments of Emergency Medicine, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea
- Correspondence: ; Tel.: +82-31-219-7750
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18
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Naidoo S, Kusel BS, Gopalan PD. Upper airway obstruction and sepsis following endotracheal intubation in paediatric cardiac surgical patients in South Africa. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.5.2808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- S Naidoo
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - BS Kusel
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - PD Gopalan
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
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19
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Klabusayová E, Klučka J, Kratochvíl M, Musilová T, Vafek V, Skříšovská T, Djakow J, Kosinová M, Havránková P, Štourač P. Airway Management in Pediatric Patients: Cuff-Solved Problem? CHILDREN (BASEL, SWITZERLAND) 2022; 9:1490. [PMID: 36291426 PMCID: PMC9600438 DOI: 10.3390/children9101490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.
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Affiliation(s)
- Eva Klabusayová
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Milan Kratochvíl
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Tereza Musilová
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Václav Vafek
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Tamara Skříšovská
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 31 Hořovice, Czech Republic
| | - Martina Kosinová
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Pavla Havránková
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, The Donaustadt Clinic, Lango Bardenstraße 122, 1220 Vienna, Austria
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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20
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Duncan L, Correia M, Mogane P. A Survey of Paediatric Rapid Sequence Induction in a Department of Anaesthesia. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091416. [PMID: 36138726 PMCID: PMC9497683 DOI: 10.3390/children9091416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/04/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: Rapid sequence induction (RSI) is carried out by anaesthetists to secure the airway promptly in patients who are at risk of aspirating gastric content during induction of anaesthesia. RSI requires variation in the paediatric population. We conducted a survey to investigate current practice of paediatric RSI by anaesthetists. (2) Methods: A descriptive, contextual, cross-sectional research design was followed. The study population consisted of all anaesthetists working in the Department of Anaesthesia at the University of the Witwatersrand. Data was collected in the form of a self-administered questionnaire. (3) Results: Of 138 questionnaires that were distributed, 126 were completed. Clinical indication for RSI was predominantly for appendicitis with peritonitis (115/124; 92.7%). Preoxygenation was performed by 95.1% of anaesthetists for children, 87% for infants and 89.4% for neonates. Cricoid pressure was used significantly more in children (56%) than in infants (20.8%) and neonates (10.3%) (p < 0.001). Rocuronium was the paralytic agent of choice in children (42.7%) and infants (38.2%), while cisatracurium was used most frequently in neonates (37.4%). Suxamethonium was used least in neonates. Cuffed ETTs were used most frequently for children (99.2%) and least for neonates (49.6%). Eighty-five percent of anaesthetists omitted cricoid pressure during RSI for pyloromyotomy, for which a controlled RSI was performed more by consultants and senior registrars (p < 0.01). A classic RSI was performed by 53.6% of anaesthetists for laparotomy for small bowel obstruction. Consultants and PMOs were more likely to intubate a child for forearm MUA who was starved for 6 h and received opioids (p < 0.05). Controlled RSI with cisatracurium was the technique of choice for Tenkhoff insertion in a child with renal failure. (4) Conclusions: RSI practice for paediatric patients varied widely among anaesthetists. This may be attributed to a combination of anaesthetic experience, training in paediatric anaesthesia, and patient specific factors, along with the individualised clinical scenario’s aspiration risk. A controlled RSI technique appears to be implemented more frequently by anaesthetists with increased experience.
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Affiliation(s)
- Lloyd Duncan
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Correspondence:
| | - Michelle Correia
- Department of Anaesthesiology, Nelson Mandela Children’s Hospital, Johannesburg 2000, South Africa
| | - Palesa Mogane
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
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Thakkar K, Sethuraman M, Hrishi AP. Pediatric Microcuff Tube for Neurosurgical Procedures: A Boon or Bane? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1750092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractPediatric Microcuff endotracheal tubes have come into vogue in the last few years. It overcomes the problems faced with the uncuffed or conventional cuffed tubes used in the pediatric population. In addition, the more distal placement of the polyurethane cuffs in these tubes eliminates the risk of airway mucosal injury and hence postoperative stridor. This makes it an attractive option for neurosurgical patients where there is a high incidence of cranial nerve deficit, airway edema, and the requirement of prolonged postoperative ventilation. But due to this particular design, Murphy's eye is not incorporated in the tube, which can potentially hamper ventilation, especially when used for long duration surgery. With the help of our case report, we would like to warn the readers regarding this life-threatening complication that resulted in hypoxia in a 1-year-old child in the postoperative period.
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Affiliation(s)
- Keta Thakkar
- Department of Neuroanesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manikandan Sethuraman
- Division of Neuroanesthesia, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Ajay P. Hrishi
- Division of Neuroanesthesia, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences, Thiruvananthapuram, Kerala, India
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22
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Use of cuffed endotracheal tubes in infants less than 5 kilograms: A retrospective cohort study. J Pediatr Surg 2022; 57:375-381. [PMID: 33785203 DOI: 10.1016/j.jpedsurg.2021.02.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Improved understanding of airway anatomy and refinement of equipment have led to the increased use of cuffed endotracheal tubes (ETTs) in infants and children. Despite expanded evidence on the potential advantages of cuffed ETTs in pediatric patients, there remains limited data on their use in infants less than 5 kilograms (kg). The current study retrospectively evaluates the perioperative use of cuffed ETTs in infants weighing 2-5 kg. METHODS This is a retrospective study from a tertiary care children's hospital involving a 3-year period. Data regarding anesthetic care, airway management, and postoperative course were retrospectively retrieved from the electronic medical record. RESULTS The study cohort included 1162 patients, 1086 of whom had their tracheas intubated with a cuffed ETT and 76 with an uncuffed ETT. Patients were divided into two groups for analysis: 2 to <3 kg and 3 to 5 kg. In both weight groups, cuffed ETTs resulted in a decreased need for more than one laryngoscopy and a change in ETT size with no increase in postoperative airway effects including stridor. CONCLUSIONS These data provide additional information regarding the efficacy and safety of cuffed ETTs in neonates and infants.
