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Toh TW, Goh JHF, Lie SA, Leong CKL, Hwang NC. Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management. J Cardiothorac Vasc Anesth 2024; 38:2412-2425. [PMID: 38964992 DOI: 10.1053/j.jvca.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/30/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024]
Abstract
Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.
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Affiliation(s)
- Timothy Weiquan Toh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Jacqueline Hui Fen Goh
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Sui An Lie
- Department of Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Carrie Kah Lai Leong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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Desai N, Ratnayake G, Onwochei DN, El-Boghdadly K, Ahmad I. Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis. Br J Anaesth 2021; 127:636-647. [PMID: 34303493 DOI: 10.1016/j.bja.2021.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.
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Affiliation(s)
- Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK.
| | - Gamunu Ratnayake
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| | - Imran Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
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Wong J, Lee JSE, Wong TGL, Iqbal R, Wong P. Fibreoptic intubation in airway management: a review article. Singapore Med J 2019; 60:110-118. [PMID: 30009320 PMCID: PMC6441687 DOI: 10.11622/smedj.2018081] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.
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Affiliation(s)
- Jolin Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - John Song En Lee
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | | | - Rehana Iqbal
- Department of Anaesthesia, St George’s Hospital, London, United Kingdom
| | - Patrick Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Lee J, Ng VV, Teo C, Wong P. Use of a trans-tracheal rapid insufflation of oxygen device in a "cannot intubate, cannot oxygenate" scenario in a parturient -a case report. Korean J Anesthesiol 2019; 72:381-384. [PMID: 30776879 PMCID: PMC6676036 DOI: 10.4097/kja.d.18.00334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background The trans-tracheal rapid insufflation of oxygen (TRIO) device is less commonly used and is an alternative to trans-tracheal jet ventilation for maintaining oxygenation in a "cannot intubate, cannot oxygenate" (CICO) scenario. Case We report the successful use of this device to maintain oxygenation after jet ventilator failure in a parturient who presented with the CICO scenario during the procedure for excision of laryngeal papilloma. Conclusions A stepwise approach to the airway plan and preparation for an event of failure is essential for good materno-fetal outcomes. The TRIO device may result in inadequate ventilation that can lead to hypercarbia and respiratory acidosis. Hence, it should only be used as a temporizing measure before a definitive airway can be secured.
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Affiliation(s)
- John Lee
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | - Von Vee Ng
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | - Constance Teo
- Department of Otolaryngology, Singapore General Hospital, Singapore
| | - Patrick Wong
- Department of Anesthesiology, Singapore General Hospital, Singapore
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Zou T, Huang Z, Hu X, Cai G, He M, Wang S, Huang P, Yu B. Clinical application of a novel endoscopic mask: a randomized controlled, multi-center trial in patients undergoing awake fiberoptic bronchoscopic intubation. BMC Anesthesiol 2017; 17:79. [PMID: 28619016 PMCID: PMC5472943 DOI: 10.1186/s12871-017-0370-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/31/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Awake fiberoptic bronchoscopic tracheal intubation is usually regarded as an effective method in the management of predicted difficult airway. Hypoxia during awake nasal fiberoptic bronchoscopic intubation leads to discontinuation of the procedure, prolonged manipulation time and increased risk of severe complications. The main aim of the study was to test whether the novel endoscopic mask is helpful for hypoxia during the intubation. METHODS This was a randomized, controlled, multi-center study. 55 patients were recruited, but one patient was lost to follow-up. Finally, 54 patients (19 man and 35 women) were analyzed. After entering the operating room, nasal catheter oxygen-providing was given in the control group, and the treatment group received endoscopic mask oxygen-providing, with a flow rate of 3 L/min, lasting into the end of the intubation. Primary outcomes included mean arterial pressure, heart rate, minimum pulse oxygen saturation and incidence of pulse oxygen saturation ≤ 90%. Secondary outcomes included number of intubation attempts and time to intubation. All outcomes were finally measured. RESULTS Minimum pulse oxygen saturation during awake nasal fiberoptic bronchoscopic tracheal intubation was significantly higher in the endoscopic mask intubation group (91.7% ± 4.7%) than that the nasal catheter intubation group (87.6% ± 8.2%, P = 0.031. Furthermore, the incidence of pulse oxygen saturation ≤ 90% was significantly lower in the endoscopic mask intubation group (20.0%, 5/25) than that in the nasal catheter intubation group (51.7%, 15/29, P = 0.037). But mean arterial pressure of during intubation was significantly higher in the endoscopic mask group (100.0 ± 13.3 vs 90.3 ± 21.8, P = 0.049). In addition, there were no differences in the number of intubation attempts (P = 0.45) or time to intubation between the two groups (P = 0.38). CONCLUSIONS The endoscopic mask was safely used in awake fiberoptic bronchoscopic tracheal intubation, with advantages of stable blood pressure and potential prevention of desaturation. Beginners for the intubation procedure and patients at high risk of hypoxia could benefit from the use of the endoscopic mask. TRIAL REGISTRATION Trial registration: www.chictr.org.cn . Registration No.: ChiCTR-TRC-13004086. Date of Registration: 8th, Sep, 2013.
