Emergency Tracheostomy in Two Airway Trauma Patients Suspected of COVID-19: A Case Report

Diagnostic Accuracy of Suprasternal Versus Subxiphoid Ultrasonography for Endotracheal Intubation

Background

Airway management is an important skill for emergency physicians, and confirmation of correct endotracheal tube (ETT) placement is a crucial component of airway management.

Objectives

Due to the occurrence of incorrect ETT positioning in emergency departments, the present study aimed to compare the diagnostic sensitivity of ultrasound using suprasternal and subxiphoid methods for confirming the correct placement of ETT compared to capnography.

Methods

This cross-sectional study was conducted by examining patients requiring intubation. Ultrasound was performed by two independent emergency medical assistants using two suprasternal and subxiphoid methods to confirm correct ETT placement; the results were then interpreted. To observe the tube passage through the vocal cords, capnography and lung auscultation were applied as the gold standards, and the results of two ultrasound methods were compared.

Results

A total of 66 patients, who were intubated in the emergency department, participated in this study. The positive and negative predictive values, sensitivity, and specificity of supernatural ultrasound were 96.72%, 80%, 98.33%, and 66.67%, respectively. Also, positive and negative predictive values, sensitivity, and specificity of subxiphoid ultrasound were 97.95%, 29.41%, 80%, and 83.33%, respectively. The diagnostic odds ratios of suprasternal and subxiphoid ultrasounds were 1.026 and 1.024 compared to capnography, respectively.

Conclusions

Ultrasonography using the suprasternal method was feasible. Considering the high sensitivity and specificity of this method in confirming correct ETT placement, it produced reliable results. Overall, this modality can be used as one of the main methods to verify correct ETT placement in emergency departments.

Diagnostic Accuracy of Combined Mallampati and Wilson Score to Predict Difficult Intubation in Obese Patients: A Descriptive Cross-Sectional Study

Background

Airway protection during anesthesia is often the primary concern of anesthetists when working with obese patients and always is a difficult task due to increased exposure to harmful effects of apnea, hypoxia, and impaired respiratory mechanics.

Objectives

The primary goal of this research was to determine the diagnostic accuracy of combined Mallampati and Wilson score in detecting difficult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intubation as the gold standard.

Methods

This descriptive cross-sectional study was done in 300 obese patients with BMI > 29.9 kg/m². Modified Mallampati and Wilson score was recorded preoperatively for each patient in the sitting position by the primary investigator. Endotracheal intubation grades were also recorded, and grades IIb, III, and IV were regarded as difficult intubation according to the Cormack-Lehane intubation classification.

Results

The mean age was 46.76 ± 15.57 years. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the combined Mallampati and Wilson score for detecting difficult laryngoscopy and difficult intubation were 75.0, 98.8, 92.9, 95.0, and 94.6%, respectively.

Conclusions

Combined Mallampatti and Wilson score is highly accurate in the initial diagnostic workup of obese patients at risk of difficult intubation. It is easy to calculate and lower the risk of intubation-related complications and failure.

Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic

Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.

Investigating the Effect of Expiratory Time Constant on Outcome in Intubated Patients with Acute Respiratory Failure Caused by COVID-19 in Critical Care Unit: A Research Study

Background

The coronavirus disease 2019 (COVID-19) has a high prevalence and mortality worldwide. Thousands of patients with acute respiratory failure caused by COVID-19 are daily hospitalized in intensive care units (ICUs) around the world. Many of these patients require full mechanical respiratory support and long-term ventilator use. Using different ventilators and calculating important variables can be helpful in meeting therapeutic needs of patients.

Objectives

The aim of present study was to investigate the effect of expiratory time constant (RCEXP) on the course of treatment and duration of mechanical ventilation in patients with acute respiratory failure hospitalized in ICU.

Methods

The present cross-sectional study was conducted on 60 patients with acute respiratory failure who were hospitalized in the ICU and underwent mechanical ventilation due to COVID-19 in the first six months of 2020. The variables of RCEXP, lung compliance and lung resistance in all patients were recorded daily and analyzed. Then, based on clinical outcome, the patients were divided into two groups: the patients with wean outcome (N = 40) and those with death outcome (N = 20).

Results

The mean ± SD of lung compliance in patients who were separated from ventilator and patients with death outcome were 74.73 (18.58) mL/cm H₂O and 36.92 (10.56) mL/cm H₂O, respectively, which was statistically significant (P = 0.001). The mean ± SD of lung resistance in patients who were separated from ventilator and patients with death outcome were calculated at 9.25 (4.62) and 14 (6.5), respectively, which was statistically significant (P = 0.015). Also, there was a statistically significant difference between the two groups in terms of mean ± SD of RCEXP (0.67 (0.23) vs. 0.49 (0.19), P = 0.010).

