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Arora L, Sharma S, Carillo JF. Obesity and anesthesia. Curr Opin Anaesthesiol 2024; 37:299-307. [PMID: 38573180 DOI: 10.1097/aco.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.
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Affiliation(s)
- Lovkesh Arora
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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2
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Haag AK, Tredese A, Bordini M, Fuchs A, Greif R, Matava C, Riva T, Scquizzato T, Disma N. Emergency front-of-neck access in pediatric anesthesia: A narrative review. Paediatr Anaesth 2024; 34:495-506. [PMID: 38462998 DOI: 10.1111/pan.14875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/14/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life-threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front-of-neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front-of-neck access in children. METHODS A comprehensive literature was performed the use of emergency front-of-neck access (eFONA) in infants and children. RESULTS Eighty-six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported. CONCLUSION Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.
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Affiliation(s)
- Anna-Katharina Haag
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alberto Tredese
- Unit for Research in Anesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Martina Bordini
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research in Anesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Clyde Matava
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tommaso Scquizzato
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Disma
- Unit for Research in Anesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
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López Viloria C, Torío Marcos M, Díez Burón F. [Implementation of a difficult airway unit: A latent need in our days]. J Healthc Qual Res 2024; 39:198-199. [PMID: 38212184 DOI: 10.1016/j.jhqr.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 01/13/2024]
Affiliation(s)
- C López Viloria
- Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, España.
| | - M Torío Marcos
- Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, España
| | - F Díez Burón
- Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, España
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Emerson T. Responding to an Airway Concern. AORN J 2024; 119:349-351. [PMID: 38661432 DOI: 10.1002/aorn.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 04/26/2024]
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Marković D, Šurbatović M, Milisavljević D, Marjanović V, Stošić B, Stanković M. Prediction of a Difficult Airway Using the ARNE Score and Flexible Laryngoscopy in Patients with Laryngeal Pathology. Medicina (Kaunas) 2024; 60:619. [PMID: 38674265 PMCID: PMC11051977 DOI: 10.3390/medicina60040619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: The ARNE score was developed for the prediction of a difficult airway for both general and ear, nose and throat (ENT) surgery with a universal cut-off value. We tested the accuracy of this score in the case of laryngeal surgery and provided an insight into its effects in combination with flexible laryngoscopy. Materials and Methods: This prospective pilot clinical study included 100 patients who were being scheduled for microscopic laryngeal surgery. We calculated the ARNE score for every patient, and flexible laryngoscopy was provided preoperative. Difficult intubation was assessed according to the intubation difficulty score (IDS). Results: A total of 33% patients had difficult intubation according to the IDS. The ARNE score showed limited accuracy for the prediction of difficult intubation in laryngology with p < 0.0001 and an AUC of 0.784. Flexible laryngoscopy also showed limitations when used as an independent parameter with p < 0.0001 and an AUC of 0.766. We defined a new cut-off value of 15.50 for laryngology, according to the AUC. After the patients were divided into two groups, according to the new cut-off value and provided cut-off value, the AUC improved to 0.707 from 0.619, respectively. Flexible laryngoscopy improved the prediction model of the ARNE score to an AUC of 0.882 and of the new cut-off value to an AUC of 0.833. Conclusions: It is recommended to use flexible laryngoscopy together with the ARNE score in difficult airway prediction in patients with laryngeal pathology. Also, the universally recommended cut-off value of 11 cannot be effectively used in laryngology, and a new cut-off value of 15.50 is recommended.
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Affiliation(s)
- Danica Marković
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center in Niš, 18000 Niš, Serbia; (V.M.); (B.S.)
| | - Maja Šurbatović
- Clinic for Anesthesiology and Intensive Therapy, Military Medical Academy, 11000 Belgrade, Serbia;
- Faculty of Medicine of the Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
| | - Dušan Milisavljević
- Otolaryngology Clinic, University Clinical Center in Niš, 18000 Niš, Serbia; (D.M.); (M.S.)
- Department Otorhinolaryngology, Faculty of Medicine, Univeristy in Niš, 18000 Niš, Serbia
| | - Vesna Marjanović
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center in Niš, 18000 Niš, Serbia; (V.M.); (B.S.)
- Department Surgery and Anesthesiology and Reanimatology, Faculty of Medicine, University in Niš, 18000 Niš, Serbia
| | - Biljana Stošić
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center in Niš, 18000 Niš, Serbia; (V.M.); (B.S.)
- Department Surgery and Anesthesiology and Reanimatology, Faculty of Medicine, University in Niš, 18000 Niš, Serbia
| | - Milan Stanković
- Otolaryngology Clinic, University Clinical Center in Niš, 18000 Niš, Serbia; (D.M.); (M.S.)
- Department Otorhinolaryngology, Faculty of Medicine, Univeristy in Niš, 18000 Niš, Serbia
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Cook TM, Oglesby F, Kane AD, Armstrong RA, Kursumovic E, Soar J. Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024; 79:368-379. [PMID: 38031494 DOI: 10.1111/anae.16187] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.
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Affiliation(s)
- T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- School of Medicine, University of Bristol, Bristol, UK
| | - F Oglesby
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - A D Kane
- Department of Anaesthesia, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK
- Royal College of Anaesthetists, London, UK
| | - R A Armstrong
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Royal College of Anaesthetists, London, UK
| | - E Kursumovic
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Royal College of Anaesthetists, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
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Feth M, Fritz S, Grübl T, Gliwitzky B, Düsterwald S, Bathe J, Bernhard M, Hossfeld B. [Airwaymangement in Emergencies]. Dtsch Med Wochenschr 2024; 149:458-469. [PMID: 38565120 DOI: 10.1055/a-2220-1411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Emergency airway management is a rare but essential emergency medical intervention directly impacting morbidity and mortality of emergency patients. The success of airway management depends on various factors such as patient anatomy, environmental aspects and the provider performing the procedure. Therefore, the use of a clearly structured algorithm for anticipating the difficult airway in emergency situations is strongly recommended. Our article explains different ways of securing the airway as part of a structured algorithm as well as pitfalls and helpful tips.
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Waheed S, Razzak JA, Khan N, Raheem A, Mian AI. Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department. BMC Emerg Med 2024; 24:40. [PMID: 38468215 DOI: 10.1186/s12873-024-00958-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/29/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. METHOD This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. RESULTS The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. CONCLUSION DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.
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Affiliation(s)
- Shahan Waheed
- Department of Emergency Medicine, Aga Khan University & Hospital (AKUH), Karachi, Pakistan.
| | - Junaid Abdul Razzak
- Department of Emergency Medicine, New York Presbyterian Weill Cornell Medicine, New York, USA
| | - Nadeemullah Khan
- Department of Emergency Medicine, Aga Khan University & Hospital (AKUH), Karachi, Pakistan
| | - Ahmed Raheem
- Department of Emergency Medicine, Aga Khan University & Hospital (AKUH), Karachi, Pakistan
| | - Asad Iqbal Mian
- Department of Emergency Medicine, Aga Khan University & Hospital (AKUH), Karachi, Pakistan
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9
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Pirlich N, Berk A, Hummel R, Schmidtmann I, Epp K, Kriege M, Wittenmeier E. Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre. PLoS One 2024; 19:e0299071. [PMID: 38427680 PMCID: PMC10906896 DOI: 10.1371/journal.pone.0299071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION While awake tracheal intubation (ATI) is regarded as the gold standard for difficult airway management according to current guidelines, there seems to be a reluctance in its application. This retrospective cohort study, conducted at a German tertiary hospital over a 2-year period, aimed to demonstrate that integrating awake tracheal intubation using flexible bronchoscopy (ATI:FB) into routine airway management makes it a successful and safe approach. MATERIALS AND METHODS In 2019 and 2020, records from the data acquisition system (DAQ) and archived anesthesia records were screened to evaluate the specifics of ATI:FB procedures, focusing on overall success and safety. Analysis included complications, time required for ATI:FB, and potential influencing factors such as patient characteristics, indication, medical/operative specialty, sedation technique, route and experience of anesthesiologist. Logistic regression assessed the impact of various variables on occurrence of complications and linear regression, with log(time) as the dependent variable, evaluated median time required to perform ATI:FB. RESULTS ATI:FB constituted 4.3 % (n = 1,911) of all airway management procedures, predominantly observed in dental, oral, and maxillofacial surgery (46.5 %) and otorhinolaryngology (38.4 %). The success rate for ATI:FB was notably high at 99.6 %, with only 5.4 % of cases experiencing complications, including technical issues, agitation, and visibility obstruction due to mucous secretion. Complication risk was influenced by the medical specialty and the experience of the anesthesiologist. A strong effect was observed in otorhinolaryngology (OR = 4.54, 95 % CI [1.64; 14.06]). The median time required for ATI:FB was 16 minutes (IQR: 11 to 23), with factors such as indication (p < 0.0001), experience of anesthesiologist (p < 0.0001), sedation technique (p = 0.0408), priority of the procedure (p = 0.0134), and medical/operative specialty (p < 0.0001) affecting the duration. The median time required for ATI:FB differed significantly based on the experience of the anesthesiologist (p < 0.0001). CONCLUSION ATI:FB proves successful and safe, with low complications and manageable procedural time. Experience of the anesthesiologist is a modifiable factor enhancing safety, emphasizing the need for ATI:FB integration into routine airway management.
