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Devanand NA, Thiruvenkatarajan V, Liu WM, Sirisinghe I, Court-Kowalski S, Pryor L, Gatley A, Sethi S, Sundararajan K. Outcomes of percutaneous versus surgical tracheostomy in an Australian Quaternary Intensive Care Unit: An entropy-balanced retrospective study. J Intensive Care Soc 2024; 25:279-287. [PMID: 39224423 PMCID: PMC11366180 DOI: 10.1177/17511437241238877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Background Studies comparing percutaneous tracheostomy (PT) and surgical tracheostomy (ST) complications in the critically ill patient population with high acuity, complexity, and severity of illness are sparse. This study evaluated the outcomes of elective PT versus ST in such patients managed at a quaternary referral center. Aims The primary aim was to detect a difference in hospital mortality between the two techniques. The secondary aims were to compare Intensive Care Unit (ICU) mortality, complications (including stoma site, tracheostomy-related, and decannulation complications), ICU and hospital length of stay, and time to decannulation. Methods This was a single-center retrospective observational study of ICU admission from August 2018 to August 2021. Patients were included if an elective tracheostomy was performed during their ICU admission. Patients with a pre-existing tracheostomy and those who underwent an obligatory tracheostomy requirement (e.g. total laryngectomy) were excluded. Cohorts were matched using Hainmueller's entropy balancing. Binary data were evaluated using logistic regression and continuous data with ordinary least squares regression. Results 349 patients with a tracheostomy were managed in the ICU during the observation period. They were predominantly males (75% in PT; 67% in ST), with a mean age in the PT and ST group of (47; SD = 18) and (55; SD = 16), respectively. After exclusion, 135 patients remained, with 63 in the PT group and 72 in the ST group. Patients receiving ST were significantly older with a higher Body Mass Index (BMI) than the PT group. There were no significant differences in gender, Acute Physiological And Chronic Health Evaluation (APACHE) III, and the Australian and New Zealand Risk Of Death (ANZROD) between the two groups. There was no difference in hospital mortality between groups (OR 0.91, CI 0.26-3.18, p = 0.88). There were also no differences in ICU mortality, ICU and hospital length of stay, and time to decannulation. PT was associated with a greater likelihood of complications (OR 4.19; 95% CI 1.73-10.13; p < 0.01). PT was associated with a greater risk of complications in those who had this performed early (<10 days of intubation) as well as late (>10 days of intubation). Conclusions Percutaneous tracheostomy was associated with higher complications compared to surgical tracheostomy. They were related to tracheostomy cuff deflation, stomal site bleeding and infection, sputum plugging, and accidental and failed decannulation. These findings have identified opportunities to improve patient outcomes.
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Affiliation(s)
| | - Venkatesan Thiruvenkatarajan
- Department of Anaesthesia, The Queen Elizabeth Hospital, SA, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Wai-Man Liu
- Research School of Finance, Actuarial Studies, and Statistics, Australian National University, Canberra, ACT, Australia
| | | | | | - Lee Pryor
- Intensive Care Unit, Department of Speech Pathology, Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
| | - Anne Gatley
- Intensive Care Unit, Department of Speech Pathology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sandeep Sethi
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
| | - Krishnaswamy Sundararajan
- Head of Intensive Care Unit, Critical Care and Perioperative Services Programme, Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
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Padala SRAN, Raju R, Kiran M, Seema S. Acute Kinking of Pilot Balloon Tubing-A Rare Complication of Endotracheal Intubation. Ann Card Anaesth 2024; 27:293-294. [PMID: 38963379 PMCID: PMC11315243 DOI: 10.4103/aca.aca_38_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
| | - Rinu Raju
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Molli Kiran
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Seema Seema
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. 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 II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Narwani V, Dacey S, Lerner MZ. Adverse Events Associated With Tracheostomy: A MAUDE Database Analysis. Otolaryngol Head Neck Surg 2024; 170:391-395. [PMID: 37622490 DOI: 10.1002/ohn.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Tracheotomy is one of the most common procedures. Although tracheostomy complications have been extensively studied, literature related to device complications is scarce. The objective of this study is to describe complications associated with tracheostomies utilizing the Manufacturer and User Facility Device Experience (MAUDE) database. STUDY DESIGN Retrospective cross-sectional study. SETTING The US Food and Drug Administration's (FDA) MAUDE database (2015-2020). METHODS The FDA's MAUDE database was queried for all reports on adverse events related to tracheostomy from January 1, 2015 to December 31, 2020. RESULTS A total of 3086 adverse events related to open tracheostomy and 52 related to percutaneous tracheostomy were identified. For open tracheostomy, 2872 (93%), were related to device malfunction, and 214 (7%) consisted of patient-related factors. The most frequently reported device-related adverse event was cuff malfunction, with 1834 (59%) reported events, which includes cuff deflation, pilot balloon malfunction, and cuff inflation line malfunction. The most frequently reported patient-related adverse events were tracheostomy tube obstruction with 67 events (2%). For percutaneous tracheostomy, 38 (73%) events were related to device malfunction, and 14 (27%) were related to patient injury. The most frequently reported adverse events were cuff malfunction (29%), safety ridge malfunction (17%), and bleeding (10%). CONCLUSION The MAUDE database is a useful tool that can be utilized to complement existing literature in identifying common and rare adverse events associated with tracheostomy device-related failures, which are mostly reliant on isolated, published case reports.
