Magnitude, associated factors of difficult airway, and predictive value of airway examinations among maxillofacial surgery patients at public hospitals in Southern Ethiopia: a multicentre cross-sectional study

Background

"Difficult airway" is the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, laryngoscopy, and difficulty with tracheal intubation, or both. Associated factors and predictive value difficult airways, maxillofacial surgery study setup is under studied.

Objective

To determine the magnitude and associated factors of difficult airways and predictive value of airway examinations among adult patients who underwent maxillofacial surgery at public hospitals in Southern Ethiopia 2022.

Methods and materials

An institutional-based multicenter cross-sectional study was conducted among 250 maxillofacial patients from March to 30 June 2022 at selected hospitals. The data were entered into Epi_Data software version 4.3 and analyzed by STATA software version 14. All variables that were statistically significant in bivariate analysis, at the P less than 0.25, were included in the multivariate logistic regression analysis. The predictive value or the effectiveness of airway examinations in predicting difficult airways was analyzed by receiver operating curve.

Results

In the current study, the magnitude of difficult airways was 21.2% (95% CI = 16.3-26.1%) and the magnitude of difficult intubation, difficult laryngoscopy, and difficult mask ventilation was 6.4% (95% CI 3.3-9.4%), 9.6% (95% CI 6.1-13%), and 13.6% (95% CI (9.1-16.8%), respectively. History of head and neck surgery adjusted odds ratio (AOR)=6.3, 95% CI (2.85-14.34), cervical collar AOR=4.9, 95% CI (1.96-12.49), and cervical spine injury AOR=2.4, 95% CI (1.07-5.38) were independently and significantly associated with difficulty of airway. Modified Mallampati class and sternomental distance were identified as good preoperative tests to predict difficult laryngoscopy, intubation, and mask ventilation.

Conclusion and recommendation

The magnitude of difficult airways was maxillofacial surgery. Among various airway assessment tests, no single test was perfectly accurate. Anaesthesia professionals are recommended to use a combination of preoperative airway assessments.

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024.

STUDY SELECTION

We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945).

DATA SYNTHESIS

We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL.

CONCLUSIONS

In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

Assessment of predictive value of thyromental height in predicting difficult laryngoscopy compared with Mallampati, and thyromental distance among surgical patient who will take general anesthesia at selected governmental hospital cross-sectional study: Ethiopia, 2022

Background

Anesthesiologists must always perform a preoperative airway examination to identify individuals who will have challenging laryngoscopy. In an effort to identify the most accurate airway predictor, numerous authors have evaluated a number of predictive assays. Thyromental height test (TMHT), a new airway predictor, has recently been demonstrated to have good predictive value in determining difficult airways. This study's main objective was to assess the diagnostic effectiveness of the TMHT and compare it to other known airway predictors, such as the modified Mallampati test (MMT) and the thyromental distance (TMD).

Objective

To assess the predictive value of TMHT in predicting difficult laryngoscopy compared to modified MMT and TMD among patients who will take general anesthesia.

Method

In this prospective, observational study, which took place from March 2021 to May 2021, 247 people of either sex who were older than 18 but not more than 65 and scheduled for elective surgery under general anesthesia participated. The receiver operating characteristic (ROC) curve was used to identify the proper cut-off values for TMHT, and the Fisher exact test was used to calculate the correlation.

Result

Incidence of Difficult laryngoscopy was 13.4%. For TMHT the cut-off values were 4.9 cm and it had a sensitivity of 78.8%, a specificity of 89.7%, a positive predictive value (PPV) of 54.2%, and a negative predictive value (NPV) of 96.5%, respectively. When compared to other parameters, like TMD, and MMT. TMHT had the highest sensitivity, specificity, PPV, and NPV. (P<0.000).

Conclusion and recommendation

Of all the airway assessments, the TMHT had the highest accuracy and odds ratio for predicting difficult laryngoscopy with the highest odds ratio and accuracy. TMHT has to be validated in broader patient groups because it appears to be a possible single anatomical marker for predicting the likelihood of a difficult laryngoscopy. It needs more research because it isn't assessed in pediatrics and pregnant women.

Effect of self-directed versus traditional learning model on nurses' airway management competencies and patients' airway-related incidents

INTRODUCTION

Self-directed learning (SDL) stands as a contemporary approach to learning, offering efficient and sustainable strategies for enhancing knowledge and practices. Given the pivotal role of nurses in ensuring patient safety and care effectiveness, this study aims to assess the impact of the SDL model compared to the traditional learning model (TLM) on elevating nurses' airway management (AM) competencies and minimizing airway-related incidents.

METHODOLOGY

The study employed an experimental research design using a posttest-only control group structure within a two-group comparison framework. Seventy-two nurses participated, with 35 in the study group and 37 in the control group at the Obstetrics and Gynecology Hospital affiliated with Cairo University, Egypt. The trial was carried out between February 2020 and July 2021. Following an assessment of SDL readiness for the intervention group, they received SDL model training based on Knowles' SDL principles, while the control group received TLM. The primary endpoint was a significant elevation in nurses' airway management competency, with the secondary outcome being a significant decrease in airway-related incidents reported by nurses. Competency assessments occurred immediately after completion of the intervention and again three months later.