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Affiliation(s)
- Nina Pirlich
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Alexander Berk
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Regina Hummel
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katharina Epp
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marc Kriege
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Riva T, Goerge S, Fuchs A, Greif R, Huber M, Lusardi AC, Riedel T, Ulmer FF, Disma N. Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model. Paediatr Anaesth 2024; 34:225-234. [PMID: 37950428 DOI: 10.1111/pan.14796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches. AIMS The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques. METHODS Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation. RESULTS The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants. CONCLUSIONS The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05499273.
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Affiliation(s)
- Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Goerge
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riedel
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Francis F Ulmer
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Berger JA, Nelson O, Staben J, Javia LR, Simpao AF, Khalek N, Oliver ER, Adzick NS, Lin EE. Immediate postdelivery airway management of neonates with prenatally diagnosed micrognathia: A retrospective observational study. Paediatr Anaesth 2024; 34:267-273. [PMID: 38069629 DOI: 10.1111/pan.14806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Micrognathic neonates are at risk for upper airway obstruction, and many require intubation in the delivery room. Ex-utero intrapartum treatment is one technique for managing airway obstruction but poses substantial maternal risks. Procedure requiring a second team in the operating room is an alternative approach to secure the obstructed airway while minimizing maternal risk. The aim of this study was to describe the patient characteristics, airway management, and outcomes for micrognathic neonates and their mothers undergoing a procedure requiring a second team in the operating room at a single quaternary care children's hospital. METHODS This was a retrospective descriptive study. Subjects had prenatally diagnosed micrognathia and underwent procedure requiring a second team in the operating room between 2009 and 2021. Collected data included infant characteristics, delivery room airway management, critical events, and medications. Follow-up data included genetic testing and subsequent procedures within 90 days. Maternal data included type of anesthetic, blood loss, and incidence of transfusion. RESULTS Fourteen deliveries were performed via procedure requiring a second team in the operating room during the study period. 85.7% were male, and 50% had a genetic syndrome. Spontaneous respiratory efforts were observed in 93%. Twelve patients (85.7%) required an endotracheal tube or tracheostomy. Management approaches varied. Medications were primarily a combination of atropine, ketamine, and dexmedetomidine. Oxygen desaturation was common, and three patients experienced bradycardia. There were no periprocedural deaths. Follow-up at 90 days revealed that 78% of patients underwent at least one additional procedure, and one patient died due to an unrelated cause. All mothers underwent cesarean deliveries under neuraxial anesthesia. Median blood loss was 700 mL [IQR 700 mL, 800 mL]. Only one mother required a blood transfusion for pre-procedural placental abruption. DISCUSSION Procedure requiring a second team in the operating room is a safe and effective approach to manage airway obstruction in micrognathic neonates while minimizing maternal morbidity. CONCLUSIONS Though shown to be safe and effective, more data are needed to support the use of procedure requiring a second team in the operating room as an alternative to ex-utero intrapartum treatment for micrognathia outside of highly specialized maternal-fetal centers.
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Affiliation(s)
- Jessica A Berger
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James Staben
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Luv R Javia
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Clinical Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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van Zundert AAJ, Gatt SP, van Zundert TCRV, Hagberg CA, Pandit JJ. Supraglottic Airway Devices: Present State and Outlook for 2050. Anesth Analg 2024; 138:337-349. [PMID: 38215712 DOI: 10.1213/ane.0000000000006673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Correct placement of supraglottic airway devices (SGDs) is crucial for patient safety and of prime concern of anesthesiologists who want to provide effective and efficient airway management to their patients undergoing surgery or procedures requiring anesthesia care. In the majority of cases, blind insertion of SGDs results in less-than-optimal anatomical and functional positioning of the airway devices. Malpositioning can cause clinical malfunction and result in interference with gas exchange, loss-of-airway, gastric inflation, and aspiration of gastric contents. A close match is needed between the shape and profile of SGDs and the laryngeal inlet. An adequate first seal (with the respiratory tract) and a good fit at the second seal of the distal cuff and the gastrointestinal tract are most desirable. Vision-guided insertion techniques are ideal and should be the way forward. This article recommends the use of third-generation vision-incorporated-video SGDs, which allow for direct visualization of the insertion process, corrective maneuvers, and, when necessary, insertion of a nasogastric tube (NGT) and/or endotracheal tube (ETT) intubation. A videoscope embedded within the SGD allows a visual check of the glottis opening and position of the epiglottis. This design affords the benefit of confirming and/or correcting a SGD's position in the midline and rotation in the sagittal plane. The first clinically available video laryngeal mask airways (VLMAs) and multiple prototypes are being tested and used in anesthesia. Existing VLMAs are still not perfect, and further improvements are recommended. Additional modifications in multicamera technology, to obtain a panoramic view of the SGD sitting correctly in the hypopharynx and to prove that correct sizes have been used, are in the process of production. Ultimately, any device inserted orally-SGD, ETT, NGT, temperature probe, transesophageal scope, neural integrity monitor (NIM) tubes-could benefit from correct vision-guided positioning. VLMAs also allow for automatic recording, which can be documented in clinical records of patients, and could be valuable during teaching and research, with potential value in case of legal defence (with an airway incident). If difficulties occur with the airway, documentation in the patient's file may help future anesthesiologists to better understand the real-time problems. Both manufacturers and designers of SGDs may learn from optimally positioned SGDs to improve the design of these airway devices.
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Affiliation(s)
- André A J van Zundert
- From the Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, & The University of Queensland, Brisbane, Queensland, Australia
| | - Stephen P Gatt
- Department of Anaesthesia, University of New South Wales, Kensington, New South Wales, Australia
- Department of anaesthesia, Udayana University, Bali, Indonesia
| | | | - Carin A Hagberg
- Department of Anesthesiology & Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaideep J Pandit
- Department of Anaesthesia, University of Oxford, Oxford, United Kingdom
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Forestell B, Ramsden S, Sharif S, Centofanti J, Al Lawati K, Fernando SM, Welsford M, Nichol G, Nolan JP, Rochwerg B. Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:e89-e99. [PMID: 37962112 DOI: 10.1097/ccm.0000000000006112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA. DATA SOURCES We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023. STUDY SELECTION We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management. DATA EXTRACTION Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935). DATA SYNTHESIS We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty). CONCLUSIONS In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sophie Ramsden
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - John Centofanti
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Kumait Al Lawati
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham Nichol
- Departments of Emergency Medicine and Medicine, Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Anesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
| | - Bram Rochwerg
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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14
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Ramos RA, Aguiar AR, Lima CG, Resende R. Oropharyngeal Hemorrhage and Difficult Airway Management: A Decision Not to Intubate. J Emerg Med 2024; 66:133-138. [PMID: 38290880 DOI: 10.1016/j.jemermed.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 10/10/2023] [Accepted: 10/22/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Bleeding in the upper airways is an important cause of airway-related death. A higher incidence of airway management failure and complications after intubation attempts in the emergency department (ED) had been suggested. Airway management of patients with active oropharyngeal hemorrhage may be challenging, leading the clinician to modify the approach. CASE REPORT A 57-year-old woman presented to the ED with oropharyngeal hemorrhage after an extensive invasive dental procedure. She was on long-term warfarin therapy due to aortic and mitral valve replacement, which she suspended 5 days prior and restarted the day after the procedure. Besides the active bleeding, swelling, and hematoma of the face, the patient had other signs of "difficult airway," so there were serious questions on when and how to manage the airway. Several strategies to address the airway were considered, the main point being an early versus later intubation. As the patient remained clinically stable, she was conservatively managed with local hemostasis and coagulopathy reversal. The patient was transferred to the intensive care unit, where she remained stable and was successfully discharged after restart on warfarin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When faced with an oropharyngeal hemorrhage, emergency physicians may be compelled to secure and protect the airway. This could be achieved by planning several strategies. Nevertheless, in selected patients, and considering the circumstances, not addressing the airway is a reasonable and justifiable alternative.