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Affiliation(s)
- Tianxiao Zou
- Department of Anesthesiology, Tongji Hospital affiliated to Tongji University, Shanghai, China. NO.389, Xincun Road, Putuo District, Shanghai, China
| | - Zhenling Huang
- Department of Anesthesiology, Renji Hospital affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoxue Hu
- Department of Anesthesiology, Shanghai Guanghua Hospital, Shanghai, China
| | - Guangyu Cai
- Department of Anesthesiology, Tongji Hospital affiliated to Tongji University, Shanghai, China. NO.389, Xincun Road, Putuo District, Shanghai, China
| | - Miao He
- Department of Anesthesiology, Tongji Hospital affiliated to Tongji University, Shanghai, China. NO.389, Xincun Road, Putuo District, Shanghai, China
| | - Shanjuan Wang
- Department of Anesthesiology, Renji Hospital affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ping Huang
- Department of Anesthesiology, Renji Hospital affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Yu
- Department of Anesthesiology, Tongji Hospital affiliated to Tongji University, Shanghai, China. NO.389, Xincun Road, Putuo District, Shanghai, China.
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Markova L, Stopar-Pintaric T, Luzar T, Benedik J, Hodzovic I. A feasibility study of awake videolaryngoscope-assisted intubation in patients with periglottic tumour using the channelled King Vision®videolaryngoscope. Anaesthesia 2016; 72:512-518. [DOI: 10.1111/anae.13734] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 11/27/2022]
Affiliation(s)
- L. Markova
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - T. Stopar-Pintaric
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
- Institute of Anatomy; Faculty of Medicine; University of Ljubljana; Ljubljana Slovenia
| | - T. Luzar
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - J. Benedik
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - I. Hodzovic
- Department of Anaesthesia, Intensive Care and Pain Medicine; School of Medicine; Cardiff University; Cardiff UK
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Li LW, He L, Ai Y, Chu Q, Zhang W. Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery. J Surg Res 2016; 203:206-10. [DOI: 10.1016/j.jss.2016.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 02/03/2016] [Accepted: 03/07/2016] [Indexed: 11/29/2022]
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Abstract
The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom's 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists' difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.
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Affiliation(s)
- Patrick Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Jolin Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - May Un Sam Mok
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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9
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Badiger S, John M, Fearnley RA, Ahmad I. Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system. Br J Anaesth 2015; 115:629-32. [PMID: 26253608 DOI: 10.1093/bja/aev262] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Awake fibre-optic intubation is a widely practised technique for anticipated difficult airway management. Despite the administration of supplemental oxygen during the procedure, patients are still at risk of hypoxia because of the effects of sedation, local anaesthesia, procedural complications, and the presence of co-morbidities. Traditionally used oxygen-delivery devices are low flow, and most do not have a sufficient reservoir or allow adequate fresh gas flow to meet the patient's peak inspiratory flow rate, nor provide an adequate fractional inspired oxygen concentration to prevent desaturation should complications arise. METHODS A prospective observational study was conducted using a high-flow humidified transnasal oxygen-delivery system during awake fibre-optic intubation in 50 patients with anticipated difficult airways. RESULTS There were no episodes of desaturation or hypercapnia using the high-flow system, and in all patients the oxygen saturation improved above baseline values, despite one instance of apnoea resulting from over-sedation. All patients reported a comfortable experience using the device. CONCLUSIONS The high-flow nasal oxygen-delivery system improves oxygenation saturation, decreases the risk of desaturation during the procedure, and potentially, optimizes conditions for awake fibre-optic intubation. The soft nasal cannulae uniquely allow continuous oxygenation and simultaneous passage of the fibrescope and tracheal tube. The safety of the procedure may be increased, because any obstruction, hypoventilation, or periods of apnoea that may arise may be tolerated for longer, allowing more time to achieve ventilation in an optimally oxygenated patient.