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Abstract
BACKGROUND Endotracheal intubation is a commonly performed procedure in neonates, the risks of which are well-described. Some endotracheal tubes (ETT) are equipped with a cuff that can be inflated after insertion of the ETT in the airway to limit leak or aspiration. Cuffed ETTs have been shown in larger children and adults to reduce gas leak around the ETT, ETT exchange, accidental extubation, and exposure of healthcare workers to anesthetic gas during surgery. With improved understanding of neonatal airway anatomy and the widespread use of cuffed ETTs by anesthesiologists, the use of cuffed tubes is increasing in neonates. OBJECTIVES To assess the benefits and harms of cuffed ETTs (inflated or non-inflated) compared to uncuffed ETTs for respiratory support in neonates. SEARCH METHODS We searched CENTRAL, PubMed, and CINAHL on 20 August 2021; we also searched trial registers and checked reference lists to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs, and cluster-randomized trials comparing cuffed (inflated and non-inflated) versus uncuffed ETTs in newborns. We sought to compare 1. inflated, cuffed versus uncuffed ETT; 2. non-inflated, cuffed versus uncuffed ETT; and 3. inflated, cuffed versus non-inflated, cuffed ETT. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We identified one eligible RCT for inclusion that compared the use of cuffed (inflated if ETT leak greater than 20% with cuff pressure 20 cm H2O or less) versus uncuffed ETT. The author provided a spreadsheet with individual data. Among 76 infants in the original manuscript, 69 met the inclusion and exclusion criteria for this Cochrane Review. We found possible bias due to lack of blinding and other bias. We are very uncertain about frequency of postextubation stridor, because the confidence intervals (CI) of the risk ratio (RR) were very wide (RR 1.36, 95% CI 0.35 to 5.25; risk difference (RD) 0.03, -0.11 to 0.18; 1 study, 69 participants; very low-certainty evidence). No neonate was diagnosed with postextubation subglottic stenosis; however, endoscopy was not available to confirm the clinical diagnosis. We are very uncertain about reintubation for stridor or subglottic stenosis because the CIs of the RR were very wide (RR 0.27, 95% CI 0.01 to 6.49; RD -0.03, 95% CI -0.11 to 0.05; 1 study, 69 participants; very low-certainty evidence). No neonate had surgical intervention (e.g. endoscopic balloon dilation, cricoid split, tracheostomy) for stridor or subglottic stenosis (1 study, 69 participants). Neonates randomized to cuffed ETT may be less likely to have a reintubation for any reason (RR 0.06, 95% CI 0.01 to 0.45; RD -0.39, 95% CI -0.57 to -0.21; number needed to treat for an additional beneficial outcome 3, 95% CI 2 to 5; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about accidental extubation because the CIs of the RR were wide (RR 0.82, 95% CI 0.12 to 5.46; RD -0.01, 95% CI -0.12 to 0.10; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about all-cause mortality during initial hospitalization because the CIs of the RR were extremely wide (RR 2.46, 95% CI 0.10 to 58.39; RD 0.03, 95% CI -0.05 to 0.10; 1 study, 69 participants; very low-certainty evidence). There is one ongoing trial. We classified two studies as awaiting classification because outcome data were not reported separately for newborns and older infants. AUTHORS' CONCLUSIONS Evidence for comparing cuffed versus uncuffed ETTs in neonates is limited by a small number of babies in a single RCT with possible bias. There is very low certainty evidence for all outcomes of this review. CIs of the estimate for postextubation stridor were wide. No neonate had clinical evidence for subglottic stenosis; however, endoscopy results were not available to assess the anatomy. Additional RCTs are necessary to evaluate the benefits and harms of cuffed ETTs (inflated and non-inflated) in the neonatal population. These studies must include neonates and be conducted both for short-term use (in the setting of the operating room) and chronic use (in the setting of chronic lung disease) of cuffed ETTs.
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Affiliation(s)
- Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Luca Moresco
- Pediatric and Neonatology Unit, Ospedale San Paolo, Savona, Italy
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern at Dallas, Dallas, Texas, USA
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Somayaji S, Bharathi BM, Tulasi T, Sheriff NK, Bagliker J. Prediction of endotracheal tube size in pediatric population using ultrasonographic subglottic diameter and age-related formulas: A comparative study. Anesth Essays Res 2022; 16:1-6. [PMID: 36249135 PMCID: PMC9558668 DOI: 10.4103/aer.aer_11_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/06/2022] [Accepted: 04/15/2022] [Indexed: 11/04/2022] Open
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Collins PAW. A modified adjustable oral RAE microcuff ® endotracheal tube. Paediatr Anaesth 2022; 32:89-90. [PMID: 34757682 DOI: 10.1111/pan.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/01/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Peter A W Collins
- Faculty of Medicine, Discipline of Anesthesia, Memorial University, St. John's, NL, Canada
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27
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Bibl K, Pracher L, Küng E, Wagner M, Roesner I, Berger A, Hermon M, Werther T. Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis. Front Pediatr 2022; 10:864766. [PMID: 35633947 PMCID: PMC9130697 DOI: 10.3389/fped.2022.864766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Endotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis. METHODS In this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations. RESULTS A total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT. CONCLUSION In this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.