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Affiliation(s)
- Rui A Ramos
- Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, Senhora da Hora, Portugal
| | - Ana Rita Aguiar
- Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, Senhora da Hora, Portugal
| | - Clara Gaio Lima
- Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, Senhora da Hora, Portugal
| | - Rita Resende
- Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, Senhora da Hora, Portugal
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15
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Svendsen CN, Glargaard GL, Lundstrøm LH, Rosenstock CV, Haug AC, Afshari A, Hesselfeldt R, Strøm C. Flexible bronchoscopic intubation through a supraglottic airway device: An evaluation of consultant anaesthetist performance. Acta Anaesthesiol Scand 2024; 68:178-187. [PMID: 37877551 DOI: 10.1111/aas.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/04/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Few clinical studies investigate technical skill performance in experienced clinicians. METHODS We undertook a prospective observational study evaluating procedural skill competence in consultant anaesthetists who performed flexible bronchoscopic intubation (FBI) under continuous ventilation through a second-generation supraglottic airway device (SAD). Airway management was recorded on video and performance evaluated independently by three external assessors. We included 100 adult patients undergoing airway management by 25 anaesthetist specialists, each performing four intubations. We used an Objective Structured Assessment of Technical Skills-inspired global rating scale as primary outcome. Further, we assessed the overall pass rate (proportion of cases where the average of assessors' evaluation for every domain scored ≥3); the progression in the global rating scale score; time to intubation; self-reported procedural confidence; and pass rate from the first to the fourth airway procedure. RESULTS Overall median global rating scale score was 29.7 (interquartile range 26.0-32.7 [range 16.7-37.7]. At least one global rating scale domain was deemed 'not competent' (one or more domains in the evaluation was scored <3) in 30% of cases of airway management, thus the pass rate was 70% (95% CI 60%-78%). After adjusting for multiple testing, we found a statistically significant difference between the first and fourth case of airway management regarding time to intubation (p = .006), but no difference in global rating scale score (p = .018); self-reported confidence before the procedure (p = .014); or pass rate (p = .109). CONCLUSION Consultant anaesthetists had a median global rating scale score of 29.7 when using a SAD as conduit for FBI. However, despite reporting high procedural confidence, at least one global rating scale domain was deemed 'not competent' in 30% of cases, which indicates a clear potential for improvement of skill competence among professionals.
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Affiliation(s)
| | - Gine L Glargaard
- Department of Anaesthesiology, New North Zealand Hospital, Hillerød, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, New North Zealand Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte V Rosenstock
- Department of Anaesthesiology, New North Zealand Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne C Haug
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Arash Afshari
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Juliane Marie Centre Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Hesselfeldt
- Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen, Denmark
| | - Camilla Strøm
- Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen, Denmark
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Cochran-Caggiano N, Holliday J, Howard C. A Novel Intubation Technique: Bougie Introduction Via Ducanto Suction Catheter. J Emerg Med 2024; 66:221-224. [PMID: 38296765 DOI: 10.1016/j.jemermed.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/04/2023] [Accepted: 11/04/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Airway management is a defining skill that demands mastery by emergency physicians. Airway emergencies pose considerable morbidity and mortality risks. Familiarity with, and mastery of, a variety of airway management approaches and equipment can prove invaluable for management of anatomically and physiologically difficult airways. CASE REPORT A 67-year-old woman presented to a level II trauma after a motor vehicle collision. Emergency medical services reported left-sided injuries, including diminished breath sounds. She arrived in extremis with dyspnea and hypoxia refractory to supplemental oxygen. A portable chest x-ray study showed a considerable traumatic diaphragmatic hernia. Initial attempts at intubation via video laryngoscopy were unsuccessful. Difficulties were attributed to anatomic variation, possibly due to the traumatic diaphragmatic hernia, and hematemesis. The airway was repositioned after removal of a cervical collar and suction-assisted laryngoscopy airway decontamination was performed under video guidance. During airway decontamination, the tip of a DuCanto suction catheter (SSCOR) became located at the level of the vocal cords, prompting the decision to control the airway via utilization of the DuCanto suction catheter and a bougie. The suction tubing was disconnected, a bougie was inserted through the catheter, and the DuCanto was subsequently removed and replaced with a cuffed endotracheal tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Airway emergencies are imminent life threats. Familiarity with a variety of tools and techniques allows for definitive airway management via primary, back-up, and contingency plans to secure anatomically or physiologically difficult airway.
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Affiliation(s)
| | - Jordan Holliday
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Cory Howard
- Emergency Medicine Residency, HCA Florida Brandon Hospital, Brandon, Florida
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Bielka K, Kuchyn I, Fomina H, Khomenko O, Kyselova I, Frank M. Difficult airway simulation-based training for anaesthesiologists: efficacy and skills retention within six months. BMC Anesthesiol 2024; 24:44. [PMID: 38297196 PMCID: PMC10829367 DOI: 10.1186/s12871-024-02423-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND The aim of this study was to evaluate how anaesthesiologists manage a "cannot intubate, can ventilate" (CI) and "cannot intubate, cannot ventilate" (CICV) scenarios, and how following simulation training will affect their guideline adherence, skills and decision-making immediately after training and 6 months later. METHODS A prospective controlled study was conducted from July to December 2022. Anaesthesiologists who applied for the continuous medical education course "Difficult Airway Management" were involved in the study. Each volunteer participated in two simulation scenarios (CI, CICV) with structural debriefing after each scenario. After the first simulation round, volunteers were trained in difficult airway management according to DAS guidelines, using the same equipment as during the simulation. The participants repeated the simulation scenarios the day after the training and six months later. The primary and secondary endpoints were compared between three rounds: initial simulation (Group 1), immediately after training (Group 2), and six months after training (Group 3). RESULTS A total of 24 anaesthesiologists consented to participate in the study and completed the initial survey form. During the first session, 83.3% of participants had at least one major deviation from the DAS protocol. During the first CICV scenario, 79% of participants made at least one deviation from the DAS protocol. The second time after simulation training, significantly better results were achieved: the number of anaesthesiologists, who attempted more than 3 laryngoscopies decreased (OR = 7 [1.8-26.8], p = 0.006 right after training and OR = 3.9 [1.06-14.4], p = 0.035 6 month later); the number, who skipped the supralaryngeal device attempt, call for help and failure to initiate surgical airway also decreased. Simulation training also significantly decreases the time to call for help, cricothyroidotomy initiation time, and mean desaturation time and increases the odds ratio of successful cricothyroidotomy (OR 0.02 [0.003-0.14], p < 0.0001 right after training and OR = OR 0.02 [0.003-0.16] 6 months after training). CONCLUSIONS Anaesthesiologists usually display major deviations from DAS guidelines while managing CI and CICV scenarios. Simulation training improves their guideline adherence, skills, and decision-making when repeating the simulation immediately after training and 6 months later. STUDY REGISTRATION NCT05913492, clinicaltrials.gov, 22/06/2023.