Conclusions

According to the results of this study, there was a significant difference between high resistance, low compliance, RCEXP, and weaning success of intubation in patients hospitalized in the ICU.

Comparison of RAMP and New Modified RAMP Positioning in Laryngoscopic View During Intubation in Patients with Morbid Obesity: A Randomized Clinical Trial

Background

The prevalence of obesity is increasing worldwide, and anesthesiologists are facing challenges in the airway management of such patients. Excessive adipose tissue influences pharyngeal spaces and affects the laryngoscopic grade. Standard ramp positioning is time-consuming and difficult to prepare, and requires expensive equipment.

Objectives

The aim of this study was to compare the standard ramp position with the proposed low-cost and easily accessible modified ramp position in laryngoscopic view during the intubation of patients with morbid obesity.

Methods

In this single-blind clinical trial, 84 patients candidate for bariatric surgery at Rasoul Akram Hospital in 2020 were assigned to the rapid airway management positioner (RAMP) (R) and new modified RAMP (MR) groups by the block randomization method. The laryngoscopic view of the glottis based on the Cormack-Lehane scale, ventilation quality, duration of intubation, intubation attempts, oxygen saturation at the end of intubation, and the need for backward, upward, rightward pressure (BURP) maneuver for successful intubation were recorded. Normal distribution tests and Mann-Whitney and Kruskal-Wallis tests were used to analyze the data.

Results

The results showed no significant differences between the two groups regarding ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for BURP maneuvers during intubation (P > 0.05).

Conclusions

The two methods are not significantly different, and the new modified ramp position can be used with more ease and availability and less cost.

Invasive Airway "Intubation" in COVID-19 Patients; Statistics, Causes, and Recommendations: A Review Article

CONTEXT

Severe coronavirus disease 2019 (COVID-19) can induce acute respiratory distress, which is characterized by tachypnea, hypoxia, and dyspnea. Intubation and mechanical ventilation are strategic treatments for COVID-19 distress or hypoxia.

METHODS

We searched PubMed, Embase, and Scopus databases to identify relevant randomized control trials, observational studies, and case series published from April 1, 2021.

RESULTS

24 studies were included in this review. Studies had been conducted in the USA, China, Spain, South Korea, Italy, Iran, and Brazil. Most patients had been intubated in the intensive care unit. Rapid sequence induction had been mostly used for intubation. ROX index can be utilized as the predictor of the necessity of intubation in COVID-19 patients. According to the studies, the rate of intubation was 5 to 88%. It was revealed that 1.4 - 44.5% of patients might be extubated. Yet obesity and age (elderly) are the only risk factors of delayed or difficult extubation.

CONCLUSIONS

Acute respiratory distress in COVID-19 patients could require endotracheal intubation and mechanical ventilation. Severe respiratory distress, loss of consciousness, and hypoxia had been the most important reasons for intubation. Also, increased levels of C-reactive protein (CRP), ferritin, d-dimer, and lipase in combination with hypoxia are correlated with intubation. Old age, diabetes mellitus, respiratory rate, increased level of CRP, bicarbonate level, and oxygen saturation are the most valuable predictors of the need for mechanical ventilation. ICU admission mortality following intubation was found to be 15 to 36%. Awake-prone positioning in comparison with high-flow nasal oxygen therapy did not reduce the risk of intubation and mechanical ventilation. There was no association between intubation timing and mortality of the infected patients. Noninvasive ventilation may have survival benefits.

Safety of Healthcare Workers During the Airway Management in Adult and Pediatric Patients with COVID-19

Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has spread worldwide. Although the majority of patients show mild symptoms, the disease can rapidly progress in severe cases and develop acute respiratory distress syndrome (ARDS) that may lead to therapeutic interventions, including oxygenation, tracheal intubation, and mechanical ventilation. It is suggested that the new coronavirus spreads mostly via droplets, surface contact, and natural aerosols. Hence, high-risk aerosol-producing procedures, such as endotracheal intubation, may put the healthcare workers at a high risk of infection. In the course of managing patients with COVID-19, it is essential to prioritize the safety of healthcare workers. Hence, this review study aimed to summarize new guidelines and proper airway management in adult and pediatric COVID-19 patients.

Predicting Risk Score for Mechanical Ventilation in Hospitalized Adult Patients Suffering from COVID-19

Background

COVID-19 has become a pandemic since December 2019, causing millions of deaths worldwide. It has a wide spectrum of severity, ranging from mild infection to severe illness requiring mechanical ventilation. In the middle of a pandemic, when medical resources (including mechanical ventilators) are scarce, there should be a scoring system to provide the clinicians with the information needed for clinical decision-making and resource allocation.

Objectives

This study aimed to develop a scoring system based on the data obtained on admission, to predict the need for mechanical ventilation in COVID-19 patients.