RESULTS

A statistically significant difference was observed between the control and intervention groups regarding their practice and knowledge scores, with p-values of 0.02 and < 0.01, respectively. Additionally, the clinically relevant difference between control and intervention groups was evidenced by the effect size (ES) Cohen's d in both practices and knowledge levels (-0.56 and - 1.55, respectively). A significant difference was also noted between the first post-assessment and the paired second post-assessment concerning nurses' knowledge and practices among control and intervention groups, as indicated by the paired t-test with p < .01. Over three months, the intervention group reported 18 airway incidents, while the control group reported 24, with no statistically significant difference (> 0.05).

CONCLUSION

The SDL model significantly enhanced nurses' competencies in AM compared to the TLM. However, the efficacy of both learning models diminishes over time. Although nurses who underwent SDL model reported fewer airway incidents compared to those who received TLM approach of learning, no statistically significant difference was detected.

TRIAL REGISTRATION

The study has been registered with Clinical Trials.gov under the registration number (NCT04244565) on 28/01/2020.

Front of neck airway in Finnish helicopter emergency medical services

INTRODUCTION

An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS).

MATERIALS AND METHODS

This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed.

RESULTS

A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1).

CONCLUSION

The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.

Evaluation of neck ultrasound measurements as a difficult airway predictor: A prospective observational study

This study aimed to investigate the relationship between cervical measurements and difficult airways using ultrasonographic measurements. American Society of Anesthesiologists grade I to III, male or female, 120 adult patients, undergoing elective surgery were enrolled in the study. The study involved measuring the distance of the trachea, cricoid cartilage, thyroid cartilage, vocal cord anterior commissure, and hyoid bone to the skin using a 10 to 13 MHz linear ultrasound probe in the transverse plane. Additionally, the length of the cricothyroid and thyrohyoid membranes, along with their distance from the skin, were measured using the probe in the sagittal plane. Subsequently, another experienced anesthesiologist conducted mask ventilation and intubation after the patient's induction of general anesthesia. Throughout this process, the patient was assessed for difficulties in mask ventilation, laryngoscopy, and intubation. 28 (23.3%) patients had a difficult airway. Analyzing the measurements associated with difficult airways, the most reliable predictor was the epiglottis midline-skin distance [AUC (area under the curve): 0.847, P < .001, cutoff: >19.9, sensitivity: 78.6%, specificity: 79.4%]. Additionally, other factors such as hyoid bone to skin distance, thyroid cartilage to skin distance, thyrohyoid membrane to skin distance, and vocal cord anterior commissure-skin distance were also identified as predictors for a difficult airway. The increase in the distance of the epiglottis midline, vocal cord anterior commissure, hyoid bone, thyrohyoid membrane, and thyroid cartilage to the skin at the level of the isthmus measured by ultrasonography is predictive of difficult airways. Based on our study outcomes, we assert that ultrasonographic evaluation can be used in the prediction of difficult airways.

Impact of Radiotherapy on Endotracheal Intubation Quality Metrics in Patients with Esophageal Cancer: A Challenge for Advanced Airway Management?

(1) Background: Currently, no data are available in the literature investigating the influence of radiotherapy (RT) on endotracheal intubation success in patients with esophageal cancer. This study aims to evaluate the impact of RT on endotracheal intubation quality metrics in patients with esophageal cancer. (2) Methods: Patients with esophageal cancer who underwent RT followed by surgery between 2012 and 2023 at the University Hospital Heidelberg, Germany, were retrospectively analyzed. (3) Results: Fifty-five patients, predominantly males 65.5% with a mean age of 64 years, were enrolled. Overall, 81.8% of the patients had an ASA class of III, followed by 27.2% ASA II. The mean prescribed cumulative total dose to the primary tumor and lymph node metastasis was 48.2 Gy with a mean single dose of 1.8 Gy. The mean laryngeal total dose was 40.0 Gy. Direct laryngoscopy was performed in 80.0% of cases, followed by 12.1% videolaryngoscopy, and 7.2% required fiberoptic intubation. Overall, 96.4% of patients were successfully intubated on the first attempt. (4) Conclusions: It has been demonstrated that post-RT effects can increase the risk of airway management difficulties and complications. The results of our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer who had undergone RT.

Difficult Airway Assessment Based on Multi-View Metric Learning

The preoperative assessment of difficult airways is of great significance in the practice of anesthesia intubation. In recent years, although a large number of difficult airway recognition algorithms have been investigated, defects such as low recognition accuracy and poor recognition reliability still exist. In this paper, we propose a Dual-Path Multi-View Fusion Network (DMF-Net) based on multi-view metric learning, which aims to predict difficult airways through multi-view facial images of patients. DMF-Net adopts a dual-path structure to extract features by grouping the frontal and lateral images of the patients. Meanwhile, a Multi-Scale Feature Fusion Module and a Hybrid Co-Attention Module are designed to improve the feature representation ability of the model. Consistency loss and complementarity loss are utilized fully for the complementarity and consistency of information between multi-view data. Combined with Focal Loss, information bias is effectively avoided. Experimental validation illustrates the effectiveness of the proposed method, with the accuracy, specificity, sensitivity, and F1 score reaching 77.92%, 75.62%, 82.50%, and 71.35%, respectively. Compared with methods such as clinical bedside screening tests and existing artificial intelligence-based methods, our method is more accurate and reliable and can provide a reliable auxiliary tool for clinical healthcare personnel to effectively improve the accuracy and reliability of preoperative difficult airway assessments. The proposed network can help to identify and assess the risk of difficult airways in patients before surgery and reduce the incidence of postoperative complications.