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Affiliation(s)
- Vishal Narwani
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sydney Dacey
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael Z Lerner
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Kriege M, Demare T, Ruemmler R, Schmidtmann I, Wojciechowski J, Busch A, Ott T. Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)-A Prospective, Randomised Controlled Study. J Clin Med 2023; 13:16. [PMID: 38202022 PMCID: PMC10779719 DOI: 10.3390/jcm13010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios. METHODS After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min. RESULTS In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02). CONCLUSION The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial.
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Affiliation(s)
- Marc Kriege
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg—University Mainz, 55131 Mainz, Germany
| | - Tim Demare
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg—University Mainz, 55131 Mainz, Germany
| | - Robert Ruemmler
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg—University Mainz, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Centre, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Janosh Wojciechowski
- Department of Anaesthesiology and Intensive Care, Asklepios Paulinen Hospital Wiesbaden, 65197 Wiesbaden, Germany
| | - Anneke Busch
- Department of Anaesthesiology and Intensive Care, Asklepios Paulinen Hospital Wiesbaden, 65197 Wiesbaden, Germany
| | - Thomas Ott
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg—University Mainz, 55131 Mainz, Germany
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6
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Feifei Y, Junhai Z, Xiaoxiao G. Nursing Care of Patient With Tracheostomy Tube Cuff Rupture Caused by Tracheal Polyp: A Case Report. Crit Care Nurse 2023; 43:52-58. [PMID: 37257874 DOI: 10.4037/ccn2023649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Tracheostomy is common in patients with critical illness. Mechanical ventilation requires the airway to be closed by an inflated tracheostomy tube cuff. Tracheostomy tube cuff rupture is a serious complication of airway management. This case study summarizes the nursing care of a patient who received prolonged mechanical ventilation and had recurrent tracheostomy tube cuff ruptures caused by a tracheal polyp. CLINICAL FINDINGS AND DIAGNOSIS An 81-year-old woman was admitted because of acute exacerbation of chronic obstructive pulmonary disease. The patient had undergone percutaneous tracheostomy 3 years earlier because of difficulty in weaning from the ventilator and had recurrent lung infections that led to respiratory failure. A tracheal polyp was identified as the cause of multiple tracheostomy tube cuff ruptures. OUTCOMES After the tracheal polyp was removed with bronchofiberscope guidance, the patient remained hospitalized because of difficulty in ventilator weaning but had no further tracheostomy tube cuff ruptures. CONCLUSION Tracheal polyps that cause tracheostomy tube cuff ruptures are rare, but nurses should be alert to their occurrence. If a tube cuff ruptures in a patient receiving long-term mechanical ventilation, bronchoscopy should be performed as soon as possible to allow for early identification of the cause and ensure patient safety.
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Affiliation(s)
- Ye Feifei
- Ye Feifei is a nurse, Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Zhen Junhai
- Zhen Junhai is a physician, Department of Critical Care Medicine, Zhejiang Hospital
| | - Guan Xiaoxiao
- Guan Xiaoxiao is a nurse, Department of Critical Care Medicine, Zhejiang Hospital
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7
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Ryoo SH, Karm MH, Park SU, Kim HJ, Seo KS. Air leakage due to the cuff hanging on the vocal cords during nasotracheal intubation: a case report. J Dent Anesth Pain Med 2023; 23:39-43. [PMID: 36819601 PMCID: PMC9911962 DOI: 10.17245/jdapm.2023.23.1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Nasotracheal intubation is commonly performed under general anesthesia in oral and maxillofacial surgery. For the convenience of surgery, nasal Ring-Adair-Elwyn (RAE) tubes are mainly used. Because the nasal RAE tubes were bent in an "L" shape, the insertion depth was limited. Particularly, it is necessary to accurately determine the appropriate depth of the RAE tubes in children. Several types of nasal RAE tubes are used in the medical market, which vary in material and length. We performed endotracheal intubation using a nasal RAE tube for double-jaw surgery, but air leakage persisted even when the air pressure in the cuff was increased. When checked with a laryngoscope, it was confirmed that the tube was pushed out, and the cuff was caught on the vocal cords, causing air leakage. Since inserting the tube deeply did not solve the problem, replacing it with a nasal RAE tube (Polar™, Preformed Tracheal Tube, Smith Medical, Inc., USA) did not cause air leakage; thus, we reported this case.
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Affiliation(s)
- Seung-Hwa Ryoo
- Department of Dental Anesthesiology, Seoul National University, School of Dentistry, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University, School of Dentistry, Seoul, Korea
| | - Se-Ung Park
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, Seoul National University, School of Dentistry, Seoul, Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Seoul National University, School of Dentistry, Seoul, Korea
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8
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Jain D, Kaur M, Jobin SP, Gaikwad VB. Rare cause of intraoperative endotracheal cuff deflation. J Anaesthesiol Clin Pharmacol 2022; 38:666-667. [PMID: 36778798 PMCID: PMC9912861 DOI: 10.4103/joacp.joacp_597_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/14/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Dhruv Jain
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Manpreet Kaur
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sunderraj Prabhavati Jobin
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Balnath Gaikwad
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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9
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Byerly SE, Yeh DD. The Role of Indirect Calorimetry in Care of the Surgical Patient. CURRENT SURGERY REPORTS 2022; 10:186-191. [PMID: 36119549 PMCID: PMC9472180 DOI: 10.1007/s40137-022-00326-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/08/2022]
Abstract
Purpose of Review This is a review of recent literature on the role of indirect calorimetry in surgical nutrition. Recent Findings All critical care societal guidelines recommend the use of indirect calorimetry as the standard of care to determine energy needs. Recent studies confirm discrepancy between measured and equation-predicted energy expenditure and further demonstrate improved outcomes with indirect calorimetry-guided nutrition. Patients that undergo ECMO, CRRT and those with COVID-19 would benefit from the use of indirect calorimetry. Summary Indirect calorimetry-guided nutrition is the standard of care in mechanically ventilated surgical patients.