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Affiliation(s)
- Kateryna Bielka
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine.
| | - Iurii Kuchyn
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine
| | - Hanna Fomina
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine
| | - Olena Khomenko
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine
| | - Iryna Kyselova
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine
- Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Michael Frank
- Postgraduate department of Surgery, Anaesthesiology and Intensive Care, Bogomolets National Medical University, Kyiv, 01601, Ukraine
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Yu CJ, Rigueiro F, Backfish-White K, Cartwright J, Moore C, Mitchell SA, Boyer T. Cricothyrotomy in Acute Upper Gastrointestinal Bleed: A Difficult Airway Simulation Case for Anesthesiology Residents. MedEdPORTAL 2024; 20:11378. [PMID: 38230362 PMCID: PMC10789914 DOI: 10.15766/mep_2374-8265.11378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/09/2023] [Indexed: 01/18/2024]
Abstract
Introduction Patients with acute upper gastrointestinal bleeding may have challenging airways. This simulation teaches anesthesiology residents the skill of cricothyrotomy as a surgical last resort while managing acute bleeding in the airway. Methods The simulation involved a 55-year-old patient with history of alcohol abuse admitted to the ICU with hematemesis and acute blood loss for esophagogastroduodenoscopy in the ICU setting. The mannequin had tubing in the posterior oropharynx connected to a pressurized bag of simulated blood hidden from view. While conversing, the patient began to cough and gag, and the bag of fluid was opened, filling the posterior oropharynx with blood, which prompted immediate intubation attempts, designed to fail no matter what the learners attempted. When residents requested a surgical airway, they were provided with a cricothyrotomy kit and a task trainer to perform the procedure. Residents were evaluated using a behavior checklist, debriefed, then asked to complete a postsimulation survey. Results Fifty-eight anesthesiology residents completed the simulation and provided feedback via a 5-point Likert scale of agreement. Most residents quickly recognized the need for emergency intubation. Eighty-eight percent of participants strongly agreed that the simulation was a valuable learning experience, with 99% stating it increased their confidence and clinical decision-making in handling similar scenarios in the future. Discussion This simulation provides a chance to practice valuable airway management skills that increase resident confidence in cricothyrotomy. Future work may examine if these skills and confidence levels are sustainable over time and if they are applied in future patient encounters.
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Affiliation(s)
- Corinna J. Yu
- Assistant Professor, Department of Anesthesia, Indiana University School of Medicine
| | - Frank Rigueiro
- Fourth-Year Medical Student, Indiana University School of Medicine
| | - Kevin Backfish-White
- Assistant Professor, Department of Anesthesia, Indiana University School of Medicine
| | - Johnny Cartwright
- Simulation Specialist, Department of Anesthesia, Indiana University School of Medicine
| | - Christopher Moore
- Simulation Specialist, Department of Anesthesia, Indiana University School of Medicine
| | - Sally A. Mitchell
- Associate Professor, Department of Anesthesia, Indiana University School of Medicine
| | - Tanna Boyer
- Associate Professor, Department of Anesthesia, Indiana University School of Medicine
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Rowland MJ, Hazkani I, Becerra D, Jagannathan N, Ida J. An analysis of a new rapid difficult airway response team in a vertically built children's hospital. Paediatr Anaesth 2024; 34:60-67. [PMID: 37697891 DOI: 10.1111/pan.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital. HYPOTHESIS Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location. METHODS A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality. RESULTS There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h. CONCLUSIONS A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.
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Affiliation(s)
- Matthew J Rowland
- Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Inbal Hazkani
- Department of Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Danielle Becerra
- Department of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - Jonathan Ida
- Department of Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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20
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Lima LC, Cumino DDO, Vieira AM, Silva CHRD, Neville MFL, Marques FO, Quintão VC, Carlos RV, Fujita ACG, Barros HÍM, Garcia DB, Ferreira CBT, Barros GAMD, Módolo NSP. Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care. Braz J Anesthesiol 2024; 74:744478. [PMID: 38147975 PMCID: PMC10877349 DOI: 10.1016/j.bjane.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.
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Affiliation(s)
- Luciana Cavalcanti Lima
- Instituto Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Faculdade Pernambucana de Saúde, Recife, PE, Brazil
| | - Débora de Oliveira Cumino
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Mariana Fontes Lima Neville
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Anestesiologia, Dor e Terapia Intensiva, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil
| | | | - Vinicius Caldeira Quintão
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brazil
| | - Ricardo Vieira Carlos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Ana Carla Giosa Fujita
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | - Hugo Ítalo Melo Barros
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Guilherme Antonio Moreira de Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil.
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22
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Krebs W, Newmyer A, Dzurik A, Burgard K, Scaff T, Waltmire J, Wilson T, Kimmett C, Stausmire J, Buderer N. Does the Location of Endotracheal Intubation Affect the Success of Airway Management in a Helicopter Air Ambulance Service? A Simulation Study. Air Med J 2024; 43:19-22. [PMID: 38154834 DOI: 10.1016/j.amj.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/19/2023] [Accepted: 09/02/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Airway management is a cornerstone of helicopter air ambulance patient management. The purpose of this study was to evaluate the overall quality of airway management of critical care crews in 3 common locations for intubation. METHODS This was a prospective observational simulation study assessing the overall airway management of critical care providers managing simulated patients in an emergency department, helicopter, and ambulance. Composite scores were obtained and compared with respect to physical environment and provider certification level. RESULTS Fifty-four participants completed the simulations. The median score for the emergency department was 100; for ambulance, it was 80; and for helicopter, it was 80. Ambulance scores were significantly lower than emergency department scores (median difference = -5 points, P = .002) as were helicopter scores (median difference = -10 points, P < .001). The small sample size limited the statistical power to detect differences in provider type, and no statistically significant differences were found in these groups. CONCLUSION In this study, the physical location of airway management negatively impacted the overall airway management success as determined by a standardized composite score. This suggests that airway management may have the highest rate of success in an emergency department as opposed to ground ambulance or helicopter air ambulance settings.
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Affiliation(s)
- William Krebs
- Mercy Health St Vincent Emergency Medicine Residency, Toledo, OH; Mercy Health Life Flight Network, Toledo, OH; Department of Emergency Medicine, The Ohio State University, Columbus, OH.
| | - Aileen Newmyer
- Mercy Health St Vincent Emergency Medicine Residency, Toledo, OH
| | - Alexander Dzurik
- Mercy Health St Vincent Emergency Medicine Residency, Toledo, OH
| | | | - Tyler Scaff
- Mercy Health St Vincent Emergency Medicine Residency, Toledo, OH
| | | | - Todd Wilson
- Mercy Health Life Flight Network, Toledo, OH
| | - Cora Kimmett
- Mercy Health St Vincent Medical Center, Toledo, OH
| | - Julie Stausmire
- Mercy Health St Vincent Emergency Medicine Residency, Toledo, OH
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Xiong L, Liu J, Li H, Tan Y, Tang L, Du M, Xu Y. Airway management with Hi-flow nasal cannula oxygen in children with severe laryngeal obstruction. Int J Pediatr Otorhinolaryngol 2024; 176:111828. [PMID: 38109807 DOI: 10.1016/j.ijporl.2023.111828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The aim of this study was to report our initial experience in airway management in young children with severe laryngeal obstruction. Hi-flow nasal cannula oxygen (HFNO) with spontaneous respiration was used as a new airway management strategy in young children undergoing suspension laryngoscopic surgery. METHODS Children aged between 1 day and 24 months scheduled for suspension laryngoscopy were retrospectively studied. The data collected included the patients' age, gender, American Society of Anaesthesiologists physical status classification, comorbidities, preoperative physiological status, methods of induction and maintenance of anesthesia, course of the disease and surgical options, lowest oxygen saturation recorded, transcutaneous CO2, duration of operation, and patients' need for rescue methods. RESULTS A total of 38 patients successfully underwent suspension laryngoscopy under HFNO with spontaneous respiration. 19 patients were less than 1 year old (7 neonates), while the other half were less than or equal to 2 years old. The median [IQR (range)] lowest oxygen saturation recorded during the operation was 98 [93-99 (91-99)] %. The median [IQR (range)] duration of HFNO with spontaneous respiration was 65 [45-100 (30-200)] minutes. The median [IQR (range)] PCO2/PtcCO2 at the end of the spontaneous ventilation period was 54 [48-63 (39-70)] mmHg, which was the same as the preoperative PCO2 despite a long operation time. CONCLUSIONS HFNO with spontaneous respiration emerged as a new airway management strategy in young children with severe laryngeal obstruction that was beneficial in maintaining oxygenation and was superior to transnasal humidified rapid insufflation ventilatory exchange (THRIVE) in terms of the rising rate of PCO2 in these patients, thereby prolonging the safety time of the operation.