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Affiliation(s)
- S Badiger
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE9 3RT, UK
| | - M John
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE9 3RT, UK
| | - R A Fearnley
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE9 3RT, UK
| | - I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE9 3RT, UK
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10
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Law JA, Morris IR, Brousseau PA, de la Ronde S, Milne AD. The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study. Can J Anaesth 2015; 62:736-44. [PMID: 25907462 DOI: 10.1007/s12630-015-0387-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/07/2015] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Awake tracheal intubation is one recommended option to address select situations in the management of a patient with an anticipated difficult airway. A scarcity of data exists on how often awake intubation is performed or whether its use is changing over time, particularly with the increasingly widespread availability of video laryngoscopy. This retrospective database review was undertaken to determine the incidence, success, and complications of awake intubation and the incidence of other tracheal intubation techniques in the operating room over a 12-yr period (2002-2013) at our institution. METHODS The Anesthesia Information Management System in use at a Canadian tertiary care centre was searched for all awake intubations that occurred during the years 2002-2013. Records were also searched to identify airway methods other than direct laryngoscopy that may have been used after the induction of general anesthesia. Changes in both the incidence of awake intubation and in the use of video laryngoscopy over the 12 years were analyzed using linear regression modelling. RESULTS Of 146,252 cases performed under general anesthesia with endotracheal intubation, 1,554 intubations (1.06%) were performed awake. There was no significant change in the rate of awake intubation over the studied years (slope -1.4(-4) incidence·year(-1); 95% confidence interval [CI]: -3.0(-4) to 3.0(-5); P = 0.102). The relatively steady rate of awake intubation occurred despite a significant increase in the use of video laryngoscopy over the same time (slope 0.080 incidence·year(-1); 95% CI: 0.076 to 0.083; P < 0.001), particularly from 2009 onwards. Attempted awake intubation failed in 31 (2%) of the cases. Self-reported complications occurred in 15.7% of successful procedures. In addition, in a convenience sample of three years (2011-2013), the rate at which each of 49 attending staff performed awake intubation varied widely from 0-3.4 awake intubations per 100 cases of general anesthesia with endotracheal intubation. CONCLUSIONS At our tertiary care centre, we did not find a significant change in the use of awake tracheal intubation over the studied years 2002-2013 despite increasing availability and use of video laryngoscopy. It appears that awake tracheal intubation retains an important and consistent role in the management of the difficult airway.
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Affiliation(s)
- J Adam Law
- Department of Anesthesia, Dalhousie University, QEII Health Sciences Centre, Halifax, Infirmary Site, 1796 Summer Street, Halifax, NS, B3H 3K9, Canada,
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Nielsen EW, Hull JH, Backer V. High prevalence of exercise-induced laryngeal obstruction in athletes. Med Sci Sports Exerc 2014; 45:2030-5. [PMID: 23657163 DOI: 10.1249/mss.0b013e318298b19a] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Unexplained respiratory symptoms reported by athletes are often incorrectly considered secondary to exercise-induced asthma. We hypothesized that this may be related to exercise-induced laryngeal obstruction (EILO). This study evaluates the prevalence of EILO in an unselected cohort of athletes. METHODS We retrospectively reviewed the prevalence of EILO in a cohort of athletes (n = 91) referred consecutively during a 2-yr period for asthma workup including continuous laryngoscopy during exercise (CLE) testing. We compared clinical characteristics and bronchial hyperreactivity between athletes with and without EILO. RESULTS Of 88 athletes who completed a full workup, 31 (35.2%) had EILO and 38 (43.2%) had a positive bronchoprovocation or bronchodilator reversibility test. The presence of inspiratory symptoms did not differentiate athletes with and without EILO. Sixty-one percent of athletes with EILO and negative bronchoprovocation and bronchodilator reversibility tests used regular asthma medication at referral. CONCLUSIONS In athletes with unexplained respiratory symptoms, EILO is an important differential diagnosis not discerned from other etiologies by clinical features. These findings have important implications for the assessment and management of athletes presenting with persistent respiratory symptoms despite asthma therapy.