Enhancing Laryngoscopy Mastery: The Impact of Autonomous Practice with Feedback-Providing Simulators

Mastery learning with fixed end points and variable training time leads to more consistent expertise but is difficult to implement. Here we piloted mastery learning of laryngoscopy with independent practice. 35 learners participated in independent mastery learning on a manikin that provides automated performance feedback. A pre- and postpractice assessment of intubation skills was completed. After an average of 21 minutes of open practice, the percentage of subjects that met mastery criteria improved from 24% to 89% (P < .05). Independent intubation practice with manikin feedback facilitated mastery learning, enhanced procedural education, and may impact clinical care.

Clinical evaluation of laryngeal mask airways in video-assisted thoracic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS).

METHODS

The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results.

RESULTS

Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001).

CONCLUSION

Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future.

The effect of a dedicated intensivist staffing to a medical emergency team on airway management in general wards

Although medical emergency teams (METs) have been widely introduced, studies on the importance of a dedicated intensivist staffing to METs are lacking. A single-center retrospective before-and-after study was performed. Deteriorating patients who required emergency airway management in general wards by MET were included in this study. We divided the study period according to the presence of a dedicated intensivist staff in MET: (1) non-staffed period (from January 2016 to February 2018, n = 971) and (2) staffed period (from March 2018 to December 2019, n = 651), and compared emergency airway management-related variables and outcomes between the periods. Among 1622 patients included, mean age was 63.0 years and male patients were 64.2% (n = 1042). The first-pass success rate was significantly increased in the staffed period (85.9% in the non-staffed vs 89.2% in the staffed; P = .047). Compliance to rapid sequence intubation was increased (9.4% vs 34.4%; P < .001) and vocal cords were more clearly open (P < .001) in the staffed period. The SpO2/FiO2 ratio (median [interquartile range], 125 [113-218] vs 136 [116-234]; P = .007) and the ROX index (4.6 [3.4-7.6] vs 5.1 [3.6-8.5]; P = .013) at the time of intubation was higher in the staffed period, suggesting the decision on intubation was made earlier. The post-intubation hypoxemia was less commonly occurred in the staffed period (7.2% vs 4.2%, P = .018). In multivariate analysis, the rank of operator was a strong predictor of the first-pass success (adjusted OR [95% CI], 2.280 [1.639-3.172]; P < .001 for fellow and 5.066 [1.740-14.747]; P < .001 for staff, relative to resident). In our hospital, a dedicated intensivist staffing to MET was associated with improved emergency airway management in general wards. Staffing an intensivist to MET needs to be encouraged to improve the performance of MET and the patient safety.

Comparison of Macintosh Laryngoscope, King Vision®, VividTrac®, AirAngel Blade®, and a Custom-Made 3D-Printed Video Laryngoscope for Difficult and Normal Airways in Mannequins by Novices-A Non-Inferiority Trial

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended.

Glottis Recognition Software Development Using Artificial Intelligence

The use of video laryngoscopes has enhanced the visualization of the vocal cords, thereby improving the accessibility of tracheal intubation. Employing artificial intelligence (AI) to recognize images obtained through video laryngoscopy, particularly when marking the epiglottis and vocal cords, may elucidate anatomical structures and enhance anatomical comprehension of anatomy. This study investigates the ability of an AI model to accurately identify the glottis in video laryngoscope images captured from a manikin. Tracheal intubation was conducted on a manikin using a bronchoscope with recording capabilities, and image data of the glottis was gathered for creating an AI model. Data preprocessing and annotation of the vocal cords, epiglottis, and glottis were performed, and human annotation of the vocal cords, epiglottis, and glottis was carried out. Based on the AI's determinations, anatomical structures were color-coded for identification. The recognition accuracy of the epiglottis and vocal cords recognized by the AI model was 0.9516, which was over 95%. The AI successfully marked the glottis, epiglottis, and vocal cords during the tracheal intubation process. These markings significantly aided in the visual identification of the respective structures with an accuracy of more than 95%. The AI demonstrated the ability to recognize the epiglottis, vocal cords, and glottis using an image recognition model of a manikin.

Validation of Difficult Airway Physiological Score (DAPS) in Critically Ill Adults Undergoing Endotracheal Intubation in the Emergency Department

Background

Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital.

Methods

This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician's anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity.

Results

Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS <10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n = 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p < 0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p < 0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71-0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%.

Conclusion

The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial

Importance

Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.

Objective

To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.

Design, Setting, and Participants

Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.

Interventions

Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.

Main Outcomes and Measures

The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.

Results

Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).

Conclusion and Relevance

In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT04701762.

Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.

Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

BACKGROUND

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS).

METHODS

The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head.

RESULTS

From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13).

DISCUSSION

Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Baseline Gastric Volume in Fasting Diabetic Patients Is Not Higher than That in Nondiabetic Patients: A Cross-sectional Noninferiority Study

BACKGROUND

The physiology of diabetes mellitus can increase the risk of perioperative aspiration, but there is limited and contradictory evidence on the incidence of "full stomach" in fasting diabetic patients. The aim of this study is to assess the baseline gastric content (using gastric ultrasound) in diabetic and nondiabetic patients scheduled for elective surgery who have followed standard preoperative fasting instructions.