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Affiliation(s)
- Saskya E. Byerly
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science Center, 910 Madison Ave, #220, Memphis, TN 38163 USA
- University of Tennessee Health Science Center, 910 Madison Ave, #224, Memphis, TN 38163 USA
| | - D. Dante Yeh
- Department of Surgery, Division of Trauma and Acute Care Surgery, Denver Health, 777 Bannock St, Denver, CO MC020680204 USA
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Tamura Y, Saiki E, Hayashi Y. Unexpected tracheal tube cuff leak due to tracheal deformity in a patient with bronchiectasis. Anaesth Rep 2022; 10:ANR312196. [PMID: 36439300 PMCID: PMC9679975 DOI: 10.1002/anr3.12196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Y. Tamura
- Anesthesiology ServiceKaizuka City HospitalKaizukaOsakaJapan
| | - E. Saiki
- Anesthesiology ServiceKaizuka City HospitalKaizukaOsakaJapan
| | - Y. Hayashi
- Anesthesiology ServiceYoka Municipal HospitalYabuHyougoJapan
- Yoka Municipal HospitalYabuHyougoJapan
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11
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Pier MM, Pasick LJ, Benito DA, Nogues J, Thakkar P, Joshi AS, Goodman JF. Adverse Events Associated With Electromyogram Endotracheal Tubes in Thyroid and Parathyroid Surgery. J Patient Saf 2022; 18:171-176. [PMID: 34325465 DOI: 10.1097/pts.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Thyroid and parathyroid surgeries are frequently performed with the aid of electromyogram endotracheal tubes. However, the most common adverse events have not been reported comprehensively. This study aimed to summarize the device adverse events, patient complications, and subsequent interventions related to electromyogram endotracheal tubes. METHODS In this retrospective cross-sectional analysis, the US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for electromyogram endotracheal tube adverse events between 2010 and 2020. Data were extracted for devices used in thyroid and parathyroid surgery. RESULTS Of 198 included reports, the most common device-related adverse events were loss of response to nerve stimulation (34.8%), cuff perforation (18.2%), and tube lumen obstruction (13.6%). Of 98 patient complications, the most common included ventilation failure (n = 50), airway trauma (n = 22), and recurrent laryngeal nerve injury (n = 5). There was 1 periprocedural death reported. Reported interventions include reintubation performed in 60.1% of all device adverse events, extended hospitalization in 27.3% of airway trauma events, and 5 tracheostomies performed for ventilation failure events. Forty-one events resulted in case delays and 13 events led to aborted cases. The most reported adverse events occurred in 2018 (n = 35) and 2015 (n = 30). CONCLUSIONS The most commonly reported adverse events associated with electromyogram endotracheal tubes include loss of response to nerve stimulation, cuff perforation, ventilation failure, and airway trauma. Subsequent interventions include reintubation, tracheostomy, extended hospitalization, and aborted cases. Surgical teams should consider these adverse events when consenting patients and using these devices in thyroid and parathyroid cases.
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Affiliation(s)
- Matthew M Pier
- From the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA
| | - Luke J Pasick
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Daniel A Benito
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Juan Nogues
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Punam Thakkar
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Arjun S Joshi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joseph F Goodman
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
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12
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Budde AM, Kadar RB, Jabaley CS. Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways. Curr Opin Anaesthesiol 2022; 35:130-136. [PMID: 35131969 DOI: 10.1097/aco.0000000000001105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated. RECENT FINDINGS Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation. SUMMARY Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.
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Affiliation(s)
- Anna M Budde
- Division of Critical Care Medicine, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rachel B Kadar
- Section of Critical Care Medicine, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine
- Emory Critical Care Center, Atlanta, GA
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13
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Methodological Aspects of Indirect Calorimetry in Patients with Sepsis-Possibilities and Limitations. Nutrients 2022; 14:nu14050930. [PMID: 35267903 PMCID: PMC8912694 DOI: 10.3390/nu14050930] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/13/2022] Open
Abstract
The aim of the review was to analyse the challenges of using indirect calorimetry in patients with sepsis, including the limitations of this method. A systematic review of the literature was carried out. The analysis concerned the methodology and presentation of research results. In most studies assessing energy expenditure, energy expenditure was expressed in kcal per day (n = 9) and as the mean and standard deviation (n = 7). Most authors provided a detailed measurement protocol, including measurement duration (n = 10) and device calibration information (n = 7). Ten papers provided information on the day of hospitalisation when the measurements were obtained, nine on patient nutrition, and twelve on the criteria for inclusion and exclusion of participants from the study. Small study group sizes and study at a single centre were among the most cited limitations. Studies assessing energy expenditure in patients with sepsis by indirect calorimetry differ in the methodology and presentation of results, and their collective analysis is difficult. A meta-analysis of the results could enable multi-site and large patient evaluation. Standardisation of protocols and presentation of all collected data would enable their meta-analysis, which would help to achieve greater knowledge about metabolism in sepsis.