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Affiliation(s)
- Ling Xiong
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Jianxia Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Haisu Li
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Yanzhe Tan
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Linlin Tang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Min Du
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Ying Xu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China; Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing, 400014, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China; National Clinical Research Center for Child Health and Disorders, Chongqing, 400014, China; Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.
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24
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Lim KS. Prevention of airway fires during tracheostomy is preferable. Comment on: Simulation training results in performance retention for the management of airway fires: A prospective observational study. Anaesth Intensive Care 2024; 52:72. [PMID: 37802489 DOI: 10.1177/0310057x231196908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
- Kar-Soon Lim
- Department of Anaesthesia and Pain Management, Concord Repatriation General Hospital, Concord, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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25
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Martins MP, Ortenzi AV, Perin D, Quintas GCS, Malito ML, Carvalho VH. Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults. Braz J Anesthesiol 2024; 74:744477. [PMID: 38135152 PMCID: PMC10877351 DOI: 10.1016/j.bjane.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.
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Affiliation(s)
| | - Antonio V Ortenzi
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Oncologia e Radiologia, Campinas, SP, Brazil
| | - Daniel Perin
- Universidade de São Paulo (USP), Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brazil
| | - Guilherme C S Quintas
- Hospital da Restauração, Hospital Universitário Oswaldo Cruz, CET Hospital Getúlio Vargas, Recife, PE, Brazil
| | | | - Vanessa H Carvalho
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Oncologia e Radiologia, Campinas, SP, Brazil
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26
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Massimiliano S, Daniele T. From Brobdingnag to Lilliput: Gulliver's travels in airway management guidelines. Br J Anaesth 2024; 132:21-24. [PMID: 38036322 DOI: 10.1016/j.bja.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Neonatal airway management comes with exclusive anatomical, physiological, and environmental complexities, and probably higher incidences of accidents and complications. No dedicated airway management guidelines were available until the recently published first joint guideline released by a task force supported by the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia and focused on airway management in children under 1 yr of age. The guideline offers a series of recommendations based on meticulous methodology including multiple Delphi rounds to complement the sparse and scarce available evidence. Getting back from Brobdingnag, the land of giants with many guidelines available, this guideline represents a foundational cornerstone in the land of Lilliput.
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Affiliation(s)
- Sorbello Massimiliano
- Head of Anesthesia and Intensive Care, Department of Anaesthesia "Giovanni Paolo II" Hospital, Ragusa, Italy.
| | - Trevisanuto Daniele
- Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
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27
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Wong P, Sleigh JW. Airway management of lingual tonsillar hypertrophy: A narrative review. Anaesth Intensive Care 2024; 52:16-27. [PMID: 38006611 DOI: 10.1177/0310057x231196910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. We found 89 patients in various case reports, from which we derived 92 cases to analyse. 64% of cases were assessed as having a normal airway. Difficult and impossible face mask ventilation occurred in 29.6% and 1.4% of cases, respectively. Difficult intubation and failed intubation occurred in 89.1% and 21.7% of cases, respectively. Multiple attempts (up to six) at intubation were performed, with no successful intubation after the third attempt with direct laryngoscopy. Some 16.5% of patients were woken up and 4.3% required emergency front of neck access. Complications included oesophageal intubation (10.9%), bleeding (9.8%) and severe hypoxia (3.2%). Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.
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Affiliation(s)
- Patrick Wong
- Department of Anaesthesia and Pain Medicine, Te Whatu Ora Health New Zealand Waikato, Hamilton, New Zealand
| | - Jamie W Sleigh
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
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28
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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29
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Kamyszek RW, Schechtman SA, Peoples EE, Grenda DR, Jewell ES, Shah NJ, Klumpner TT, Healy DW, Cloyd BH. Airway management beyond the operating room; the effectiveness of a standardized airway protocol. J Clin Anesth 2023; 91:111259. [PMID: 37717462 DOI: 10.1016/j.jclinane.2023.111259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Reed W Kamyszek
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Samuel A Schechtman
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Emily E Peoples
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Dane R Grenda
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Elizabeth S Jewell
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Nirav J Shah
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Thomas T Klumpner
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - David W Healy
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States
| | - Benjamin H Cloyd
- Department of Anesthesiology, Michigan Medicine, University of Michigan Medical School, Ann Arbor, United States.
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Nakayama R, Bunya N, Uemura S, Sawamoto K, Narimatsu E. Prehospital Advanced Airway Management and Ventilation for Out-of-Hospital Cardiac Arrest with Prehospital Return of Spontaneous Circulation: A Prospective Observational Cohort Study in Japan. PREHOSP EMERG CARE 2023; 28:470-477. [PMID: 37748189 DOI: 10.1080/10903127.2023.2260479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The relationship among advanced airway management (AAM), ventilation, and oxygenation in patients with out-of-hospital cardiac arrest (OHCA) who achieve prehospital return of spontaneous circulation (ROSC) has not been validated. This study was designed to evaluate ventilation and oxygenation for each AAM technique (supraglottic devices [SGA] or endotracheal intubation [ETI]) using arterial blood gas (ABG) results immediately after hospital arrival. METHODS This observational cohort study, using data from the Japanese Association for Acute Medicine OHCA Registry, included patients with OHCA with prehospital and hospital arrival ROSC between July 1, 2014, and December 31, 2019. The primary outcomes were the partial pressure of carbon dioxide in the arterial blood (PaCO2) and partial pressure of oxygen in the arterial blood (PaO2) in the initial ABG at the hospital for each AAM technique (SGA or ETI) performed by paramedics. The secondary outcome was favorable neurological outcome (cerebral performance category [CPC] 1 or 2) for specific PaCO2 levels, which were defined as good ventilation (PaCO2 ≤45 mmHg) and insufficient ventilation (PaCO2 >45 mmHg). RESULTS This study included 1,527 patients. Regarding AAM, 1,114 and 413 patients were ventilated using SGA and ETI, respectively. The median PaCO2 and PaO2 levels were 74.50 mmHg and 151.35 mmHg in the SGA group, while 66.30 mmHg and 173.50 mmHg in the ETI group. PaCO2 was significantly lower in the ETI group than in the SGA group (12.55 mmHg; 95% CI 15.27 to 8.20, P-value < 0.001), while no significant difference was found in PaO2 by multivariate linear regression analysis. After stabilizing inverse probability of weighting (IPW), the adjusted odds ratio for favorable neurological outcome at 1 month was significant in the good ventilation group compared to the insufficient ventilation cohort (adjusted odds ratio = 2.12, 95%CI: 1.40 to 3.19, P value < 0.001). CONCLUSION The study showed that in OHCA patients with prehospital ROSC, the PaCO2 levels in the initial ABG were lower in the group with AAM by ETI than in the SGA group. Furthermore, patients with prehospital ROSC and PaCO2 ≤45 mmHg on arrival had an increased odds of favorable neurological outcome after stabilized IPW adjustment.