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Affiliation(s)
- Katharina Bibl
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lena Pracher
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Erik Küng
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Imme Roesner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Hermon
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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Strobel AM, Driver BE, Slusher T, Rowland-Fisher A, Reardon RF. Adjunct Devices for the Pediatric Difficult Airway: A Case Report. Ann Emerg Med 2021; 79:348-351. [PMID: 34952727 DOI: 10.1016/j.annemergmed.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Indexed: 01/27/2023]
Abstract
This is a case report of a pediatric patient with a difficult airway, in which several airway adjuncts were used simultaneously to successfully provide adequate oxygenation and ventilation during cardiac arrest. Difficult airways are low-incidence, high-risk emergencies in children, and airway adjuncts may be used infrequently, let alone in combination. Included in the discussion of this case are a description of each airway adjunct and a discussion of the process needed to incorporate airway adjuncts safely and effectively into patient care.
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Affiliation(s)
- Ashley M Strobel
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School Masonic Children's Hospital, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN.
| | - Brian E Driver
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Tina Slusher
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Andrea Rowland-Fisher
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Robert F Reardon
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
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Thomas RE, Erickson S, Hullett B, Minutillo C, Lethbridge M, Vijayasekaran S, Agrawal S, Bulsara MK, Rao SC. Comparison of the efficacy and safety of cuffed versus uncuffed endotracheal tubes for infants in the intensive care setting: a pilot, unblinded RCT. Arch Dis Child Fetal Neonatal Ed 2021; 106:614-620. [PMID: 33879529 DOI: 10.1136/archdischild-2020-320764] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/25/2021] [Accepted: 04/06/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To study effectiveness and safety of cuffed versus uncuffed endotracheal tubes (ETTs) in small infants in the intensive care unit (ICU). DESIGN Pilot RCT. SETTING Neonatal and paediatric ICUs of children's hospital in Western Australia. PARTICIPANTS Seventy-six infants ≥35 weeks gestation and infants <3 months of age, ≥3 kg. INTERVENTIONS Patients randomly assigned to Microcuff cuffed or Portex uncuffed ETT. MAIN OUTCOMES MEASURES Primary outcome was achievement of optimal ETT leak in target range (10%-20%). Secondary outcomes included: reintubations, ventilatory parameters, ventilatory complications, postextubation complications and long-term follow-up. RESULTS Success rate (achievement of mean leak in the range 10%-20%) was 13/42 (30.9%) in the cuffed ETT group and 6/34 (17.6%) in uncuffed ETT group (OR=2.09; 95% CI (0.71 to 6.08); p=0.28). Mean percentage time within target leak range in cuffed ETT group 28% (IQR: 9-42) versus 15% (IQR: 0-28) in uncuffed ETT group (p=0.01). There were less reintubations to optimise size in cuffed ETT group 0/40 versus 10/36 (p<0.001). No differences were found in gaseous exchange, ventilator parameters or postextubation complications. There were fewer episodes of atelectasis in cuffed ETT group 0/42 versus 4/34 (p=0.03). No patient had been diagnosed with subglottic stenosis at long-term follow-up. CONCLUSIONS There was no difference in the primary outcome, though percentage time spent in optimal leak range was significantly higher in cuffed ETT group. Cuffed ETTs reduced reintubations to optimise ETT size and episodes of atelectasis. Cuffed ETTs may be a feasible alternative to uncuffed ETTs in this group of patients. TRIAL REGISTRATION NUMBER ACTRN12615000081516.
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Affiliation(s)
- Rebecca E Thomas
- Department of Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Simon Erickson
- Department of Paediatric Critical Care, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Bruce Hullett
- Department of Anaesthetics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Corrado Minutillo
- Department of Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Martyn Lethbridge
- Department of Anaesthetics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Sachin Agrawal
- Department of Neonatology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Shripada C Rao
- Department of Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Wani TM, John J, Bahun V, AlGhamdi F, Tumin D, Tobias JD. Endotracheal tube cuff position in relation to the cricoid in children: A retrospective computed tomography-based analysis. Saudi J Anaesth 2021; 15:403-408. [PMID: 34658727 PMCID: PMC8477782 DOI: 10.4103/sja.sja_396_21] [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: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022] Open
Abstract
Background: The use of cuffed endotracheal tubes (ETT) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: In this retrospective study, the ETT cuff position was examined on the sagittal plane images of neck and chest CT scans of 44 children. The position of the proximal and the distal aspect of the ETT cuff inside the trachea was recorded in relation to the vertebral levels. The vertebral levels were used to estimate the location of the cricoid ring and its relationship to the cuff. Results: The vertebrae were used as the primary landmarks to define the position of the cricoid and its relationship to the cuff of the ETT. Correlating vertebral levels with the cricoid for different age groups, the proximal (cephalad) edge of the ETT cuff was below the cricoid in 41 of 44 patients (93%). The ETT cuff was deep in 6 patients, below the 1st thoracic vertebra, with 2 ETTs in the right mainstem bronchus. Conclusion: This is the first study demonstrating that the cuff of the ETT and its position in the trachea can be identified on CT imaging in children. The ETT cuff was below the level of the cricoid in the majority of patients irrespective of the patient's age as well as the size, make, and type of ETT.