METHODS

This was a prospective, noninferiority study of 180 patients (84 diabetic and 96 nondiabetic patients). Bedside ultrasound was used for qualitative and quantitative assessment of the gastric antrum in the supine and right lateral decubitus positions. Fasting gastric volume was estimated based on the cross-sectional area of the gastric antrum and a validated model. The hypothesis was that diabetic patients would not have a higher baseline fasting gastric volume compared to nondiabetic patients, with a noninferiority margin of 0.4 ml/kg. Secondary aims included the comparison of the incidence of full stomach (solid content or more than 1.5 mL/kg of clear fluid), estimation of the 95th percentile of the gastric volume distribution in both groups, and examination of the association between gastric volume, glycemic control, and diabetic comorbidities.

RESULTS

The baseline gastric volume was not higher in diabetic patients (0.81 ± 0.61 ml/kg) compared to nondiabetic patients (0.87 ± 0.53 ml/kg) with a mean difference of -0.07 ml/kg (95% CI, -0.24 to 0.10 ml/kg). A total of 13 (15.5%) diabetic and 11 (11.5%) nondiabetic patients presented more than 1.5 ml/kg of gastric volume (95% CI for difference, -7.1 to 15.2%). There was little correlation between the gastric volume and either the time since diagnosis or HbA1C.

CONCLUSIONS

The data suggest that the baseline gastric volume in diabetic patients who have followed standard fasting instructions is not higher than that in nondiabetic patients.

EDITOR’S PERSPECTIVE

Teamwork matters: team situation awareness to build high-performing healthcare teams, a narrative review

Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Point-of-care ultrasound for airway management in the emergency and critical care setting

Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.

Postoperative Upper Airway Blood Clot After Tonsillectomy Requiring a Suction Catheter Without Side Holes for Removal: A Case Report

We present a case of acute dyspnea due to postoperative oral bleeding after tonsillectomy, wherein a blood clot obscured the laryngeal structures to such an extent that no recognizable structures could be identified. A larger-bore suction catheter without side holes proved necessary to solve the problem. The case illustrates how a gradually forming blood clot can remain asymptomatic until reaching a size where it poses an airway threat and highlights the necessity for readily available larger-bore suction devices without side holes. We consider this as an important reminder of the unpredictable nature of blood clot formation and its management.

Scope of artificial intelligence in airway management

The evolution of artificial intelligence (AI) systems in the field of anaesthesiology owes to notable advancements in data processing, databases, algorithmic programs, and computation power. Over the past decades, its accelerated progression has enhanced safety in anaesthesia by improving the efficiency of equipment, perioperative risk assessments, monitoring, and drug administration systems. AI in the field of anaesthesia aims to improve patient safety, optimise resources, and improve the quality of anaesthesia management in all phases of perioperative care. The use of AI is likely to impact difficult airway management and patient safety considerably. AI has been explored to predict difficult intubation to outperform conventional airway examinations by integrating subjective factors, such as facial appearance, speech features, habitus, and other poorly known features. This narrative review delves into the status of AI in airway management, the most recent developments in this field, and its future clinical applications.

The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were 'uncommon' (10-100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being 'common' (100-1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent.

Prevalence and risk factors of difficult mask ventilation: A systematic review and meta-analysis

STUDY OBJECTIVE

This meta-analysis aimed at identifying the risk factors for and their strengths in predicting difficult mask ventilation (MV) through a systematic approach.

DESIGN

Meta-analysis of observational studies.

SETTING

Operating room.

INTERVENTION

Airway- or patient-related risk factors for difficult MV reported in over 20% of eligible studies identified through literature review.

PATIENTS

Adults receiving anesthetic induction with requirement of MV.

MEASUREMENTS

Databases including EMBASE, MEDLINE, Google Scholar, and Cochrane Library were searched from inception to July 2022. The primary outcomes were the identification of commonly reported risk factors for MV and a comparison of their strengths in difficult MV prediction, while the secondary outcomes were the prevalence of difficult MV in the general population and those with obesity.

MAIN RESULTS

Meta-analysis of 20 observational studies involving 335,846 patients identified 13 risk factors with predictive strengths (all p < 0.05): neck radiation (OR = 5.0, five studies, n = 277,843), increased neck circumference (OR = 4.04, 11 studies, n = 247,871), obstructive sleep apnea (OSA) (OR = 3.61, 12 studies, n = 331,255), presence of beard (OR = 3.35, 12 studies, n = 295,443), snoring (OR = 3.06, 14 studies, n = 296,105), obesity (OR = 2.99, 11 studies, n = 278,297), male gender (OR = 2.76, 16 studies, n = 320,512), Mallampati score III-IV (OR = 2.36, 17 studies, n = 335,016), limited mouth opening (OR = 2.18, six studies, n = 291,795), edentulous (OR = 2.12, 11 studies, n = 249,821), short thyroid-mental distance (OR = 2.12, six studies, n = 328,311), old age (OR = 2, 11 studies, n = 278,750), and limited neck movement (OR = 1.98, nine studies, n = 155,101). The prevalence of difficult MV was 6.1% (16 studies, n = 334,694) and 14.4% (four studies, n = 1152) in the general population and those with obesity, respectively.

CONCLUSIONS

Our results demonstrated the strengths of 13 most common risk factors for predicting difficult MV, which may serve as an evidence-based reference for clinicians to incorporate into their daily practice.