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14
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Sindwani G, Tempe D, Suri A, Arora MK. Leaks around the endotracheal tube cuff – A must know fact in COVID Era and a simple solution! J Anaesthesiol Clin Pharmacol 2022; 38:S130-S131. [PMID: 36060164 PMCID: PMC9438812 DOI: 10.4103/joacp.joacp_654_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/14/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022] Open
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15
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Xiang L, Cao M, Wang Y, Song X, Tan M, Zhang X. Could clinical nursing procedures lead to tracheal cuff pressure drop? A prospective observational study. J Clin Nurs 2021; 31:623-632. [PMID: 34296490 DOI: 10.1111/jocn.15920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 12/01/2022]
Abstract
AIM To evaluate the dynamic changes in tracheal cuff pressure before and after four clinical nursing procedures including sputum suction, oral care, atomisation inhalation, and turning over, and thus provide references for the adjustment time of cuff pressure in clinical practice. BACKGROUND Cuff pressure must be kept within the range of 25-30 cmH2 O to ensure effective ventilation and prevent aspiration, while maintaining tracheal blood flow perfusion. DESIGN A prospective observational study. METHODS The cuff pressure of 56 intubated patients was adjusted to 28-30 cmH2 O. A cuff pressure monitor was used to continuously monitor cuff pressure changes before and after four clinical nursing procedures (sputum suction, oral care, atomisation inhalation, and turning over) and the cuff pressures at various time points were compared. The semi-quantitative cough strength score (SCSS) was used to evaluate cough strength during sputum suction and the effect of cough strength on cuff pressure during sputum suction. This study followed the STROBE checklist for cross-sectional studies. RESULTS The cuff pressures during the four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care, all temporarily increased (p < 0.001) and decreased to varying degrees 20 min later (p < 0.001). Among them, the cuff pressure rose the highest under a state of moderate or strong coughing during sputum suction (78.38 ± 12.13 cmH2 O) and dropped the most at 20 min after the procedure (21.71 ± 4.80 cmH2 O). CONCLUSIONS The four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care can all cause different degrees of cuff pressure drop. The decision on whether the cuff pressure needs to be corrected depends on the specific situation. RELEVANCE TO CLINICAL PRACTICE During clinical practice, the cuff pressure can be individually corrected according to different clinical nursing procedures, which can increase the qualified rate of cuff pressure and reduce the workload of nurses.
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Affiliation(s)
- Lijun Xiang
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Meng Cao
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Yuan Wang
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Xuemei Song
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Miaoqin Tan
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Xiaomei Zhang
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
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16
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Seo SH, Lee JM, Lee JJ, Ahn EJ, Choi GJ, Kang H. Repeated endotracheal tube cuff tears during nasotracheal intubation due to nasal cavity orthodontic micro-implant - A case report. Anesth Pain Med (Seoul) 2021; 16:398-402. [PMID: 34233408 PMCID: PMC8828625 DOI: 10.17085/apm.21015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
Background Nasotracheal intubation is generally performed for intraoral surgery. Case A 34-year-old female patient who underwent orthognathic surgery exhibited repeated endotracheal tube cuff tears during nasotracheal intubation. After intubation, leaks developed, and torn endotracheal cuff was observed in the removed endotracheal tube. Subsequently, re-intubation through the same nasal cavity was performed immediately, but leakage from the torn endotracheal tube cuff was re-observed. A leakage test of the extubated tube revealed air bubbles and leaks near the tube cuff due to the tear. Nasotracheal intubation was performed through the other nasal cavity, and there were no leakage findings or abnormalities. During the course of the surgery, the surgeon noticed that the orthodontic micro-implant deposited in the mid-tube cavity was exposed to the nasal cavity. Conclusions We aimed to emphasize caution and discuss the possibility that orthodontic micro-implants that are not confirmed during preoperative evaluation may cause repeated endotracheal tube cuff tears.
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Affiliation(s)
| | | | | | | | | | - Hyun Kang
- Corresponding Author: Hyun Kang, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea Tel: 82-2-6299-2586, Fax: 82-2-6299-2585 E-mail:
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17
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Nakanishi T, Sobue K. Pilot line damage at the embedded part of a sutured endotracheal tube intubated via a tracheostomy stoma. Saudi J Anaesth 2021; 15:79-80. [PMID: 33824654 PMCID: PMC8016050 DOI: 10.4103/sja.sja_830_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/02/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Toshiyuki Nakanishi
- Department of Anesthesiology and Intensive Care Medicine, Naagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Naagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
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18
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Subramaniam DR, Oren L, Willging JP, Gutmark EJ. Evaluating the biomechanical characteristics of cuffed-tracheostomy tubes using finite element analysis. Comput Methods Biomech Biomed Engin 2021; 24:1595-1605. [PMID: 33761806 DOI: 10.1080/10255842.2021.1902511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this study was to perform finite element analysis (FEA) of cuff inflation within an anatomically accurate model of an adult trachea in four different cuffed-tracheostomy tube designs. The leakage quantified by the distance between the cuff and trachea was largest for the Tracoe cuff and smallest for the Portex cuff. The smooth muscle stresses were greatest for the Portex and least for the Distal cuff, respectively. The proposed FEA model offers a promising approach to virtually evaluate the sealing efficacy of cuffed-tracheostomy tubes and the tracheal wall stresses induced by cuff inflation, prior to application.