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Affiliation(s)
- Tariq M Wani
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | - Jiju John
- Department of Anesthesiology, Sidra Medicine, Doha, Qatar
| | | | - Faris AlGhamdi
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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Peyton J, Foglia E, Lee GS. Pediatric Airway Anatomy and Tracheal Tubes: It Is Not All About the Cuff. Anesth Analg 2021; 133:891-893. [PMID: 34524987 DOI: 10.1213/ane.0000000000005705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- James Peyton
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Foglia
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gi Soo Lee
- Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
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Owusu-Bediako K, Turner H, Syed O, Tobias J. Options for Intraoperative Repair of a Cut Pilot Balloon on the Endotracheal Tube. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:265-269. [PMID: 34512044 PMCID: PMC8423496 DOI: 10.2147/mder.s323982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/20/2021] [Indexed: 12/27/2022] Open
Abstract
Severing of the pilot balloon of an endotracheal tube (ETT) results in cuff deflation and may lead to complications including inadequate patient ventilation, increased risk of aspiration and infection, and operating room air pollution with anesthetic gases. In situations where ETT exchange or reintubation may pose a significant risk to the patient, temporary repair of the severed cuff tubing can be helpful until it is safe to address the problem with replacing the ETT. Simple and effective repair methods can be achieved using readily available materials in the operating room, including intravenous cannulas, hypodermic syringes, and epidural clamp connectors. However, choosing which technique or method depends mainly on personal preference, equipment availability, and provider comfort and experience. We present a 12-year-old adolescent who presented for anesthetic care for extensive burn injury. During removal of the dressing around the head and face, the tubing of the pilot balloon of the ETT was inadvertently cut. Options for dealing with such problems are discussed, including techniques to allow for temporary repair and re-inflation of the deflated cuff.
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Affiliation(s)
- Kwaku Owusu-Bediako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Henry Turner
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Omar Syed
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Cobb MJ. Just Breathe: Tips and Highlights for Managing Pediatric Respiratory Distress and Failure. Emerg Med Clin North Am 2021; 39:493-508. [PMID: 34215399 DOI: 10.1016/j.emc.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.
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Affiliation(s)
- Megan J Cobb
- University of Maryland School of Medicine, Department of Emergency Medicine; Maryland Emergency Medicine Network, Upper Chesapeake Emergency Medicine, 500 Upper Chesapeake Dr, Bel Air, MD 21014, USA.
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Park S, Ahn J, Yoon SU, Choo KS, Kim HJ, Chung M, Kim HY. Prediction of endotracheal tube size using a printed three-dimensional airway model in pediatric patients with congenital heart disease: a prospective, single-center, single-group study. Korean J Anesthesiol 2021; 74:333-341. [PMID: 34053213 PMCID: PMC8342841 DOI: 10.4097/kja.21114] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/30/2021] [Indexed: 01/07/2023] Open
Abstract
Background To determine the correct size of endotracheal tubes (ETTs) for endotracheal intubation of pediatric patients, new methods have been investigated. Although the three-dimensional (3D) printing technology has been successful in the field of surgery, there are not many studies in the field of anesthesia. The purpose of this study was to evaluate the accuracy of a 3D airway model for prediction of the correct ETT size, and compare the results with a conventional age-based formula in pediatric patients. Methods Thirty-five pediatric patients under six years of age who were scheduled for congenital heart surgery were enrolled. In the pre-anesthetic period, the patient’s computed tomography (CT) images were converted to Standard Triangle Language (STL) files using the 3D conversion program. A Fused Deposition Modelling (FDM) type 3D printer was used to print 3D airway models from the sub-glottis to the upper carina. ETT size was selected by inserting various sized cuffed-ETTs to a printed 3D airway model. Results The 3D method selected the correct ETT size in 21 out of 35 pediatric patients (60%), whereas the age-based formula selected the correct ETT size in 9 patients (26%). Conclusions Prediction of the correct size of ETTs using a printed 3D airway model demonstrated better results than the age-based formula. This suggests that the selection of ETT size using a printed 3D airway model may be feasible for helping minimize re-intubation attempts and complications in patients with congenital heart disease and/or those with an abnormal range of growth and development.
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Affiliation(s)
- Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Jisoo Ahn
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Sung Uk Yoon
- Department of Biomedical Engineering, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Ki Seok Choo
- Departmentsof Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Minwoo Chung
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute, Yangsan, Korea
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Mertz S. [Ventilation in Pediatric Anesthesia]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:342-354. [PMID: 34038973 DOI: 10.1055/a-1189-8044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
About nine percent of all anesthesia procedures per year are performed in children. The risk for complications in pediatric anesthesia is higher in comparison with adults. There are significant differences in anatomy, physiology and pharmacology between pediatric and adult patients. Respiratory complications and circulations dysregulation occur more often in children. The most important consideration in the safe practice of pediatric anesthesia is to ensure a patent airway. Appropriate intraoperative management of newborns and infants needs a senior anesthetist with good knowledge and clinical experience including the management of possible complications.