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Affiliation(s)
- Ryuichi Nakayama
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Balafar M, Pouraghaei M, Paknezhad SP, Abad SNA, Soleimanpour H. Evaluation the quality of bag-mask ventilation by E/C, T/E and hook technique (a new proposed technique). BMC Anesthesiol 2023; 23:384. [PMID: 37996828 PMCID: PMC10666307 DOI: 10.1186/s12871-023-02349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 11/20/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Bag-Mask Ventilation (BMV) is a crucial skill in managing emergency airway situations and induction of general anesthesia. Ensuring proficient BMV execution is imperative for healthcare providers. Various techniques exist for performing BMV. This study aims to compare the quality of ventilation achieved using the E/C technique, Thenar Eminence (T/E) technique and a novel approach referred to as the hook technique. The goal is to identify the most effective single-person BMV method. METHOD We conduct a pilot study on manikins involving 63 medical staff members who used the hook technique for ventilation. Subsequently, we obtained ethical approval and patient guardian consent to perform the study on 492 emergency department (ED) patients. These patients were randomly divided into three groups, with each group subjected to one three ventilation techniques. The study focused on patients requiring reliable airway management for rapid sequence intubation (RSI). Ventilation was administrated using bag-mask device connected to the capnograph. End-tidal CO2 (ETCO2) levels were recorded. Demographic data were collected and analyzed by SPSS software version 22. Success rates were reported as frequency (percentage) as well as mean ± standard deviation. RESULT Comparing partial pressure of CO2 (PCO2) results obtained via capnography between T/E, E/C and hook techniques, we found that the successful ventilation rate was 87.2% for T/E, 89.6% for E/C, and 93.3% for the hook methods. The hook method demonstrated significantly higher success rate compared to the other two techniques (P-value = 0.038). Furthermore, we observed statistically significant trends in PCO2 changes between measurements both within and between groups (P-value < 0/001). CONCLUSION Our study indicates that the hook method achieved notably higher success rate in ventilation compared to the T/E and E/C methods. This suggests that the hook method, which involves a chin lift maneuver while securely fitting the mask, could serve as a novel BMV technique, particularly for resuscitation with small hands for a prolonged use without fatigue and finger discomfort. Our finding contributes to the development of a new BMV method referred to as the hook technique. TRIAL REGISTRATION IRCT registration number: IRCT20121010011067N5. URL of trial registry record: https://www.irct.ir/trial/57420 .
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Affiliation(s)
- Moloud Balafar
- Emergency and trauma care research center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahboub Pouraghaei
- Emergency and trauma care research center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Pouya Paknezhad
- Emergency and trauma care research center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Critchley JD, Ferguson C, Kidd E, Ward P, McNarry AF, Theodosiou CA, Alexander N. Simple steps towards improving safety in obstetric airway management: A quality improvement project. Eur J Anaesthesiol 2023; 40:826-832. [PMID: 37646501 DOI: 10.1097/eja.0000000000001897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society state that 'a videolaryngoscope should be immediately available for all obstetric general anaesthetics'. OBJECTIVE To report the incidence of videolaryngoscopy use, and other airway management safety interventions, in an obstetric population before and after various quality improvement interventions. DESIGN Prospective data collection was undertaken over 18 months, divided into three separate 6-month periods: June to November 2019; March to August 2021; January to June 2022. These periods relate to evaluation of specific quality improvement interventions. SETTING The project was carried out in a large tertiary referral obstetric unit. PATIENTS We identified 401 pregnant women (> 20 weeks' gestation) and postnatal women (up to 48 h post delivery) undergoing an obstetric surgical procedure under general anaesthesia. INTERVENTIONS To standardise practice, an intubation checklist was introduced in December 2020 and multidisciplinary staff training in August 2021. MAIN OUTCOME MEASURES Primary outcome measures were use of a Macintosh-style videolaryngoscope and tracheal intubation success. Secondary outcome measures were use of an intubation checklist; low flow nasal oxygen; and ramped patient positioning. RESULTS Data from 334 tracheal intubations (83.3% of cases) were recorded. Videolaryngoscope use increased from 60% in 2019, to 88% in 2021, to 94% in 2022. Tracheal intubation was successful in all patients, with 94% first pass success overall and only 0.9% requiring three attempts. Use of secondary outcome measures also increased: low flow nasal oxygen from 48% in 2019 to 90% in 2022; ramped positioning from 95% in 2021 to 97% in 2022; and checklist use from 63% in 2021 to 92% in 2022. CONCLUSIONS We describe the successful adoption of simple safety measures introduced into routine practice. These comprised videolaryngoscopy, ramped positioning and low flow nasal oxygen. Their introduction was supported by the implementation of an intubation checklist and multidisciplinary team training.
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Affiliation(s)
- Julia D Critchley
- From the Department of Anaesthesia, Edinburgh Royal Infirmary, Edinburgh (JDC, CF, EK, CAT, NA), the Department of Anaesthesia, St John's Hospital, Livingston (PW), The Departments of Anaesthesia, Western General and St John's Hospital, Edinburgh, UK (AFM)
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Buasuk T, Khongcheewinrungruang N, Suphathamwit A. Difficult airway code activation for emergency endotracheal intubation outside the operating room in a tertiary care university hospital of Thailand: A single-center retrospective observational study. Medicine (Baltimore) 2023; 102:e34907. [PMID: 37904363 PMCID: PMC10615514 DOI: 10.1097/md.0000000000034907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 08/03/2023] [Indexed: 11/01/2023] Open
Abstract
Emergency airway management outside the operating room (OR) is a higher risk procedure as compared to the OR setting. Inappropriate airway management leading to complications, including pulmonary aspiration, dental trauma, esophageal intubation, prolonged recovery, unplanned intensive care unit admission and death. The emergency difficult airway management team of Siriraj hospital has been established since 2018 under the name of Code-D delta. The aim of this study is to determine the rate of Code D-delta activation, the performance of the code, the complications and outcome of the patients. This is a single-centered, observational, and retrospective study included all adult patient who was emergency intubated outside the OR between July and November 2020. The criteria for code D-delta activation included failed intubation for more than 2 attempts and suspected difficult intubation. The collected data were categorized into Code D-delta activation and non-activation group. The primary outcome was a frequency of Code D-delta activation. The demographic data, ward and indication of activation, intubation process, the complications of intubation were also collected and analyzed. During the study period, 247 patients with 307 intubations were included. The incidence of code D-delta activation was 8.14%. Regarding indication of activation, failed intubation more than 2 attempts was 40%, while suspected difficult intubation was 92%. Respiratory failure was the highest main diagnosis at 36%. The highest rate of activation was from medicine ward (60%), followed by surgery ward (16%) and emergency department (16%). Regarding the code responses and intubation performance, 7 and 10 minutes were the median time from call to scene in- and out- of official hours. The success rate of intubation at scene by code D-delta team was 85%. The airway and other complications were comparable between groups. This is the first study about emergency difficult airway management team in university hospital of Thailand. This study showed the rate of Code-D delta activation, the emergency airway management code, was 8.14% with the success rate of 85% at scene. Emergency airway management outside the operating room is particularly challenging. Airway assessment, planning, decision making of the team relevant to the patients outcomes.
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Affiliation(s)
- Tarinee Buasuk
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Aphichat Suphathamwit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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April MD, Driver B, Schauer SG, Carlson JN, Bridwell RE, Long B, Stang J, Farah S, De Lorenzo RA, Brown CA. Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study. Am J Emerg Med 2023; 72:95-100. [PMID: 37506583 DOI: 10.1016/j.ajem.2023.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/24/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.