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Affiliation(s)
| | - Liran Oren
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Paul Willging
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ephraim J Gutmark
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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19
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DeWitt AL, Acker J, Larkin TA, Potenziano JL, Schmidt JM. Compatibility and Safety Implications Associated with Interfacing Medical Devices in Neonatal Respiratory Care: A Case Example Using the Inhaled Nitric Oxide Delivery System. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:27-35. [PMID: 33628066 PMCID: PMC7899041 DOI: 10.2147/mder.s268477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/19/2021] [Indexed: 11/23/2022] Open
Abstract
Over the past decade, international organizations have instituted strict regulations for the safe use of connected medical devices. The International Organization for Standardization and the Medical Device Single Audit Program instituted certifications to ensure that connected devices are compatible and operate within their proper clinical parameters. These efforts came about, in part, as a consequence of clinicians’ decisions to use nonstandard, modified, or improvised devices for purposes outside the original manufacturers’ approved parameters. Unapproved device modifications can be associated with increased risk of dosing errors, monitoring errors, tubing misconnections and serious or potentially fatal adverse events; furthermore, health care providers who implement unapproved device modifications may assume legal and financial liability should harm come to patients as a consequence of the modification. Using the inhaled nitric oxide delivery system as an example, the objective of this paper is to raise awareness of the potential dangers associated with unapproved modification and interfacing of therapeutic gas delivery systems and ventilators in the neonatal intensive care unit setting. The paper also highlights the rationale and necessity for rigorous validation processes that ensure that interfaced medical devices perform as intended in the clinical setting.
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Affiliation(s)
| | - Jaron Acker
- Medical Device Marketing, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Thomas A Larkin
- Device Engineering R&D, Mallinckrodt Pharmaceuticals Ireland Ltd., Dublin, Ireland
| | - Jim L Potenziano
- Scientific Affairs, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
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20
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Kumar A, Kumar A, Kumar N, Kumar A. Endotracheal tube inflation tubing defect: an unusual cause of intraoperative volume leak. J Clin Monit Comput 2020; 35:1239-1240. [PMID: 33095350 DOI: 10.1007/s10877-020-00607-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
Loss of endotracheal cuff pressure can lead to airway compromise and loss of volume delivery in mechanical ventilation requiring immediate intervention. A 40 years old male posted for bilateral interpositional arthroplasty was intubated nasally with 7.5 mm flexometallic endotracheal tube. In the intraoperative period airway leak was detected due to loss of cuff pressure even after repeated attempt of cuff inflation. After changing endotracheal tube, leak was detected from the inflation tubing distal to the cuff, which was apparent only when cuff pressure was increased above 30 cm of H2O.
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Affiliation(s)
- Abhyuday Kumar
- Department of Anesthesiology, AIIMS Patna, Room No. 15, OPD Block, Phulwarisarif, Patna, Bihar, India.
| | - Amarjeet Kumar
- Department of Trauma & Emergency, AIIMS Patna, Patna, India
| | - Neeraj Kumar
- Department of Trauma & Emergency, AIIMS Patna, Patna, India
| | - Ajeet Kumar
- Department of Anesthesiology, AIIMS Patna, Patna, India
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21
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Cambruzzi M, Minghella E. Tracheal misplacement of a temperature probe in a dog during general anaesthesia. Vet Anaesth Analg 2020; 47:725-727. [PMID: 32778455 DOI: 10.1016/j.vaa.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/04/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Martina Cambruzzi
- Anaesthesia Department, Langford Veterinary Referral Hospital, University of Bristol, Langford, UK.
| | - Enzo Minghella
- Anaesthesia Department, Langford Veterinary Referral Hospital, University of Bristol, Langford, UK
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22
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Karmali S, Rose P. Tracheal tube size in adults undergoing elective surgery - a narrative review. Anaesthesia 2020; 75:1529-1539. [PMID: 32415788 DOI: 10.1111/anae.15041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 12/17/2022]
Abstract
Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with 7-7.5 mm and 8-8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6-6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim-line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator-induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri-operative management.
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Affiliation(s)
- S Karmali
- Department of Anaesthesiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - P Rose
- Department of Anaesthesiology, Vancouver General Hospital, Vancouver, BC, Canada
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23
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Cuff Failure of Spiral-Filled Polyvinyl Chloride Endotracheal Tube Immediately after Tracheal Intubation Using a Channeled Videolaryngoscope (Pentax Airway Scope). Case Rep Anesthesiol 2020; 2020:3658092. [PMID: 32231803 PMCID: PMC7085831 DOI: 10.1155/2020/3658092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/19/2020] [Indexed: 12/02/2022] Open
Abstract
We report on a case of mechanical damage to the spiral-filled polyvinyl chloride endotracheal tube that occurred shortly after tracheal intubation using a channeled videolaryngoscope (Pentax airway scope). We also found this problem in two other cases among 350 neurosurgery patients over the past 5 years. Prior to intubation, we did not observe any defect in the cuff. However, the cuff could not be filled with air immediately after the intubation. Anesthesiologists should be aware that, during tracheal intubation using an airway scope, friction between the endotracheal tube and inner surface of the introducer might result in sudden rupture of the cuff.
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24
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Cabrera JA. Air leak from a tracheal tube after intubation: a review. Anaesthesia 2019; 74:1194-1195. [DOI: 10.1111/anae.14782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Piroli A, Cutilli T, Lupi E, Marinangeli F, Varrassi G, Paladini A. Different Solutions for Damaged Nasotracheal Tube during Maxillofacial Surgery: A Case Series. Adv Ther 2019; 36:1812-1816. [PMID: 31065994 DOI: 10.1007/s12325-019-00968-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 12/19/2022]
Abstract
Difficult airway management and intraoperative tube damage are important problems during maxillofacial surgery. Damage occurs frequently during the surgery, and the anesthesiologist must be ready to find a quick and safe solution. Replacing the damaged endotracheal tube involves additional difficulties, and various factors must be evaluated. We present two cases of nasotracheal tube (NTT) damage suffered during maxillofacial surgery. The different intraoperative conditions led us to decide for the replacement of NTT in one case and for conservative action in the other. The purpose of this article is to highlight the difficulties that the anesthesiologist may have in deciding quickly what is the best approach in case the endotracheal tube is damaged during maxillofacial surgery and possibly try to provide a rapid and safe solution for the situation.