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Propst EJ, Gorodensky JH, Wolter NE. Length of the Cricoid and Trachea in Children: Predicting Intubation Depth to Prevent Subglottic Stenosis. Laryngoscope 2021; 132 Suppl 2:S1-S10. [PMID: 33973659 DOI: 10.1002/lary.29616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Define the length of the subglottis and trachea in children to predict a safe intubation depth. METHODS Patients <18 years undergoing rigid bronchoscopy from 2013 to 2020 were included. The carina and inferior borders of the cricoid and true vocal folds were marked on a bronchoscope and distances were measured. Patient age, weight, height, and chest height were recorded. Four styles of cuffed pediatric endotracheal tubes (ETT) were measured and potential positions of each cuff and tip were calculated within each trachea using five depth of intubation scenarios. Multivariate linear regression was performed to identify predictors of subglottic and tracheal length. RESULTS Measurements were obtained from 210 children (141 male, 69 female), mean (SD) age 3.21 (3.66) years. Patient height was the best predictor of subglottic length (R2 : 0.418): Lengthsg (mm) = 0.058 * height (cm) + 2.8, and tracheal length (R2 : 0.733): Lengtht (mm) = 0.485 * height (cm) + 21.3. None of the depth of intubation scenarios maintained a cuff-free subglottis for all ETT styles investigated. A formula for depth of intubation: Lengthdi (mm) = 0.06 * height (cm) + 8.8 found that no ETT cuffs would be in the subglottis and all tips would be above the carina. CONCLUSION Current strategies for determining appropriate depth of intubation pose a high risk of subglottic ETT cuff placement. Placing the inferior border of the vocal cords 0.06 * height (cm) + 8.8 from the superior border of the inflated ETT cuff may prevent subglottic cuff placement and endobronchial intubation. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Evan Jon Propst
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonah Haskel Gorodensky
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Ernst Wolter
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Zander D, Grass B, Weiss M, Buehler PK, Schmitz A. Cuffed endotracheal tubes in neonates and infants of less than 3 kg body weight-A retrospective audit. Paediatr Anaesth 2021; 31:604-610. [PMID: 33615635 DOI: 10.1111/pan.14104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Large prospective clinical studies have shown that modern cuffed pediatric tracheal tubes can be used safely, even in children weighing ≥3 kg. There is a growing interest in their use in children weighing <3 kg so that they, too, can benefit from the potential advantages, particularly the high probability of these tubes fitting into and sealing the pediatric airway at the first intubation attempt. This study aimed to find a cut-off body weight for procedures requiring a cuffed tracheal tube to seal the airway in children weighing <3 kg and to evaluate the frequency and predictive factors for the requirement to place a cuffed instead of an uncuffed tracheal tube. METHODS This study was a retrospective analysis of 269 children weighing 2000-2999 g, primarily intubated by pediatric anesthetists. Frequency of intubation with uncuffed Sheridan tubes versus cuffed Microcuff® Pediatric Endotracheal Tube (PET) 3.0 mm ID was studied. Predictive variables were assessed by means of logistic regression analysis. The ROC curve for weight at intubation time and Youden index was calculated. RESULTS The 149 (55.4%) children were finally intubated with a cuffed tracheal tube. Logistic regression demonstrated that body weight at tracheal intubation and birth weight were the strongest predictors for the appropriateness of cuffed/uncuffed tracheal tubes. The threshold weight at tracheal intubation was 2700 g for a probability >50% of using a cuffed tracheal tube. CONCLUSION Half of the children weighing 2000-2999 g received a Microcuff® PET 3.0 mm ID, especially those with a body weight above 2700 g. Because of the anatomical dimensions in patients with a body weight of 2000-2999 g, cuffed tracheal tubes with smaller outer diameters may be required to better fit their airways.
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Affiliation(s)
- Désirée Zander
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Beate Grass
- Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland
| | - Philipp K Buehler
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland
| | - Achim Schmitz
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland
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Armstrong J, Jenner P, Poulose S, Moppett IK. The effect of saline versus air for cuff inflation on the incidence of high intra-cuff pressure in paediatric MicroCuff ® tracheal tubes: a randomised controlled trial. Anaesthesia 2021; 76:1504-1510. [PMID: 33891328 DOI: 10.1111/anae.15493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/27/2022]
Abstract
The use of cuffed tracheal tubes in paediatric anaesthesia is now common. The use of nitrous oxide in anaesthesia risks excessive tracheal tube cuff pressures, as nitrous oxide can diffuse into the cuff during the course of surgery. The aim of this single-centre, prospective, randomised controlled trial was to compare the effect of saline versus air for the inflation of tracheal tube cuffs on the incidence of excessive intra-operative cuff pressure in children undergoing balanced anaesthesia with nitrous oxide. Children (age ≤ 16 y) were randomly allocated to receive either saline (saline group) or air (air group) to inflate the cuff of their tracheal tube. The pressure in the tracheal tube cuff was measured during surgery and brought down to the initial inflation level if it breached a safe limit (25 cmH2 O). Post-extubation adverse respiratory events were noted. Data from 48 patients (24 in each group), aged 4 months to 16 y, were analysed. The requirement for reduction in intra-cuff pressure occurred in 1/24 patients in the saline group, compared with 16/24 patients in the air group (p < 0.001). The incidence of extubation-related adverse events was similar in the saline and air groups (15/24 vs. 13/24, respectively; p = 0.770). The use of saline to inflate the cuff of paediatric cuffed tubes reduces the incidence of high intra-cuff pressures during anaesthesia. This may provide a pragmatic extra safety barrier to help reduce the incidence of excessive tracheal cuff pressure when nitrous oxide is used during paediatric anaesthesia.