Methods

This study included COVID-19 patients admitted to Sina Hospital, Tehran University of Medical Sciences from February 20 to May 29, 2020. Patients' data on admission were retrospectively recruited from Sina Hospital COVID-19 Registry (SHCo-19R). Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were performed to identify the predictive factors for mechanical ventilation.

Results

A total of 681 patients were included in the study; 74 patients (10.9%) needed mechanical ventilation during hospitalization, while 607 (89.1%) did not. Multivariate logistic analysis revealed that age (OR,1.049; 95% CI:1.008-1.091), history of diabetes mellitus (OR,3.216; 95% CI:1.134-9.120), respiratory rate (OR,1.051; 95% CI:1.005-1.100), oxygen saturation (OR,0.928; 95% CI:0.872-0.989), CRP (OR,1.013; 95% CI:1.001-1.024) and bicarbonate level (OR,0.886; 95% CI:0.790-0.995) were risk factors for mechanical ventilation during hospitalization.

Conclusions

A risk score has been developed based on the available data within the first hours of hospital admission to predict the need for mechanical ventilation. This risk score should be further validated to determine its applicability in other populations.

The Importance of Happy Hypoxemia in COVID-19

Background

Nowadays, the new coronavirus (SARS-CoV-2) and its complications are one of the main concerns of the world. One of the most severe complications of COVID-19 is hypoxemia.

Objectives

This study aimed to assess the importance of happy hypoxemia in COVID-19.

Methods

We systematically searched web of science, PubMed, and Google scholar databases to find articles related to COVID-19 and happy hypoxemia.

Results

COVID-19 causes a type of hypoxemia named silent (happy) hypoxemia, which has an atypical clinical presentation. This type of hypoxemia has not been noted before in viral pneumonia, and there is no specific treatment for this serious complication. Patients with silent hypoxemia may develop severe hypoxemia without dyspnea and with near-normal lung compliance. These patients are awake, calm, and responsive. Although their lungs are not oxygenated efficiently, they are alert and cooperative. Their condition may be deteriorated rapidly without warning and causes death.

Conclusions

According to the findings, paying attention to happy hypoxemia is important for improving the health status of COVID-19 patients.

Electroconvulsive Therapy for a Patient with Suicide by Drinking Bleach During Treatment of COVID-19: A Case Report

Electroconvulsive therapy (ECT) was first experienced in 1938 and had been conducting without anesthesia for 30 years. In this study, the most common indication for ECT was mood disorder (major depressive disorder and bipolar I disorder). We introduce a patient with a history of COVID-19 and suicide who required emergency ECT. Electroconvulsive therapy can be life-saving in patients with suicide history or catatonic schizophrenia. Health workers are at the front line of the COVID-19 outbreak control and must follow health instructions. Aerosol-producing procedures such as suction in anesthesia for ECT may facilitate the transmission of infectious diseases such as COVID-19. When performing aerosol-producing procedures during the pandemic of novel coronavirus, every patient should be considered suspicious.

Clinical Features and Prognosis of Invasive Ventilation in Hospitalized Patients with COVID-19: A Retrospective Study

BACKGROUND

World Health Organization (WHO) declared that the outbreak of COVID-19 constituted a public health emergency of global concern.

OBJECTIVES

Owing to limited data on critically ill patients admitted to ICU, we aimed to describe the clinical characteristics and prognosis of these patients based on ventilatory variables and clinical features.

METHODS

In this retrospective study, 45 critically ill patients with laboratory-confirmed COVID-19 who were admitted to Intensive Care Unit (ICU) wards of the hospital from April 8 to May 9, 2020, were enrolled. Medical files of the patients were reviewed, and demographic and clinical characteristics, laboratory data, lung CT scan findings, causes of intubation, and outcomes of the patients were all collected.

RESULTS

The median age of the patients was 67 years (range 22 to 91), 64% were men, and hypertension was the most common comorbidity. History of close contact with previously confirmed patients was positive in 62.2% of the patients. The mean time from symptom onset to hospital admission was 5.98 ± 2.93 days. The most common symptoms at the onset of illness were dyspnea (95.6%), and gastrointestinal symptoms (22.2%) were rare. The average length of the intubation was 4.84 ± 3.28 days. The distribution of intubation causes in the deceased patients was significantly more than the recovered patients (P = 0.031). The mean score of lung CT involvement in deaths (370.26 ± 207.50) was significantly higher than the recovered patients (235.71 ± 81.21) (P = 0.042). Length of the intubation had a statistically direct correlation with respiratory rate (P = 0.03).

CONCLUSIONS

Most of the critically ill patients admitted to ICU were older men and had poor outcomes with a high mortality rate. Furthermore, the score of chest CT involvement and respiratory rate are important prognostic factors in determining the severity of the illness, requiring ventilatory support, and outcome.