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Affiliation(s)
- Emil Walsted Nielsen
- 1Respiratory Research Unit, Department of Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, DENMARK; and 2Department of Respiratory Medicine, Royal Brompton Hospital, London, England, UNITED KINGDOM
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Nicholson A, Smith AF, Lewis SR, Cook TM. Tracheal intubation with a flexible intubation scope versus other intubation techniques for obese patients requiring general anaesthesia. Cochrane Database Syst Rev 2014; 2014:CD010320. [PMID: 24443105 PMCID: PMC11238170 DOI: 10.1002/14651858.cd010320.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence of obesity (body mass index (BMI) > 30 kg/m(2)) is increasing in both developed and developing countries, leading to a rise in the numbers of obese patients requiring general anaesthesia. Obese patients are at increased risk of anaesthetic complications, and tracheal intubation can be more difficult. Flexible intubation scopes (FISs) are recommended as an alternative method of intubation in these patients. Intubation with an FIS is considered an advanced method, requiring training and experience; therefore it may be underused in clinical practice. Patient outcomes following intubation with these scopes compared with other devices have not been systematically reviewed. OBJECTIVES We wished to compare the safety and effectiveness of a flexible intubation scope (FIS) used for tracheal intubation in obese patients (BMI > 30 kg/m(2)) with other methods of intubation, including conventional direct laryngoscopy, non-standard laryngoscopy and the use of intubating supraglottic airway devices. We aimed to compare the frequency of complications, as well as process indicators, such as time taken for intubation and the proportion of first attempts that were successful, between groups using the different methods of intubation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and two trial registers on 18 January 2013, and performed reference checking and citation searching and contacted study authors to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) of participants aged 16 years and older with a BMI > 30 kg/m(2) that had compared the use of an FIS for tracheal intubation with any one of three comparison groups: direct laryngoscopy; non-standard laryngoscopy (including indirect laryngoscopy using a videolaryngoscope (VLS) or a rigid or semi-rigid stylet); or intubation of supraglottic airway devices (SADs). DATA COLLECTION AND ANALYSIS We used standard methodological approaches expected by The Cochrane Collaboration, including independent review of titles, data extraction and risk of bias assessment by two investigators. MAIN RESULTS Three eligible studies were identified, all comparing the use of an FIS with a VLS. All studies were small, with only 131 participants in total across all trials. It was impossible for the intubators to be unaware of the device used, so all studies were at high risk of performance and detection bias for outcomes related to intubation. Because of substantial differences in design between the studies, we did not combine their results in meta-analyses. The results for all outcomes were inconclusive, with no differences noted between FIS and VLS. Two studies with experienced intubators reported first attempt success rates greater than 70% in both groups and less than 5% of participants requiring a change of intubation device. No evidence was found of any difference in difficulty or time taken between FIS and VLS intubation. No serious complications or airway trauma was reported, so we were unable to address these outcomes. Bleeding was uncommon, occurring in less than 5% of participants, and we found no evidence that it was more likely in the FIS group. One small study with a novice intubator reported no successful intubations using an FIS and compared with the use of an intubating SAD and stylet, as well as with a VLS. With only five participants in each group, no conclusions can be drawn from these additional comparisons. AUTHORS' CONCLUSIONS The evidence base is sparse, and the existing literature does not address the clinical questions of patient safety posed by this review. We are therefore unable to draw any conclusions on safety or effectiveness. More primary research is needed to investigate optimal intubation techniques in obese patients, and new studies should be powered to detect differences in complications and in success rates rather than process measures such as speed, which are of limited clinical importance.
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Affiliation(s)
- Amanda Nicholson
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK, LA1 4YG
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Cook T, MacDougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012; 109 Suppl 1:i68-i85. [DOI: 10.1093/bja/aes393] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
Tracheal stenosis may occur secondary to trauma, tumors, infection, inflammatory diseases, or iatrogenic causes. Understanding these lesions requires a basic understanding of the physics of airflow. All of these patients must be carefully evaluated and require a series of tests, including pulmonary function tests and radiographic studies. Treatment of tracheal lesions is a multidisciplinary issue and requires the close participation of interventional pulmonologists, anesthesiologists, and surgeons.
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Affiliation(s)
- Geraldine Daumerie
- Department of Anesthesiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 680 Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
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