Upper Airway Nerve Block for Rigid Bronchoscopy in the Patients with Tracheal Stenosis: A Case Serie

Airway collapse hinders recovery in bronchoscopy therapy for postintubation tracheal stenosis patients

BACKGROUND

Expiratory central airway collapse (ECAC) following postintubation airway stenosis (PITS) is a rare phenomenon. The impact of airway malacia and collapse on the prognosis and the success rate of bronchoscopic interventional therapy in patients with PITS had been inadequately investigated.

OBJECTIVE

The aim of this research was to assess the influence of airway malacia and collapse on the efficacy of bronchoscopic interventional therapy in patients with PITS.

DESIGN

This retrospective analysis examined the medical documentation of individuals diagnosed with PITS who underwent bronchoscopic intervention at the tertiary interventional pulmonology center of Emergency General Hospital from 2014 to 2021.

MAIN OUTCOME MEASURES

Data pertaining to preoperative, perioperative, and postoperative stages were documented and subjected to analysis.

RESULTS

The patients in malacia and collapse group (MC group) exhibited a higher frequency of perioperative complications, including intraoperative hypoxemia, need for reoperation within 24 h, and postoperative intensive care unit admission rate (P < 0.05, respectively). Meanwhile, patients in group MC demonstrated significantly worse postoperative scores (higher mMRC score and lower KPS score) compared to those in pure stenosis group (P < 0.05, respectively), along with higher degrees of stenosis after treatment and a lower success rate of bronchoscopic intervention therapy cured (P < 0.05, respectively). Pearson analysis results showed that these terms were all significantly correlated with the occurrence of airway malacia and collapse in the airway (P < 0.05, respectively).

CONCLUSION

The presence of malacia or collapse in patients with PITS was associated with increased perioperative complications following bronchoscopic interventional therapy, and significantly reduced the long-term cure rate compared to patients with pure tracheal stenosis. Trial registration Chinese Clinical Trial Registry on 06/12/2021.

REGISTRATION NUMBER

ChiCTR2100053991.

Anesthetic management of airway stent placement by rigid bronchoscopy with superior laryngeal nerve block while preserving spontaneous breathing: A case report

Key Clinical Message

The combination of superior laryngeal nerve block can reduce the respiratory depression that occurs during management under total intravenous anesthesia.

Abstract

Anesthetic management of endobronchial stent placement by rigid bronchoscopy requires the maintenance of spontaneous breathing while suppressing upper airway reflexes. The combination of superior laryngeal nerve block (SLNB) can reduce the respiratory depression that occurs during management under total intravenous anesthesia. The patient was diagnosed as having lung cancer with invasion into the right middle bronchus and stenosis of the right main bronchus on chest computed tomography, and emergency airway stent placement was performed. Sedation was initiated with propofol and dexmedetomidine, and ultrasound-guided SLNB was performed after local anesthetic spraying into the oral cavity and trachea. Bucking was minimally controlled during insertion of the rigid bronchoscope. The patient's intraoperative hemodynamics remained stable, and there were no hypoxic events. SLNB can provide the suppression of the upper airway reflex while minimizing effects on spontaneous breathing, and may be useful for achieving balanced anesthesia during rigid bronchoscopy.

Airway nerve blocks for awake tracheal intubation: A meta-analysis of randomized control trials and trial sequential analysis

STUDY OBJECTIVE

This systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal intubation (ATI).

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

SETTING

All studies that assessed the superiority of airway anesthesia technique for awake tracheal intubation were searched in PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase and Chinese databases (including China National Knowledge Infrastructure, Wanfang database, and VIP databases) and trial registry databases from their inception to December 2022.

PATIENTS

Adult patients included in randomized controlled trials comparing airway anesthesia with or without airway nerve blocks for ATI.

INTERVENTIONS

Airway nerve (including superior laryngeal nerve, glossopharyngeal nerve, or recurrent laryngeal nerve) blocks for ATI.

MEASUREMENTS

The primary outcome was the intubation time. Secondary outcomes were quality of intubating conditions (including patient reaction to placement of the flexible scope and tracheal tube, coughing and gagging, and patient satisfaction) and overall complications during ATI.

MAIN RESULTS

Fourteen articles with 658 patients were identified for analysis. When compared with airway anesthesia without nerve blocks, airway nerve blocks significantly reduced intubation time (standardized mean difference [SMD] -2.57, 95% CI -3.59- -1.56, p < 0.00001), improved anesthesia quality of ATI with higher no reaction to placement of the flexible scope and tracheal tube (relative risk [RR] 9.87; 95% CI 4.10-23.75, p < 0.00001), lower cough or gag reflex during intubation (RR 0.35, 95% CI 0.27-0.46, p < 0.00001), higher excellent patient satisfaction rate (RR 1.88, 95% CI 1.05-3.34, p = 0.03), and lower overall complications (RR 0.29, 95% CI 0.19-0.45, p < 0.00001). The overall quality of evidence was moderate.

CONCLUSIONS

Based on current published evidence, airway nerve blocks provide better airway anesthesia quality for ATI with a shorter intubation time, better intubation conditions including higher no reaction to placement of the flexible scope and tracheal tube, lower cough or gag reflex during intubation, higher excellent patient satisfaction, and lower overall complications.

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.

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.