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Affiliation(s)
- J Armstrong
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - P Jenner
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Poulose
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - I K Moppett
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Clinical Neurosciences, University of Nottingham, UK
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Oda W, Hanamoto H, Oyamaguchi A, Togawa E, Honjyo Y, Usami N, Niwa H. Clinical Use of Preformed Microcuff® Pediatric Endotracheal Tubes in Japan. Anesth Prog 2021; 68:45-46. [PMID: 33827117 DOI: 10.2344/anpr-67-04-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/26/2019] [Indexed: 11/11/2022] Open
Abstract
Preformed cuffed oral endotracheal tubes are widely used to intubate children undergoing oral surgery. To evaluate the efficacy and safety of oral Ring-Adair-Elwyn (RAE) Microcuff® pediatric endotracheal tubes, we retrospectively investigated the endotracheal tube exchange rate and associated complications in Japanese children younger than 2 years of age undergoing cheiloplasty or palatoplasty. The exchange rate was 3.5%, and although unplanned extubations occurred in 2 patients, no severe complications were observed. Our results suggest that oral RAE Microcuff® tubes are effective and safe for intubating Japanese children younger than 2 years of age, with a low tube exchange rate and minor complications.
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Affiliation(s)
- Wakana Oda
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Hiroshi Hanamoto
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Aiko Oyamaguchi
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Eriko Togawa
- Department of Anesthesiology, Shiga General Hospital, Moriyama, Japan
| | - Yuka Honjyo
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Nayuka Usami
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Hitoshi Niwa
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, Suita, Japan
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Tolosa Pérez H, Gómez Santamaría S, Quintana Puerta L, Bedoya López MA, Echeverri Restrepo N, Gallo Parra A, Redondo Morales LM, Urrego C, Jaramillo JR, Franco Roldán C, Hugo Arias J, Socha NI. Incidence of post-anesthetic respiratory complications in pediatrics. Observational, single-center study in Medellin, Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Post-anesthetic complications, particularly respiratory complications, continue to be a source of concern due to their high frequency, particularly in pediatrics.
Objective: To describe the incidence of respiratory complications in the post-anesthesia care unit of an intermediate complexity center during a six-month period, and to explore the variables associated with major respiratory complications.
Materials and Methods: Retrospective cohort study based on clinical record reviews. The records of the post-anesthesia care unit of an intermediate complexity pediatric institution located in Medellin, Colombia, were reviewed. This center uses a nursing-based care model that includes patient extubation in the post-anesthesia care unit.
Results: The records of 1181 patients were analyzed. The cumulative incidences of major complications were bronchospasm 1.44%, laryngospasm 0.68% and respiratory depression 0.59%. There were no cases of cardiac arrest or acute pulmonary edema. A history of respiratory infection less than 15 days before the procedure, rhinitis and female sex were associated with major respiratory complications.
Conclusions: A low frequency of respiratory complications was found during care provided by nursing staff trained in anesthesia recovery and pediatric airway in the post-anesthesia care unit.
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Hanamoto H, Nakagawa H, Niwa H. Frequency of the requirement of inappropriate uncuffed tracheal tube size for pediatric patients: a retrospective observational analysis. BMC Anesthesiol 2021; 21:34. [PMID: 33535969 PMCID: PMC7856756 DOI: 10.1186/s12871-021-01258-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The insertion of inappropriately sized uncuffed endotracheal tubes (ETTs) with a tight seal or presence of air leakage may be necessary in children. This study aimed to analyze the frequency of the requirement of inappropriately sized uncuffed ETT insertion, air leakage after the ETT was replaced with one of a larger size, and factors associated with air leakage after ETT replacement. METHODS Patients under 2 years of age who underwent oral surgery under general anesthesia with uncuffed ETTs between December 2013 and May 2015 were enrolled. The ETT size was selected at the discretion of the attending anesthesiologists. A leak test was performed after intubation. The ETT was replaced when considered necessary. Data regarding the leak pressure (PLeak) and inspiratory and expiratory tidal volumes were extracted from anesthesia records. We considered a PLeak of 10 < PLeak ≤ 30 cmH2O to be appropriate. The frequencies of the requirement of inappropriately sized ETTs, absence of leakage after ETT replacement, ETT size difference, and leak rate were calculated. A logistic regression was performed, with PLeak, leak rate, and size difference included as explanatory variables and presence of leakage after replacement as the outcome variable. RESULTS Out of the 156 patients enrolled, 109 underwent ETT replacement, with the requirement of inappropriately sized ETTs being observed in 25 patients (23%). ETT replacement was performed in patients with PLeak ≤ 10 cmH2O; leakage was absent after replacement (PLeak < 30 cmH2O) in 52% of patients (25/48). In the multivariate logistic model, the leak rate before ETT replacement was significantly associated with the presence of leakage after replacement (p = 0.021). CONCLUSIONS Inappropriately sized ETTs were inserted in approximately 23% of the patients. The leak rate may be useful to guide ETT replacement.
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Affiliation(s)
- Hiroshi Hanamoto
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871, Japan.
| | - Hikaru Nakagawa
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871, Japan
| | - Hitoshi Niwa
- Department of Dental Anesthesiology, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871, Japan
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Lambercy K, Pincet L, Sandu K. Intubation Related Laryngeal Injuries in Pediatric Population. Front Pediatr 2021; 9:594832. [PMID: 33643969 PMCID: PMC7902727 DOI: 10.3389/fped.2021.594832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Laryngeal intubation related lesions (LIRL) in pediatric patients cause extreme morbidity in both elective and emergency settings. It has a wide range of presentations from minor laryngeal edema to a life-threatening airway obstruction. We report here our units' experience with LIRL in neonates, infants, and small children. Material and Methods: This is a retrospective monocentric cohort study between January 2013 and April 2019. Results: Thirty-nine patients with intubation lesions were included in the study. We looked at the lesions type, characteristics, management, and outcome. Half the patients were premature and having comorbidities. Main LIRL were subglottic stenosis (31%), ulcers (26%), granulations (18%), retention cysts (18%), posterior glottic stenosis (13%), and vocal cords edema (5%). Unfavorable lesions causing airway stenosis were associated with an intubation duration of over 1 week and were an important factor in causing airway stenosis (p < 0.05). The endoscopic treatment performed for these lesions was lesion and anatomical site-specific. Tracheostomy was needed in five patients, and was avoided in another two. Seven patients (18%) received open surgery prior to their decannulation. Conclusions: LIRL management is challenging and stressful in the pediatric population and optimal treatment could avoid extreme morbidity in them. Intubation duration and associated comorbidities are important factors in deciding the severity of these lesions. Protocols to prevent the formation of these lesions are critical.