Comparative review of airway anesthesia and sedation methods for awake intubation

PURPOSE OF REVIEW

Successful awake intubation hinges upon adequate airway anesthesia and sedation for patient comfort. This review will summarize relevant anatomy and regional anesthesia techniques to achieve airway anesthesia, and compare various airway anesthesia and sedation regimens.

RECENT FINDINGS

Overall, nerve blocks consistently provided superior airway anesthesia, shorter time to intubation, higher patient comfort, and higher postintubation patient satisfaction. Additionally, ultrasound guidance can further provide benefit by reducing the amount of local anesthetic administered, leading to denser blockade, and proving invaluable in challenging clinical situations. Regarding sedation methods, numerous studies supported the use of dexmedetomidine, with or without the addition of supplemental sedation, such as midazolam, ketamine, or opioids.

SUMMARY

Emerging evidence has indicated that nerve blocks for airway anesthesia may be superior to other methods of topicalization. Additionally, dexmedetomidine can be useful, both as monotherapy and with supplemental sedatives, to safely provide anxiolysis for the patient and increase success. However, it is crucial to note that the method of airway anesthesia and sedation regimen should be adapted to each patient and clinical situation, and knowledge of multiple techniques and sedation regimens can best equip anesthesiologists to do so.

Tongue retraction using a McIvor blade improves airway condition during fiberoptic intubation: a randomized controlled trial

Airway clearance is crucial for successful fiberoptic intubation. We hypothesized that tongue retraction using a McIvor blade could facilitate fiberoptic intubation. This randomized clinical trial aimed to compare intubation time and airway condition between the jaw thrust maneuver and tongue retraction with the McIvor blade during fiberoptic intubation. Ninety-four adult patients scheduled for elective surgery were randomly assigned to one of two groups. During fiberoptic intubation, airway clearance was secured by applying the jaw-thrust maneuver (J group) or by tongue retraction using the McIvor blade (M group). We assessed the total intubation time, number of attempts for tube advancement, and airway clearance at the soft palate and epiglottis levels. The total intubation time was significantly shorter in the M group than in the J group (p = 0.035). The number of attempts to advance the tube was significantly lower in the M group (p = 0.033). Airway clearance at the soft palate level was significantly better in the M group than in the J group (p = 0.027). Retracting the tongue with the McIvor blade demonstrated a better condition for fiberoptic intubation and shortened total intubation time compared with the jaw-thrust maneuver.Clinicalregistiration: CRIS; http://cris.nih.go.kr (KCT0002392) registered 28/07/2017.

Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study

Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.

Evaluation of free-floating tracheal intubation in weightlessness via ice-pick position with a direct laryngoscopy and classic approach with indirect videolaryngoscopy

Long duration spaceflights to the Moon or Mars are at risk for emergency medical events. Managing a hypoxemic distress and performing an advanced airway procedure such as oro-tracheal intubation may be complicated under weightlessness due to ergonomic constraints. An emergency free-floating intubation would be dangerous because of high failure rates due to stabilization issues that prohibits its implementation in a space environment. Nevertheless, we hypothesized that two configurations could lead to a high first-pass success score for intubation performed by a free-floating operator. In a non-randomized, controlled, cross-over simulation study during a parabolic flight campaign, we evaluated and compared the intubation performance of free-floating trained operators, using either a conventional direct laryngoscope in an ice-pick position or an indirect laryngoscopy with a video-laryngoscope in a classic position at the head of a high-fidelity simulation manikin, in weightlessness and in normogravity. Neither of the two tested conditions reached the minimal terrestrial ILCOR recommendations (95% first-pass success) and therefore could not be recommended for general implementation under weightlessness conditions. Free-floating video laryngoscopy at the head of the manikin had a significant better success score than conventional direct laryngoscopy in an ice-pick position. Our results, combined with the preexisting literature, emphasis the difficulties of performing oro-tracheal intubation, even for experts using modern airway devices, under postural instability in weightlessness. ClinicalTrials registration number NCT05303948.

Vie Scope® versus videolaryngoscopy in expected difficult airways: a randomized controlled trial

PURPOSE

The management of patients with an anticipated difficult airway remains challenging. We evaluated laryngeal visualization with the recently introduced Vie Scope® as a straight blade laryngoscope consisting of an illuminated tube necessitating bougie-facilitated intubation vs Macintosh videolaryngoscopy.

METHODS

We conducted a prospective randomized controlled noninferiority trial. Patients undergoing elective ear, nose, and throat or oral and maxillofacial surgery with an anticipated difficult airway were randomized 1:1 to receive tracheal intubation with the Vie Scope or Macintosh videolaryngoscope (C-MAC®). The primary outcome measure was laryngeal visualization by the percentage of glottis opening (POGO) scale. Secondary outcome measures were the time to successful intubation (TTI) and first-attempt and overall success rates.

RESULTS

We included two sets of 29 patients in our analysis. For visualization, the Vie Scope was noninferior to videolaryngoscopy (VL) with mean (standard deviation [SD]) POGO scores of 71 (31)% vs 64 (30)% in the VL group [difference in means, 7 (8)%; 95% confidence interval, -9 to 23; P = 0.38]. Mean (SD) TTI was 125 (129) sec in the Vie Scope and 51 (36) sec in the VL group (difference in means, 75 sec; 95% confidence interval, 25 to 124; P = 0.005). The first-attempt and overall success rates were 22/29 (76%) and 27/29 (93%) in both groups. Two patients per group were switched to a different device. Four accidental esophageal intubations occurred in the Vie Scope group, these were presumably due to bougie misplacement.