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Affiliation(s)
- Alba Piroli
- Department of MeSVA, University of L'Aquila, L'Aquila, Italy
| | - Tommaso Cutilli
- Department of MeSVA, University of L'Aquila, L'Aquila, Italy
| | - Ettore Lupi
- San Salvatore Teaching Hospital of L'Aquila, L'Aquila, Italy
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26
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Valentine J, Shteyman M, Samet RE. Large Iatrogenic Tracheal Injury From Attempted Endotracheal Cuff Leak Remedy: A Case Report. A A Pract 2019; 13:225-227. [DOI: 10.1213/xaa.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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27
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28
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Marti JD, Li Bassi G, Isetta V, Lazaro MR, Aguilera-Xiol E, Comaru T, Battaglini D, Meli A, Ferrer M, Navajas D, Pelosi P, Chiumello D, Torres A, Farre R. An in-vitro study to evaluate high-volume low-pressure endotracheal tube cuff deflation dynamics. Minerva Anestesiol 2019; 85:846-853. [PMID: 30871300 DOI: 10.23736/s0375-9393.19.13133-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND High-volume low-pressure (HVLP) endotracheal tube (ETT) cuffs for critically ill patients often deflate during the course of mechanical ventilation. We performed an in-vitro study to comprehensively assess HVLP cuff deflation dynamics and potential preventive measures. METHODS We evaluated 24-hour deflation of seven HVLP cuffs of cylindrical or tapered shape, and made of polyvinylchloride or polyurethane. Experiments were performed within a thermostated chamber set at 37 °C. In the first stage of experiments, the cuff pilot balloon valve was not manipulated. The cuff internal pressure was assessed hourly for 24 hours, via a linear position sensor which monitored cuff deflation displacements. Then, we re-evaluated cuff deflation of the worst-performing ETT cuffs with the cuff pilot balloon valve sealed. Finally, we inflated ETT cuffs within an artificial trachea to evaluate deflation dynamics during mechanical ventilation. RESULTS Initial tests showed an exponential decrease in cuff internal pressure in five out of seven cuffs. Cuffs of cylindrical shape and made of polyurethane demonstrated the fastest deflation rates (P<0.050 vs. cuffs of conical shape and made of polyvinylchloride). When the cuff pilot balloon valve was not sealed, the internal cuff pressure deflation rate differed significantly among ETTs (P=0.005). Yet, upon sealing the cuff pilot balloon valve and during mechanical ventilation, cuff deflation rates decreased (P<0.050). CONCLUSIONS In controlled in-vitro settings, ETT cuffs consistently deflate over time, and the cuff pilot balloon valve plays a central role in this occurrence. Deflation rate decreases when cuffs are inflated within a plastic artificial tracheal model and mechanical ventilation is activated.
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Affiliation(s)
- Joan D Marti
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain
| | - Gianluigi Li Bassi
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Valentina Isetta
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Unit of Biophysics and Bioengineering, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Miguel R Lazaro
- Unit of Biophysics and Bioengineering, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Eli Aguilera-Xiol
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Talitha Comaru
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain
| | - Denise Battaglini
- Dipartimento Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, Genoa, Italy
| | - Andrea Meli
- Unit of Anesthesia and Resuscitation, Department of Science and Health, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Miguel Ferrer
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Daniel Navajas
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Unit of Biophysics and Bioengineering, Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Institut of Bioengineering of Catalunya, Barcelona, Spain
| | - Paolo Pelosi
- Dipartimento Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, Genoa, Italy
| | - Davide Chiumello
- Unit of Anesthesia and Resuscitation, Department of Science and Health, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Antoni Torres
- Department of Pulmonary and Critical Care Medicine, Thorax Institute, Clinical Hospital, Barcelona, Spain - .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Ramon Farre
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Unit of Biophysics and Bioengineering, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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Krishnakumar M, Goyal A, Sudhir V, Reddy KM. Intraoperative endotracheal tube cuff leak during cerebral aneurysm surgery - A hard row to hoe. Indian J Anaesth 2019; 63:590-592. [PMID: 31391624 PMCID: PMC6644191 DOI: 10.4103/ija.ija_262_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Mathangi Krishnakumar
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Amit Goyal
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - V Sudhir
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Kr Madhusudan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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30
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Gopalan PD. Goldilocks and endotracheal tube cuff pressure management: Not too high, not too low. Just right …. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35i1.401. [PMID: 36959816 PMCID: PMC10029735 DOI: 10.7196/sajcc.2019.v35i1.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- P D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical
Medicine, University of KwaZulu-Natal, Durban, South Africa
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31
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DeAngelis M, Hoffman CR, Russo K. Novel method of securing 15 mm endotracheal tube adapter to avoid unnecessary tube exchange. J Clin Anesth 2018; 51:58-59. [PMID: 30096521 DOI: 10.1016/j.jclinane.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Mario DeAngelis
- Drexel University College of Medicine, Hahnemann University Hospital, Department of Anesthesiology & Perioperative Medicine, Philadelphia, PA, United States of America
| | - Christopher Ryan Hoffman
- Drexel University College of Medicine, Hahnemann University Hospital, Department of Anesthesiology & Perioperative Medicine, Philadelphia, PA, United States of America..