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Affiliation(s)
- Karma Lambercy
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Laurence Pincet
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Kishore Sandu
- Head and Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Moderne Narkosekonzepte in der Kinderanästhesie. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rodrigues JPBB, Bacci SLLDS, Pereira JM, Johnston C, Azevedo VMGDO. Frequency and characterization of the use of cuffed tracheal tubes in neonatal and pediatric intensive care units in Brazil. Rev Bras Ter Intensiva 2020; 32:235-243. [PMID: 32667452 PMCID: PMC7405737 DOI: 10.5935/0103-507x.20200038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/26/2019] [Indexed: 01/23/2023] Open
Abstract
Objective To identify the neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil that use cuffed tracheal tubes in clinical practice and to describe the characteristics related to the use of protocols and monitoring. Methods To identify the intensive care units in Brazil, the Ministry of Health’s National Registry of Health Facilities was accessed, and information was collected on 693 registered intensive care units. This was an analytical cross-sectional survey conducted through electronic questionnaires sent to 298 neonatal, pediatric and mixed intensive care units in Brazil. Results This study analyzed 146 questionnaires (49.3% from neonatal intensive care units, 35.6% from pediatric intensive care units and 15.1% from mixed pediatric intensive care units). Most of the participating units (78/146) used cuffed tracheal tubes, with a predominance of use in pediatric intensive care units (52/78). Most of the units that used cuffed tracheal tubes applied a cuff pressure monitoring protocol (45/78). The use of cuff monitoring protocols was observed in intensive care units with a physical therapy service exclusive to the unit (38/61) and in those with a physical therapist present 24 hours/day (25/45). The most frequent cause of extubation failure related to the use of cuffed tracheal tubes in pediatric intensive care units was upper airway obstruction. Conclusion In this survey, the use of cuffed tracheal tubes and the application of a cuff pressure monitoring protocol was predominant in pediatric intensive care units. The use of a monitoring protocol was more common in intensive care units that had a physical therapist who was exclusive to the unit and was present 24 hours/day.
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Affiliation(s)
- João Paulo Berti Buzzi Rodrigues
- Programa de Residência em Área Profissional da Saúde (Uni e Multiprofissional), Faculdade de Medicina, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - Suzi Laine Longo Dos Santos Bacci
- Programa de Residência em Área Profissional da Saúde (Uni e Multiprofissional), Faculdade de Medicina, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - Janser Moura Pereira
- Faculdade de Matemática, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | - Cíntia Johnston
- Departamento de Pediatria, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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The distance between the glottis and the cuff of a tracheal tube placed through three supraglottic airway devices in children: A randomised controlled trial. Eur J Anaesthesiol 2020; 36:721-727. [PMID: 31415305 DOI: 10.1097/eja.0000000000001070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND After tracheal tube insertion via various types of supraglottic airway devices, the distance from the tube cuff to the vocal cords has not been evaluated in children. OBJECTIVES The aim of this study was to evaluate the position of a tracheal tube cuff relative to the glottis in children when one of three supraglottic airway devices (I-gel, AuraGain and air-Q laryngeal airway) are used as intubation conduits. DESIGN A randomised controlled trial. SETTING Tertiary children's hospital. PATIENTS Children aged less than 7 years. INTERVENTION In vivo fibre-optic assessment and in vitro measurement. MAIN OUTCOME MEASURES The main outcome was the safety margin: the distance between the ventilation outlet of the supraglottic airway device and the beginning of the proximal cuff minus that from the ventilation outlet to the glottis. The maximum inner diameter of the cuffed tracheal tube that could be inserted, the fibre-optic view score and the oropharyngeal leak pressure were also evaluated. RESULTS The three devices exhibited significant differences in the distance from the ventilation outlet to the glottis (mean ± SD): I-gel 3.6 ± 0.6 cm, AuraGain 3.8 ± 0.7 cm, air-Q 2.8 ± 1.0 cm (P < 0.001). The safety margin was greatest with the air-Q and narrowest with the I-gel: I gel 1.9 ± 1.1 cm, AuraGain 4.4 ± 0.7 cm and air-Q 7.9 ± 1.1 cm. Using the AuraGain and air-Q, the cuffs of the tracheal tubes were predicted to be located below the glottis with one-size and two-size smaller tracheal tubes in all patients. However, using I-gel, the cuffs would be below the glottis in 69% (95% CI 49.6 to 84.5) and 29% (95% CI 14.0 to 48.4) of the patients with a one-size and two-size smaller tube, respectively. CONCLUSION The AuraGain and air-Q are well tolerated intubating conduits. The possibility of vocal cord damage is higher when the I-gel is used. TRIAL REGISTRATION www.clinicaltrials.gov (number: NCT03156166).