CONCLUSION

Visualization with the Vie Scope was noninferior to VL in patients with an anticipated difficult airway, but TTI was longer in the Vie Scope group.

STUDY REGISTRATION

ClinicalTrials.gov (NCT05044416); registered 5 September 2021.

Videolaryngoscopy in critical care and emergency locations: moving from debating benefit to implementation

The recently published INTUBE study subanalysis and DEVICE trial findings both demonstrate a clear benefit of videolaryngoscopy over direct laryngoscopy in facilitating tracheal intubation of patients in the emergency department and ICU. We consider the increasing evidence supporting the use of videolaryngoscopy, the possible reasons behind its relatively slow adoption into clinical practice, and the potential role of the hyperangulated videolaryngoscope blade. We discuss the significance of improved first-pass tracheal intubation success in reducing the overall risk of complications in critically ill patients. Additionally, we address the need for specific training in videolaryngoscopy in order to maximise patient benefit, and propose that adequate training and rehearsal opportunities in videolaryngoscopy can only be realised by widespread and regular use wherever the clinical setting.

Geometric morphometrics and machine learning from three-dimensional facial scans for difficult mask ventilation prediction

Background

Unanticipated difficult mask ventilation (DMV) is a potentially life-threatening event in anesthesia. Nevertheless, predicting DMV currently remains a challenge. This study aimed to verify whether three dimensional (3D) facial scans could predict DMV in patients scheduled for general anesthesia.

Methods

The 3D facial scans were taken on 669 adult patients scheduled for elective surgery under general anesthesia. Clinical variables currently used as predictors of DMV were also collected. The DMV was defined as the inability to provide adequate and stable ventilation. Spatially dense landmarks were digitized on 3D scans to describe sufficient details for facial features and then processed by 3D geometric morphometrics. Ten different machine learning (ML) algorithms, varying from simple to more advanced, were introduced. The performance of ML models for DMV prediction was compared with that of the DIFFMASK score. The area under the receiver operating characteristic curves (AUC) with its 95% confidence interval (95% CI) as well as the specificity and sensitivity were used to evaluate the predictive value of the model.

Results

The incidence of DMV was 35/669 (5.23%). The logistic regression (LR) model performed best among the 10 ML models. The AUC of the LR model was 0.825 (95% CI, 0.765-0.885). The sensitivity and specificity of the model were 0.829 (95% CI, 0.629-0.914) and 0.733 (95% CI, 0.532-0.819), respectively. The LR model demonstrated better predictive performance than the DIFFMASK score, which obtained an AUC of 0.785 (95% CI, 0.710-0.860) and a sensitivity of 0.686 (95% CI, 0.578-0.847). Notably, we identified a significant morphological difference in the mandibular region between the DMV group and the easy mask ventilation group.

Conclusion

Our study indicated a distinct morphological difference in the mandibular region between the DMV group and the easy mask ventilation group. 3D geometric morphometrics with ML could be a rapid, efficient, and non-invasive tool for DMV prediction to improve anesthesia safety.

Efficacy and safety of Cook staged Extubation Set in patients with difficult airway: a systematic review and meta-analysis

BACKGROUND

Cook Stage extubation is a tool developed by Cook Medical for patients with difficult airways. Multiple clinical studies demonstrated the effectiveness and safety of Cook Stage extubation Set (CSES). Currently, no systematic review evidence has been published in this field. Therefore, this study aimed to review the clinical success rate, safety, and tolerability of CSES in patients with difficult airways.

METHOD

The inclusion criteria were based on the population, intervention, comparator, outcomes, and study designs. An electronic search was conducted, and the following databases were used: PubMed, EMBASE, Cochrane Library, and Web of Science. Search keywords included difficult airway and CSES. The primary outcome was the CSES clinical success rate.The Joanna Briggs Institute Critical Appraisal tools for Case Series were used to assess the risk of bias in the included studies. R studio, version 4.2.2. was used to perform the statistical analysis. The Cochrane Q and I2 statistics were used to test the heterogeneity among all studies. Details of the included case reports were summarized in the systematic review part.

RESULTS

Five studies were eligible for meta-analysis, and 7 case reports were included for systematic review. The pooled overall CSES clinical success rate was 93% (95% CI: 85%, 97%). The CSES intolerable and complication incidence rates were 9% (95% CI: 5%, 18%) and 5% (95% CI: 2%, 12%), respectively. CSES clinical success rate was influenced by the study center and study design. The success rate of CSES was higher in multicenter and prospective design studies. Seven case reports have documented the successful operation of CSES intubation in obese, tall, oncologist, and pediatric patients.

DISCUSSION

This meta-analysis suggested that CSES have achieved a high clinical success rate in adult and pediatric patients with different physical conditions and types of surgery. The results of all original studies and meta-analysis confirmed a remarkably high tolerance rate and low overall complication rate. However, regardless of the tools chosen, a personalized, safe intubation strategy and a highly qualified anesthesiologist should be considered as the fundamental guarantee of a high clinical success rate. Future studies should also focus on the success rate of reintubation using CSES in patients with airway difficulties.