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Affiliation(s)
- Michael D April
- 14th Field Hospital, Fort Stewart, GA, United States of America; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
| | - Brian Driver
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; US Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, United States of America
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, United States of America
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, United States of America
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Jamie Stang
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Subrina Farah
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Robert A De Lorenzo
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
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Sawyer T, Yamada N, Umoren R. The difficult neonatal airway. Semin Fetal Neonatal Med 2023; 28:101484. [PMID: 38000927 DOI: 10.1016/j.siny.2023.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Nicole Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Starosolski M, Kapłan C, Kalemba A, Majewska K. The Impact of Implementing the Vortex Approach on Airway Management Performance in Stressed Medical Students: A Randomized Controlled Simulation Study. Med Sci Monit 2023; 29:e940372. [PMID: 37817571 PMCID: PMC10548838 DOI: 10.12659/msm.940372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/16/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND The ability to manage airways in emergencies is paramount, especially for less experienced medical students. Although the Vortex Approach, a useful scheme to support decision-making during airway management, promises structured guidance, there's limited research on its benefits among students. Our study aimed to evaluate student proficiency in a simulated difficult airway scenario and assess the advantages of the Vortex Approach. MATERIAL AND METHODS Medical students initially practiced on low-fidelity mannequins. Subsequently, they were divided into Vortex (n=48) and control groups (n=48). The Vortex group received specialized training. Both groups encountered a simulated scenario focusing on proper ventilation and supraglottic device insertion when traditional intubation failed. Performance was assessed using the airway management outcome score (AMOS). RESULTS The Vortex-trained group demonstrated superior capabilities. Fewer participants exceeded 3 lifeline interventions (4.2% vs 16.7%, P=0.046). The Vortex group consistently optimized subsequent attempts (31.3% vs 10.4%, P=0.01) and reduced prolonged apnea episodes (47.9% vs 81.3%, P=0.0009). Their AMOS scores were notably higher (56.3% vs 27.1%, AMOS=2, P=0.002), reflecting better patient outcomes (41.7% vs 10.4%, P=0.0005). CONCLUSIONS There is a marked need to enhance airway management skills among senior medical students. The Vortex Approach, even after brief exposure, yields significant skill improvements, underscoring its potential as a pivotal component in medical training. Integrating it into the curriculum could bridge the evident skill gap, optimizing future patient care.
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Affiliation(s)
- Michał Starosolski
- Department of Emergency Medicine, Medical University of Silesia, Katowice, Poland
| | - Cezary Kapłan
- Student Scientific Society at the Department of Emergency Medicine, Medical University of Silesia, Katowice, Poland
| | - Alicja Kalemba
- Student Scientific Society at the Department of Emergency Medicine, Medical University of Silesia, Katowice, Poland
| | - Karolina Majewska
- Student Scientific Society at the Department of Emergency Medicine, Medical University of Silesia, Katowice, Poland
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Zhang T, Zhao KY, Zhang P, Li RH. Comparison of video laryngoscope, video stylet, and flexible videoscope for transoral endotracheal intubation in patients with difficult airways: a randomized, parallel-group study. Trials 2023; 24:599. [PMID: 37735666 PMCID: PMC10512610 DOI: 10.1186/s13063-023-07641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The 2022 ASA guidelines recommend the video laryngoscope, video stylet, and flexible videoscope as airway management tools. This study aims to compare the efficacy of three airway devices in intubating patients with difficult airways. METHODS A total of 177 patients were selected and randomized into the following three groups: the video laryngoscope group (Group VL, n = 59), video stylet group (Group VS, n = 59), and flexible videoscope group (Group FV, n = 59). The success rate of the first-pass intubation, time of tracheal intubation, level of glottic exposure, and occurrence of intubation-related adverse events were recorded and analyzed. RESULTS All patients were successfully intubated with three devices. The first-pass intubation success rate was significantly higher in Groups VS and FV than in Group VL (96.61% vs. 93.22% vs. 83.05%, P < 0.01), but it was similar in the first-pass intubation success rate between Groups VS and FV(P > 0.05). The number of patients categorized as Wilson-Cormack-Lehane grade I-II was fewer in Group VL than in Groups VS and FV (77.97% vs. 98.30% vs. 100%, P = 0.0281). The time to tracheal intubation was significantly longer in Group FV(95.20 ± 4.01) than in Groups VL(44.56 ± 4.42) and VS(26.88 ± 4.51) (P < 0.01). No significant differences were found among the three groups in terms of adverse intubation reactions (P > 0.05). CONCLUSIONS In patients with difficult airways requiring intubation, use of the video stylet has the advantage of a relatively shorter intubation time, and the flexible videoscope and video stylet yield a higher first-pass intubation success rate and clearer glottic exposure than the use of the video laryngoscope. TRIAL REGISTRATION Chinese Clinical Trial Registry. No: ChiCTR2200061560, June 29, 2022.
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Affiliation(s)
- Tao Zhang
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Kai-Yuan Zhao
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Ping Zhang
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Ren-Hu Li
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China.
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Chinese Thoracic Society, Respiratory Disease Branch of Chinese Association of Geriatric Research, Respiratory Care Group of Chinese Association of Chest Physicians Respiratory Career Development Committee, Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation Medicine. [Expert consensus on clinical application of mechanical airway clearance techniques]. Zhonghua Jie He He Hu Xi Za Zhi 2023; 46:866-79. [PMID: 37589120 DOI: 10.3760/cma.j.cn112147-20230531-00280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Mechanical airway clearance techniques refer to the therapeutic method of using mechanical means to clear airway secretions and maintain airway patency. Currently, mechanical airway clearance techniques are widely used in clinical practice and have significant effects in clearing respiratory secretions, improving symptoms of respiratory distress, and preventing and reducing respiratory tract infections. However, up to now, there is no consensus, guidance, or standardized procedures for the clinical application of mechanical airway clearance techniques. Therefore, the Respiratory Care Group of Chinese Thoracic Society organized relevant experts to write the consensus on the clinical application of mechanical airway clearance techniques, and systematically describe the definition, historical development, working principles and mechanisms, and clinical applications of mechanical airway clearance techniques. The aim is to increase awareness of mechanical airway clearance techniques, to provide clinical practitioners with standardized procedures for the application of mechanical airway clearance techniques, and to guide the standardized clinical practice.
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Song F, Han C, Liu B, Qiu Y, Hou H, Yan X, Deng L. Establishment and application of cricothyrotomy in vivo. BMC Med Educ 2023; 23:552. [PMID: 37550664 PMCID: PMC10405471 DOI: 10.1186/s12909-023-04558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 07/31/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Cricothyrotomy is a procedure performed to establish an airway in critical airway events. It is performed only rarely and anesthesiologists are often unprepared when called upon to perform it. This study aimed to simulate cricothyrotomy using pig larynx and trachea models to help anesthesiologists master cricothyrotomy and improve the ability to establish cricothyrotomy quickly. METHODS The porcine larynx and trachea were dissected and covered with pigskin to simulate the structure of the anterior neck of a human patient. An animal model of cricothyrotomy was established. Forty anesthesiologists were randomly divided into four groups. Each physician performed three rounds of cricothyrotomy, and recorded the time to accomplish each successful operation. After training the cricothyrotomy procedure, a questionnaire survey was conducted for the participating residents using a Likert scale. The participants were asked to score the utility of the training course on a scale of 1 ((minimum) to 5 ((maximum). RESULTS Through repeated practice, compared with the time spent in the first round of the operation (67 ± 29 s), the time spent in the second round of the operation (47 ± 21 s) and the time spent in the third round of the operation (36 ± 11 s) were significantly shortened (P < 0.05). Results of the survey after training were quite satisfied, reflecting increased the ability of proficiency in locating the cricothyroid membrane and performing a surgical cricothyrotomy. CONCLUSION The porcine larynx and trachea model is an excellent animal model for simulating and practicing cricothyrotomy, helping anesthesiologists to master cricothyrotomy and to perform it proficiently when required.
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Affiliation(s)
- Fengxiang Song
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Cailing Han
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Bin Liu
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Yuxue Qiu
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Haitao Hou
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Xiaoqiong Yan
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China
| | - Liqin Deng
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, 750004, China.
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Yang LQ, Zhu L, Shi X, Miao CH, Yuan HB, Liu ZQ, Gu WD, Liu F, Hu XX, Shi DP, Duan HW, Wang CY, Weng H, Huang ZL, Li LZ, He ZZ, Li J, Hu YP, Lin L, Pan ST, Xu SH, Tang D, Sessler DI, Liu J, Irwin MG, Yu WF. Postoperative pulmonary complications in older patients undergoing elective surgery with a supraglottic airway device or tracheal intubation. Anaesthesia 2023; 78:953-962. [PMID: 37270923 DOI: 10.1111/anae.16030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/06/2023]
Abstract
The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1-2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference -5.6% (95%CI -8.7 to -2.5), risk ratio 0.78 (95%CI 0.67-0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.