| | - Kevin Russo
- Drexel University College of Medicine, Hahnemann University Hospital, Department of Anesthesiology & Perioperative Medicine, Philadelphia, PA, United States of America
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32
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Dayan AC, Epstein RH. Structural Integrity of a Simple Method to Repair Disrupted Tracheal Tube Pilot Balloon Assemblies. Anesth Analg 2017; 123:1158-1162. [PMID: 27607477 DOI: 10.1213/ane.0000000000001552] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND An intact pilot balloon assembly is crucial to the proper function of a cuffed tracheal tube. Disruption of the pilot balloon, transection of the inflation line, or valve incompetence results in cuff deflation, which may lead to inadequate ventilation and aspiration of secretions. Such failures typically result in tracheal tube replacement, but this may be a safety risk if a difficult reintubation is anticipated. We recently encountered such a patient who remained intubated postoperatively and in whom the inflation line was transected, causing a large leak. We describe a method to reconstitute the inflation line and report on the structural integrity of the repair. We hypothesized that the repaired assembly would maintain cuff pressure not statistically different from an intact device, but that the inflation line would be weaker. METHODS The distal (tapered) portion of a 22-gauge intravenous (IV) catheter was partially inserted into the severed end of the inflation line. A new pilot balloon was cut from an intact tracheal tube with the tubing attached, the end of which had been dilated using a 22-gauge IV catheter. The new tubing was then guided over the protruding portion of the catheter, creating an internal stent. We measured the drop in cuff pressure after 8 hours in an artificial trachea for repaired and intact tracheal tubes. We tested the integrity of the repaired segments, underwater, to high-pressure inflation. We measured the static tensile strength of the inflation line from intact and repaired tracheal tubes. Data are presented as the mean ± standard error. Differences were assessed using the unpaired, 2-sided Student t test, with P < .05 required to claim statistical significance. RESULTS Eight-hour interval measurements in 10 intact versus 10 repaired tracheal tubes demonstrated no significant difference in pressure drop (mean difference = 0.5 cm H2O; 95% confidence interval, -2.2 to 1.2 cm H2O; P = .54). There was no visible air leak from 10 repaired inflation line segments when the cuff was inflated to 120 mm Hg. The force needed to break the repaired inflation line was lower than for the intact tubing (n = 7 of each; mean difference = -21.9 N; 95% confidence interval, -25.7 to -18.1 N; P < 10). Repairs to tracheal tubes from various manufacturers with inner diameters ranging from 3.0 to 8.0 mm were successful. CONCLUSIONS Repairing a disrupted pilot balloon assembly using an IV catheter as a stent inside the inflation line is an effective temporizing measure in situations where ventilation is impaired and where tracheal tube replacement may present an excessive patient risk.
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Affiliation(s)
- Amir C Dayan
- From the *Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and †Department of Anesthesiology, Pain Management, and Perioperative Medicine, University of Miami, Miller School of Medicine, Miami, Florida
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Evaluation of pH on removed tracheal tubes after general anesthesia: a prospective observational study. J Clin Anesth 2016; 35:346-349. [DOI: 10.1016/j.jclinane.2016.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 11/23/2022]
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An Unusual Lacerated Tracheal Tube during Le Fort Surgery: Literature Review and Case Report. Case Rep Anesthesiol 2016; 2016:6298687. [PMID: 27895942 PMCID: PMC5118511 DOI: 10.1155/2016/6298687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022] Open
Abstract
Maxillofacial surgeries can present unique anesthetic challenges due to potentially complex anatomy and the close proximity of the patient's airway to the surgical field. Damage to the tracheal tube (TT) during maxillofacial surgery may lead to significant airway compromise. We report the management of a patient with a partially severed TT during Le Fort surgery for midfacial hypoplasia and management strategies based on peer-reviewed literature. This case illustrates the clinical clues associated with a damaged TT and explores the challenges of managing this potentially catastrophic issue.
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Oshima T, Berger MM, De Waele E, Guttormsen AB, Heidegger CP, Hiesmayr M, Singer P, Wernerman J, Pichard C. Indirect calorimetry in nutritional therapy. A position paper by the ICALIC study group. Clin Nutr 2016; 36:651-662. [PMID: 27373497 DOI: 10.1016/j.clnu.2016.06.010] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/09/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS This review aims to clarify the use of indirect calorimetry (IC) in nutritional therapy for critically ill and other patient populations. It features a comprehensive overview of the technical concepts, the practical application and current developments of IC. METHODS Pubmed-referenced publications were analyzed to generate an overview about the basic knowledge of IC, to describe advantages and disadvantages of the current technology, to clarify technical issues and provide pragmatic solutions for clinical practice and metabolic research. The International Multicentric Study Group for Indirect Calorimetry (ICALIC) has generated this position paper. RESULTS IC can be performed in in- and out-patients, including those in the intensive care unit, to measure energy expenditure (EE). Optimal nutritional therapy, defined as energy prescription based on measured EE by IC has been associated with better clinical outcome. Equations based on simple anthropometric measurements to predict EE are inaccurate when applied to individual patients. An ongoing international academic initiative to develop a new indirect calorimeter aims at providing innovative and affordable technical solutions for many of the current limitations of IC. CONCLUSION Indirect calorimetry is a tool of paramount importance, necessary to optimize the nutrition therapy of patients with various pathologies and conditions. Recent technical developments allow broader use of IC for in- and out-patients.