Emerging Robotic Innovations and Artificial Intelligence in Endotracheal Intubation and Airway Management: Current State of the Art

Robotic sciences have rapidly advanced and revolutionized various aspects of medicine, including the field of airway management. Robotic endotracheal intubation is an innovative method that utilizes robotic systems to aid in the accurate placement of an endotracheal tube within the trachea. This cutting-edge technique shows great promise in improving procedural precision and ensuring patient safety. In this comprehensive overview, we delve into the present status of robotic-assisted endotracheal intubation, examining its advantages, obstacles, and the potential implications it holds for the future. In addition, this review encompasses a comprehensive analysis of the existing literature and references on recent advances in robotic technology and artificial intelligence related to airway management.

A fully-automatic semi-supervised deep learning model for difficult airway assessment

Background

Difficult airway conditions represent a substantial challenge for clinicians. Predicting such conditions is essential for subsequent treatment planning, but the reported diagnostic accuracies are still quite low. To overcome these challenges, we developed a rapid, non-invasive, cost-effective, and highly-accurate deep-learning approach to identify difficult airway conditions through photographic image analysis.

Methods

For each of 1000 patients scheduled for elective surgery under general anesthesia, images were captured from 9 specific and different viewpoints. The collected image set was divided into training and testing subsets in the ratio of 8:2. We used a semi-supervised deep-learning method to train and test an AI model for difficult airway prediction.

Results

We trained our semi-supervised deep-learning model using only 30% of the labeled training samples (with the remaining 70% used without labels). We evaluated the model performance using metrics of accuracy, sensitivity, specificity, F1-score, and the area under the ROC curve (AUC). The numerical values of these four metrics were found to be 90.00%, 89.58%, 90.13%, 81.13%, and 0.9435, respectively. For a fully-supervised learning scheme (with 100% of the labeled training samples used for model training), the corresponding values were 90.50%, 91.67%, 90.13%, 82.25%, and 0.9457, respectively. When three professional anesthesiologists conducted comprehensive evaluation, the corresponding results were 91.00%, 91.67%, 90.79%, 83.26%, and 0.9497, respectively. It can be seen that the semi-supervised deep learning model trained by us with only 30% labeled samples can achieve a comparable effect with the fully supervised learning model, but the sample labeling cost is smaller. Our method can achieve a good balance between performance and cost. At the same time, the results of the semi-supervised model trained with only 30% labeled samples were very close to the performance of human experts.

Conclusions

To the best of our knowledge, our study is the first one to apply a semi-supervised deep-learning method in order to identify the difficulties of both mask ventilation and intubation. Our AI-based image analysis system can be used as an effective tool to identify patients with difficult airway conditions.

Clinical trial registration

ChiCTR2100049879 (URL: http://www.chictr.org.cn).

Point-of-Care Ultrasound in Airway Evaluation and Management: A Comprehensive Review

Airway management is a common and critical procedure in acute settings, such as the Emergency Department (ED) or Intensive Care Unit (ICU) of hospitals. Many of the traditional physical examination methods have limitations in airway assessment. Point-of-care ultrasound (POCUS) has emerged as a promising tool for airway management due to its familiarity, accessibility, safety, and non-invasive nature. It can assist physicians in identifying relevant anatomy of the upper airway with objective measurements of airway parameters, and it can guide airway interventions with dynamic real-time images. To date, ultrasound has been considered highly accurate for assessment of the difficult airway, confirmation of proper endotracheal intubation, prediction of post-extubation laryngeal edema, and preparation for cricothyrotomy by identifying the cricothyroid membrane. This review aims to provide a comprehensive overview of the key evidence on the use of ultrasound in airway management. Databases including PubMed and Embase were systematically searched. A search strategy using a combination of the term "ultrasound" combined with several search terms, i.e., "probe", "anatomy", "difficult airway", "endotracheal intubation", "laryngeal edema", and "cricothyrotomy" was performed. In conclusion, POCUS is a valuable tool with multiple applications ranging from pre- and post-intubation management. Clinicians should consider using POCUS in conjunction with traditional exam techniques to manage the airway more efficiently in the acute setting.

Scalpel cricothyrotomy versus punctured cricothyrotomy in the context of the CICO crisis. A systematic review and Meta-analysis

IMPORTANCE

The preferential use of a scalpel (SCT) or puncture techniques (PCT) for cricothyrotomy remains a controversial topic.

OBJECTIVE

We performed a systematic review and meta-analysis comparing puncture cricothyrotomy with scalpel cricothyrotomy using overall success rate, first-time success rate, and time taken to perform the procedure as the primary outcome together with complications as a secondary outcome.

EVIDENCE REVIEW

Pubmed databases, EMBASE databases, MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, from 1980 to October 2022.

FINDINGS

A total of 32 studies were included in the systematic review and meta-analysis. It also showed that PCT was close to SCT in terms of overall success rate (82.2% vs. 82.6%, Odd Ratios OR = 0.91, [95%CI: 0.52-1.58], p = 0.74) as well as first-performance success rate (62.9% vs. 65.3%, OR = 0.52, [0.22-1.25], p = 0.15). PCT does not compare favorably with SCT in terms of required time for the procedure (the mean time required for PCT versus SCT incision in the intervention groups was 0.34 standard deviations higher (Mean Difference MD = 17.12, [3.37-30.87], p = 0.01) as well as complications (21.4% vs. 15.1%, Relative Risk RR = 1.49, [0.80-2.77], p = 0.21).