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Manimalethu R, Krishna S, Shafy SZ, Hakim M, Tobias JD. Choosing endotracheal tube size in children: Which formula is best? Int J Pediatr Otorhinolaryngol 2020; 134:110016. [PMID: 32247219 DOI: 10.1016/j.ijporl.2020.110016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Various formulae have been suggested to calculate the appropriate sized endotracheal tube in children. The current study prospectively compares three commonly used formulae for selection of cuffed endotracheal tubes in children. METHODS Patients were randomized to one of three formulae (Duracher, Cole, or Khine) to determine the size of the cuffed endotracheal tube for endotracheal intubation. The fit of the tube was noted and intracuff pressure was measured using a manometer. The postoperative incidence of stridor, throat pain/soreness, and hoarseness was noted in the post-anesthesia care unit at 2, 4 and 24 h after the procedure. RESULTS The study cohort included 135 patients less than or equal to 8 years, equally divided into three groups based on age, weight, and gender. There was no difference in the intracuff pressure, the volume required to seal the airway, or the number of times in which the intracuff pressure was greater than or equal to 20 or 30 cm H2O among the three groups. Six tube changes were required in the Cole group while no tube changes were required in the Duracher group (p < 0.05). The postoperative incidence of adverse events (throat pain, hoarseness, and stridor) at 0-2 h, 2-4 h, and 24 h was higher in the Cole group when compared to the Duracher group. CONCLUSION When using an endotracheal tube with a polyurethane cuff, the Duracher formula provided the best estimate for choosing the correct size.
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Affiliation(s)
- Ria Manimalethu
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Senthil Krishna
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Shabana Z Shafy
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Mohammed Hakim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Yhim HB, Yoon SH, Jang YE, Lee JH, Kim EH, Kim JT, Kim HS. Effects of benzydamine hydrochloride on postoperative sore throat after extubation in children: a randomized controlled trial. BMC Anesthesiol 2020; 20:77. [PMID: 32247315 PMCID: PMC7126164 DOI: 10.1186/s12871-020-00995-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/30/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative sore throat (POST) is a common, undesirable result of endotracheal intubation during general anaesthesia. This study aimed to evaluate the effectiveness of benzydamine hydrochloride (BH) spray in reducing the incidence of POST in paediatric patients. METHODS This randomized, double-blind, prospective study included 142 children 6-12 years of age, who were randomly assigned to receive either BH spray or control. After induction of anaesthesia, direct laryngoscope was placed and BH spray was applied to the upper trachea and vocal cord in the BH group and intubation was performed using a cuffed tube lubricated with normal saline. Intubation in the control group was performed using a cuffed tube lubricated with normal saline without any intervention. The balloon was inflated to a pressure of 20 cmH2O. Patients were extubated after fully awakened and transferred to the post-anaesthetic care unit (PACU), where they were examined for the presence of POST and any adverse events 30 min after arrival to the PACU. Postoperative pain was evaluated using a smartphone application. RESULTS Seventy-one patients were allocated to each group. The incidence of POST in the BH group did not differ from that in the control group (control: BH = 35 (49.3%): 42 (59.2%); P = 0.238); postoperative pain was also similar between the groups. Other complications, such as breath holding, secretions, coughing, laryngospasm and desaturation events, did not differ between the groups. CONCLUSIONS Application of prophylactic BH spray to the vocal cords and upper trachea was not proven to reduce POST in paediatric patients. TRIAL REGISTRY NCT03074968 (ClinicalTrials.gov, Feb 26, 2017).
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Affiliation(s)
- Hyung-Been Yhim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
| | - Soo-Hyuk Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, #101 Daehakno, Jongnogu, Seoul, 03080, Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea.
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Fischer M, Grass B, Kemper M, Weiss M, Dave MH. Cuffed pediatric endotracheal tubes-Outer cuff diameters compared to age-related airway dimensions. Paediatr Anaesth 2020; 30:424-434. [PMID: 31785036 DOI: 10.1111/pan.13776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/15/2019] [Accepted: 11/26/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Reliable sealing of the pediatric airway requires appropriately sized tracheal tube cuffs. The aim of this study was to compare residual cuff diameters of pediatric tracheal tubes with pediatric airway dimensions. METHODS Cuff diameters of five different brands of locally marketed pediatric cuffed tracheal tubes with internal diameters of 3.0-7.0 mm were measured at a cuff pressure of 20 cm H2 O and compared with cuff diameters indicated by their manufacturers. The latter values were compared to tracheal dimensions using the Motoyama and Khine formulas for cuffed tracheal tube size selection. RESULTS There is considerable heterogeneity in cuff diameters among pediatric tracheal tube brands, except for two brands from different manufacturers (Halyard and Parker Medical) which were identically designed. Cuffs made from polyurethane revealed fewer differences (91%-118%) between measured and manufacturer-indicated values for outer cuff diameters than did those made from polyvinylchloride (91%-146%). Particularly in smaller sized tracheal tubes, cuffs did not reach 100% of the tracheal lateral diameter, while others were oversized in larger tracheal tubes, independent of the two formulas used for cuffed tracheal tube size selection. Cuff diameters indicated by the manufacturer corresponded to 86%-188% of the median and 68%-157% of the maximum mid-tracheal lateral diameter of the corresponding upper age range. CONCLUSION Our findings show that many of the cuff diameters of currently marketed tracheal tube brands lack an age-related anatomical rationale. A proposal for age-related anatomically based cuff diameters is provided for both recommendations for cuffed tracheal tube size selection in children.
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Affiliation(s)
- Martina Fischer
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Beate Grass
- Department of Intensive Care and Neonatology, University Children's Hospital, Zürich, Switzerland
| | - Michael Kemper
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Markus Weiss
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Mital H Dave
- Department of Anaesthesia and Children's Research Center, University Children's Hospital, Zürich, Switzerland
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