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Affiliation(s)
- Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana Chuou-ku, Chiba City, Chiba 260-8677, Japan.
| | - Mette M Berger
- Adult Intensive Care, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Elisabeth De Waele
- Department of Intensive Care, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Anne Berit Guttormsen
- Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, Jonas Liesvei 65, 5021 Bergen, Norway; Department of Clinical Medicine University of Bergen, Bergen, Norway; Haukeland Universitetssykehus Laboratoriebygget, 7. etg. Heis øst, Norway.
| | - Claudia-Paula Heidegger
- Service of Intensive Care, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
| | - Michael Hiesmayr
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, University Hospital of Vienna, Waehrihger Guertel 18-20, 1090 Vienna, Austria.
| | - Pierre Singer
- Critical Care Medicine, Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva 49100, Israel.
| | - Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital Huddinge, Sweden.
| | - Claude Pichard
- Nutrition Unit, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
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Flores-Franco RA. Improvised technique for measuring tracheal tube cuff pressure. World J Anesthesiol 2016; 5:36-37. [DOI: 10.5313/wja.v5.i1.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/26/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
We agree with the editorial published by Feng et al concerning the insufficient routine monitoring of tracheal tube cuff pressure (TTCP) by anesthesiologists, and propose an improvised technique that can facilitate and promote such routine monitoring by intensive care staff who attend to patients receiving mechanical ventilation. Insufficient monitoring of tracheal cuff pressure has also been documented for intensive care unit nurses. Measurements of cuff pressure are beneficial when used in management of air leakage around an endotracheal tube, and can be easily obtained with the aid of a personalized and simple technique performed using materials that are readily available in all hospitals. Other investigators have previously demonstrated the usefulness of employing an improvised technique. We considered that possible disadvantages are similar to those encountered when using standardized equipment. With our improvised technique, we seek to promote among the nursing staff the determination of the TTCP in intubated patients to reduce the risk of related medical complications.
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Bajwa SS, Haldar R, Kaur J. Lignocaine jelly: A simple solution to intraoperative endotracheal tube cuff leak. J Anaesthesiol Clin Pharmacol 2016; 32:130-1. [PMID: 27006568 PMCID: PMC4784204 DOI: 10.4103/0970-9185.173386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Rudrashish Haldar
- Department of Anaesthesia, Gian Sagar Medical College, Banur, Patiala, Punjab, India
| | - Jasleen Kaur
- Department of Anaesthesia, Gian Sagar Medical College, Banur, Patiala, Punjab, India
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Journal of Clinical Monitoring and Computing 2015 end of year summary: respiration. J Clin Monit Comput 2015; 30:7-12. [PMID: 26719297 DOI: 10.1007/s10877-015-9820-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/17/2015] [Indexed: 11/27/2022]
Abstract
This paper reviews 17 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2015, within the field of respiration. Papers were published covering monitoring and training of breathing, monitoring of gas exchange, hypoxemia and acid-base, and CO2 monitoring.
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Comparison of Pressure Changes by Head and Neck Position between High-Volume Low-Pressure and Taper-Shaped Cuffs: A Randomized Controlled Trial. BIOMED RESEARCH INTERNATIONAL 2015; 2015:386080. [PMID: 26509152 PMCID: PMC4609783 DOI: 10.1155/2015/386080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/28/2015] [Accepted: 09/17/2015] [Indexed: 02/07/2023]
Abstract
The present study compared changes in cuff pressure by head and neck position between high-volume low-pressure (HVLP) and taper-shaped (taper) cuffs in a prospective randomized clinical trial. Methods. Forty patients were intubated using tracheal tubes with either HVLP (n = 20; HVLP group) or taper-shaped (n = 20; Taper group) cuffs. Initial cuff pressure was adjusted to 15, 20, or 25 cmH2O in the neutral position. Cuff pressure was evaluated after changing the head and neck positions to flexion, extension, and rotation. Results. Cuff pressure significantly increased with flexion in both HVLP and Taper groups at all initial cuff pressures. It significantly increased with extension in the HVLP group, but not in the Taper group. Cuff pressure did not significantly differ with rotation in either group and was significantly smaller in the Taper group during flexion and extension than in the HVLP group, regardless of initial cuff pressure. Conclusion. Cuff pressure changes with head and neck flexion and extension were smaller in the Taper group than in the HVLP group. Our results highlight the potential for taper cuffs to prevent excessive cuff pressure increases with positional changes in the head and neck. This trial is registered with UMIN000016119.
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Goyal R, NarmadhaLakshmi K. Endotracheal tube cuff leak: Minor product defect or lack of cuff pressure monitoring? Indian J Crit Care Med 2015. [PMID: 26195866 PMCID: PMC4478681 DOI: 10.4103/0972-5229.158284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rakhee Goyal
- Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
| | - K NarmadhaLakshmi
- Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
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Abstract
PURPOSE OF REVIEW This review discusses our present understanding of postoperative respiratory failure (PRF) pathogenesis, risk factors, and perioperative-risk reduction strategies. RECENT FINDINGS PRF, the most frequent postoperative pulmonary complication, is defined by impaired blood gas exchange appearing after surgery. PRF leads to longer hospital stays and higher mortality. The time frame for recognizing when respiratory failure is related to the surgical-anesthetic insult remains imprecise, however, and researchers have used different clinical events instead of blood gas measures to define the outcome. Still, studies in specific surgical populations or large patient samples have identified a range of predictors of PRF risk: type of surgery and comorbidity, mechanical ventilation, and multiple hits to the lung have been found to be relevant in most of these studies. Recently, risk-scoring systems for PRF have been developed and are being applied in new controlled trials of PRF-risk reduction measures. Current evidence favors carefully managing intraoperative ventilator use and fluids, reducing surgical aggression, and preventing wound infection and pain. SUMMARY PRF is a life-threatening event that is challenging for the surgical team. Risk prediction scales based on large population studies are being developed and validated. We need high-quality trials of preventive measures, particularly those related to ventilator use in both high risk and general populations.
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