Airway equipment in Scottish emergency departments

A Manikin Study to Compare Video-Optical Intubation Stylet versus Macintosh Laryngoscope Used by Novice in Normal and Simulated Difficult Airway Intubation

Objective

To compare Macintosh laryngoscope with video-optical intubation stylet on rates and time durations of successful tracheal intubation in normal and simulated difficult airway.

Design

Crossover experimental study.

Setting

Intubation training laboratory.

Methods

A group of novices (58 medical students) attempted intubation on manikin under normal and simulated difficult airway (grade 3 larygnoscopic view) settings using both Macintosh laryngoscope and video-optical intubation stylet. The success rate, duration to intubate and occurrence of complications (oesophageal intubation and incisor breakage) when using the two different devices were measured and compared. The time results were analysed by paired t-test and categorical results by chi square test or Fisher's exact test.

Results

The success rate to intubate difficult airway using video-optical intubation stylet (0.92) was significantly higher than using Macintosh laryngoscope (0.59) (p=0.002). The mean time taken to intubate difficult airway using video-optical intubation stylet was significantly shorter than using Macintosh laryngoscope by 10.90 seconds (p=0.004). Oesophageal intubation rate was significantly higher when using Macintosh laryngoscope to intubate difficult airway compared to video-optical intubation stylet (p=0.002). There was no significant difference on the rate of incisor breakage between the two instruments.

Conclusions

Novice can learn to use both Macintosh laryngoscope and video-optical intubation stylet to intubate successfully after a short training. Video-optical intubation stylet is an effective “Plan B” instrument because it shortens the duration and increases the rate of successful intubation in difficult airway situations.

Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view

Aims:

To assess the sensitivity and specificity of right subcostal ultrasound view to confirm correct endotracheal tube intubation (ETT).

Materials and Methods:

In this prospective study, apneic or paralyzed patients who had an indication of intubation were selected. Intubation and ventilation with bag were performed by the skilled third-year emergency medicine residents. The residents, following a brief training course of ultrasonography, interpreted the diaphragm motion, and identified either esophageal or tracheal intubation. The confirmation of ETT placement was done by the sonographer. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for tracheal versus esophageal intubation.

Results:

A total of 57 patients aged 59 ± 5 who underwent ETT insertion were studied. Thirty-four of them were male (60%). Ultrasound correctly identified 11 out of 12 esophageal intubations for a sensitivity of 92% (95% CI = 62-100), but misidentified one esophageal intubation as tracheal. Sonographers correctly identified 43 out of 45 (96%) tracheal intubations for a specificity of 96% (95% CI = 85-99), but misdiagnosed two tracheal intubations as esophageal.

Conclusions:

This study suggests that diaphragm motion in right subcostal ultrasound view is an effective adjunct to diagnose ETT place in patients undergoing intubation in emergency department.

National survey to assess the content and availability of difficult-airway carts in critical-care units in the United States

We have surveyed the availability of equipment, content of difficult-airway carts (DAC), and training in the use of such equipment in intensive-care units (ICU). We devised a set of proposals regarding what constitutes the ideal DAC. We surveyed 300 ICU in the United States. The survey was conducted to inquire about the presence and content of a DAC. Only 70% of respondents had a DAC in their unit. 82% of units surveyed checked the contents of the cart daily. 80% of directors were aware of its location. 80% of units had an attached list of contents and 51% had an attached algorithm for management of a difficult airway. LMA was present in 80% followed by 35 and 30% for Combitube and pre-assembled needle cricothyroidotomy set. Under non-invasive airway devices, video laryngoscope with 48% was ahead of fibreoptic bronchoscope (38%) and lighted stylet (15%). 80% of units had a CO₂-detection device immediately available. Limited data are available on the impact of DAC in airway management in the ICU. It is strongly recommended that a DAC be present. What constitutes the ideal contents of a DAC is open to questions. We hope discussion will lead to consensus of what should or should not be included on the cart.

Need for emergency surgical airway reduced by a comprehensive difficult airway program

BACKGROUND

Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy.

METHODS

We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006).

RESULTS

The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006).

CONCLUSIONS

A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

How well equipped are ENT wards for airway emergencies?

INTRODUCTION

With increased cross cover of specialities at night and more direct triaging of casualty patients to ENT wards, there is an increased need to ensure that there is adequate provision of emergency airway management. There are currently no national guidelines on what equipment should be available on ENT wards, and the authors have devised a portable airway box with all equipment deemed necessary to manage an acute airway. We believe that all junior doctors covering ENT should have airway training and access to an airway box. The aim of this study was to determine the provision of on-ward airway equipment and training on ENT wards in England.

MATERIALS AND METHODS

A telephone survey of all English hospitals with in-patient ENT services.

RESULTS

A total of 103 departments were contacted with 98% response rate. Most wards were covered by a combination of ENT and other specialties. Results indicated that only 18% of departments had an airway box and 28% had some training in airway management.

CONCLUSIONS

Results suggest poor provision of emergency airway equipment and training on wards. We recommend the use of an airway box, and list of minimal equipment required.

A survey of the use of capnography for the confirmation of correct placement of tracheal tubes in pediatric intensive care units in the UK

BACKGROUND

The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland recommend the use of capnography to ensure correct tracheal tube placement in the theater environment. Correct tracheal tube placement is essential in the care of ventilated patient, even more vital if the patient is critically ill, if serious morbidity and mortality is to be avoided. This survey examined the availability and use of capnography to confirm correct tracheal tube placement in the pediatric intensive care unit (PICU) in the UK.

METHODS

A questionnaire concerning the use of capnography to confirm tracheal tube placement were sent to the lead clinicians of every PICU in the UK.

RESULTS

A total of 19 replies were received from 26 (73%) consultants. One unit did not have a capnograph, 13 units (68%) had one capnograph for several beds and five units (26%) had one capnograph for each bed. Two units (11%) used capnography for every intubation and in 10 units (52%) the use of capnography was dependent on individual physician preference. Eight consultants (42%) felt that confirming tracheal tube placement by capnography should be mandatory after every intubation whether in the ward, A & E, or PICU. A total of 89% of PICUs have trainees with <1 year anesthetic experience compared with 65% of adult ICUs.

CONCLUSIONS

The use of capnography to confirm tracheal tube placement may be even more important in the PICU than in adult ICU.

Secondary confirmation of endotracheal tube position by ultrasound image

OBJECTIVE

Secondary confirmation of endotracheal (ET) tube position by ultrasound image.

DESIGN

Prospective, randomized study.

SETTING

A medical center-based tertiary pediatric intensive care unit.

PATIENTS

A total of 59 patients aged from newborn to 17 yrs old underwent ET tube insertion because of cardiopulmonary arrest or impending respiratory failure.

INTERVENTION

Ultrasound imaging was performed immediately before and after the ET tube placement procedure. The most frequently used ultrasonic scanning window was the subxiphoid window at the mid-upper abdominal, just beneath the xiphoid process and the lower margin of liver. The sector angle was set as wide as possible (90 degrees) so that the bilateral diaphragm could be well scanned.

MEASUREMENTS AND MAIN RESULTS

Using the ultrasound imaging method, we successfully identified all of two esophageal intubations and eight incidents of initial ET tube misplacement, which had been positioned down to the right main bronchus. Finally, we successfully identified all 59 of the correct placements of ET tubes in the trachea.

CONCLUSIONS

Ultrasound imaging of diaphragm motion is a useful, quick, noninvasive, portable, and direct anatomic method for assessment of ET tube position. We think it should be considered the method of choice for the secondary confirmation of the ET tube position.