CONCLUSIONS AND RELEVANCE

The results show that SCT has an advantage over PCT in terms of time required for the procedure, while there is no difference in overall success rate, first-time success rate after training, and complications. The superiority of SCT may be the result of fewer and more reliable procedural steps. However, the level of evidence is low (GRADE).

Risk patterns of consecutive adverse events in airway management: a Bayesian network analysis

BACKGROUND

Minor adverse airway events play a pivotal role in the safety of airway management. Changes in airway management strategies can reduce such events, but the broader impact on airway management remains unclear.

METHODS

Minor, frequently occurring adverse airway events were audited before and after implementation of changes to airway management strategies. We used two Bayesian networks to examine conditional probabilities of subsequent airway events and to compute the likelihood of certain events given that certain previous events occurred.

RESULTS

Independent of sex, age, and American Society of Anesthesiologists physical status, targeted changes to airway management strategies reduced the risk of a first event. Obese patients were an exception, in whom no risk reduction was achieved. Frequently occurring event sequences were identified, for example the most likely event to follow difficult bag-mask ventilation was a Cormack-Lehane grade ≥3, with a risk of 14.3% (95% credible interval [CI], 11.4-17.2%). An impact of the targeted changes was detected on the likelihood of some event sequences, for example the likelihood of no consecutive event after a tracheal tube-related event increased from 43.3% (95% CI, 39.4-47.6%) to 56.4% (95% CI, 52.0-60.5%).

CONCLUSIONS

Identification of risk patterns and typical structures of event sequences provides a clinically relevant perspective on airway incidents. It further provides a means to quantify the impact of targeted airway management changes. These targeted changes can influence some event sequences, but overall, the benefit results from the cumulative effect of improvements in multiple events. Targeted airway management changes with knowledge of risk patterns and event sequences can potentially further improve patient safety in airway management.

CLINICAL TRIAL REGISTRATION

NCT02743767.

The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine

BACKGROUND

Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl.

OBJECTIVES

To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use.

METHODS

A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction.

RESULTS

Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21).

CONCLUSIONS

The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.

Implementation of video laryngoscopes and the development in airway management strategy and prevalence of difficult tracheal intubation: A national cohort study

BACKGROUND

We aimed to determine the development in the use of video laryngoscopy over a 9-year period, and its possible impact on airway planning and management.

METHODS

We retrieved 822,259 records of tracheal intubations recorded from 2008 to 2016 in the Danish Anaesthesia Database. The circumstances regarding pre-operative airway assessment, the scheduled airway management plan and the actual airway management concerning video laryngoscopy were reported for each year of observation. Further, the association between year of observation and various airway management related outcomes was evaluated by multivariate logistic regression.

RESULTS

There was a significant increase in airway management with 'advanced technique successfully used within two attempts' from 2.7% in 2008 to 15.5% in 2016 (p < .0001). This predominantly reflects use of video laryngoscopy. The prevalence of tracheal intubations 'scheduled for video laryngoscopy' increased from 3.5% in 2008 to 10.6% in 2016 (p < .0001). We found a significant increase in the prevalence of anticipated difficulties with intubations by direct laryngoscopy from 1.8% in 2008 to 5.2% in 2016 (p < .0001). The prevalence of failed tracheal intubations decreased from 0.14% in 2008 to 0.05% in 2016 (p < .0001).

CONCLUSION

From 2008 to 2016, a period of massive implementation of video laryngoscopes, a significant change in airway management behaviour was recorded. Increasingly, video laryngoscopy is becoming a first-choice device for both acute and routine airway management. Most importantly, the data showed a noticeable reduction in failed intubation over the time of observation.

Impact of direct laryngoscopy vs. videolaryngoscopy on signal quality of recurrent laryngeal nerve monitoring in thyroid surgery: a randomised parallel group trial

In thyroid surgery, intra-operative neuromonitoring signals of the recurrent laryngeal nerve can be detected by surface electrodes on a tracheal tube positioned at the vocal fold level. The incidence of difficult tracheal intubation in patients undergoing thyroidectomy for nodular goitre ranges from 5.3% to 20.5%. The aim of this study was to compare videolaryngoscopy with conventional direct laryngoscopy as methods for proper placement of the surface electrode to prevent insufficient intra-operative nerve signal quality. In this prospective randomised trial, adult patients requiring tracheal intubation during thyroid surgery were randomly allocated to two groups of C-MAC^® (Macintosh style blade) videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. Primary outcome was the incidence of insufficient signal electromyogram amplitude level (< 500 μV) after successful tracheal intubation. A total of 260 (130 per group) participants were analysed. An insufficient signal was more frequent with direct laryngoscopy (35/130, 27%), compared with C-MAC (12/130, 9%, p < 0.001). First-pass tracheal intubation success rate was lower with direct laryngoscopy (86/130 (66%)) compared with the C-MAC (125/130 (96%)) (p < 0.0001). Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (16/130 (12%)), compared with the C-MAC (0/130, (0%)) (p < 0.0001). The results suggest that videolaryngoscopy has an impact on the quality of the initial intra-operative neuromonitoring signal in patients undergoing thyroid surgery, and this technique can provide optimised surface electrode positioning.