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Affiliation(s)
- L Q Yang
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - L Zhu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
| | - X Shi
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - C H Miao
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - H B Yuan
- Shanghai Changzheng Hospital, Shanghai, China
| | - Z Q Liu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - W D Gu
- Huadong Hospital, Fudan University, Shanghai, China
| | - F Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - X X Hu
- Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - D P Shi
- Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - H W Duan
- Shanghai Pudong Hospital Fudan University Pudong Medical Center, Shanghai, China
| | - C Y Wang
- Huangpu Branch of Ninth People's Hospital Affiliated to Medical College of Shanghai Jiao Tong University, Shanghai, China
| | - H Weng
- Shanghai Fengxian District Central Hospital, Shanghai, China
| | - Z L Huang
- Ren Ji Hospital (West) affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - L Z Li
- Shanghai Pudong New Area People's Hospital, Shanghai, China
| | - Z Z He
- Ren Ji Hospital (South) affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J Li
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Y P Hu
- The Second Hospital of Wuxi affiliated to Nanjing Medical University, Wuxi, China
| | - L Lin
- The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - S T Pan
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - S H Xu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - D Tang
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - J Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - M G Irwin
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - W F Yu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Key Laboratory of Anesthesiology (Shanghai Jiao Tong University), Ministry of Education, Shanghai, China
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Khorsand S, Chin J, Rice J, Bughrara N, Myatra SN, Karamchandani K. Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room. Anesth Analg 2023; 137:124-136. [PMID: 36693019 DOI: 10.1213/ane.0000000000006371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.
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Affiliation(s)
- Sarah Khorsand
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeanette Chin
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jake Rice
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nibras Bughrara
- Department of Anesthesiology and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi-Bhabha National Institute, Mumbai, India
| | - Kunal Karamchandani
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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42
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Ji J, Langley B, Zordan R, van Dijk J, Thies HHG, Brahmbhatt A, Torcasio C, Cunningham N. Heart rate responses in critical care trainees during airway intubation: a comparison between the simulated and clinical environments. BMC Emerg Med 2023; 23:66. [PMID: 37301951 PMCID: PMC10257286 DOI: 10.1186/s12873-023-00832-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE This study aimed to compare the heart rate response to stress during airway intubations in clinical practice and a simulated environment. METHODS Twenty-five critical care registrars participated in the study over a 3-month period. Heart rate data during intubations was recorded by a FitBit® Charge 2 worn by each participant during their clinical practice, and during a single simulated airway management scenario. The heart rate range was calculated by subtracting the baseline working heart rate (BWHR) from the maximum functional heart rate (MFHR). For each airway intubation performed participants recorded an airway diary entry. Data from intubations performed in the clinical environment was compared to data from a simulated environment. Heart rate changes were observed in two ways: percentage rise (median) across the 20-min intubation period and; percentage rise at point of intubation (median). RESULTS Eighteen critical care registrars completed the study, mean age 31.8 years (SD = 2.015, 95% CI = 30.85-32.71). Throughout the 20-min peri-intubation recording period there was no significant difference in the median change in heart rates between the clinical (14.72%) and simulation (15.96%) environment (p = 0.149). At the point of intubation there was no significant difference in the median change in heart rate between the clinical (16.03%) and the simulation (25.65%) environment groups (p = 0.054). CONCLUSION In this small population of critical care trainees, a simulation scenario induced a comparable heart rate response to the clinical environment during intubation. This provides evidence that simulation scenarios are able to induce a comparable physiological stress response to the clinical environment and thus facilitates effective teaching of a high-risk procedure in a safe manner.
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Affiliation(s)
- Jackson Ji
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Bridget Langley
- Department of Anaesthesia and Acute Pain Medicine, St Vincent’s Hospital, Melbourne, Australia
| | - Rachel Zordan
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Education and Learning, St Vincent’s Hospital Melbourne, Melbourne, Australia
| | - Julian van Dijk
- Education and Learning, St Vincent’s Hospital Melbourne, Melbourne, Australia
| | | | - Anjalee Brahmbhatt
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Anaesthesia and Acute Pain Medicine, St Vincent’s Hospital, Melbourne, Australia
| | - Clarissa Torcasio
- Education and Learning, St Vincent’s Hospital Melbourne, Melbourne, Australia
| | - Neil Cunningham
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Emergency Medicine, St Vincent’s Hospital, Melbourne, Australia
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43
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Robinson AE, Pearson AM, Bunting AJ, Kennedy HJ, Prekker ME, Reardon RF, Jones GA, Simpson NS, Kummer TM, Babcock CP, Driver BE. A Practical Solution for Preoxygenation in the Prehospital Setting: A Nonrebreather Mask with Flush Rate Oxygen. PREHOSP EMERG CARE 2023; 28:215-220. [PMID: 37171895 DOI: 10.1080/10903127.2023.2213761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Prehospital clinicians need a practical means of providing adequate preoxygenation prior to intubation. A bag-valve-mask (BVM) can be used for preoxygenation in perfect conditions but is likely to fail in emergency settings. For this reason, many airway experts have moved away from using BVM for preoxygenation and instead suggest using a nonrebreather (NRB) mask with flush rate oxygen.Literature on preoxygenation has suggested that a NRB mask delivering flush rate oxygen (on a 15 L/min O2 regulator, maximum flow, ∼50 L/min) is noninferior to BVM at 15 L/min held with a tight seal. However, in the prehospital setting, where emergency airway management success varies, preoxygenation techniques have not been deeply explored. Our study seeks to determine whether preoxygenation can be optimally performed with NRB at flush rate oxygen. METHODS We performed a crossover trial using healthy volunteers. Subjects underwent 3-min trials of preoxygenation with NRB mask at 25 L/min oxygen delivered from a portable tank, NRB at flush rate oxygen from a portable tank, NRB with flush rate oxygen from an onboard ambulance tank, and BVM with flush rate oxygen from an onboard ambulance tank. The primary outcome was the fraction of expired oxygen (FeO2). We compared the FeO2 of the BVM-flush to other study groups, using a noninferiority margin of 10%. RESULTS We enrolled 30 subjects. Mean FeO2 values for NRB-25, NRB-flush ambulance, NRB-flush portable, and BVM-flush were 63% (95% confidence interval [CI] 58-68%), 74% (95%, CI 70-78%), 78% (95%, CI 74-83%), and 80% (95%, CI 75-84%), respectively. FeO2 values for NRB-flush on both portable tank and ambulance oxygen were noninferior to BVM-flush on the ambulance oxygen system (FeO2 differences of 1%, 95% CI -3% to 6%; and 6%, 95% CI 1-10%). FeO2 for the NRB-25 group was inferior to BVM-flush (FeO2 difference 16%, 95% CI 12-21%). CONCLUSIONS Among healthy volunteers, flush rate preoxygenation using NRB masks is noninferior to BVM using either a portable oxygen tank or ambulance oxygen. This is significant because preoxygenation using NRB masks with flush rate oxygen presents a simpler alternative to the use of BVMs. Preoxygenation using NRB masks at 25 L/min from a portable tank is inferior to BVM at flush rate.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Alec J Bunting
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | | | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregg A Jones
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy M Kummer
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Corey P Babcock
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Spies F, Burmester A, Schälte G. [Cricothyrotomy : Data situation, guidelines and techniques for the definitive surgical airway]. Anaesthesiologie 2023; 72:369-380. [PMID: 37154938 DOI: 10.1007/s00101-023-01279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 05/10/2023]
Abstract
Cricothyrotomy represents the final approach to secure the airway, in the course of which less invasive measures have failed. It can also primarily be carried out to establish a secure airway. This is essential to protect the patient from a significant hypoxia. This is a cannot ventilate-cannot oxygenate (CVCO) situation, which presumably all colleagues in emergency intensive care medicine and anesthesia have already been confronted with. Evidence-based algorithms for the management of a difficult airway and CVCO have been established. If oxygenation using an endotracheal tube, an extraglottic airway device or bag-valve mask ventilation all fail, the airway must be surgically secured, i.e. using cricothyrotomy. The prevalence of the CVCO situation in a prehospital setting is ca. 1%. No valid prospective randomized in vivo studies have been carried with respect to the question of the best method.
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Affiliation(s)
- Fabian Spies
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - Alexander Burmester
- Klinik für Anästhesie, Intensiv- und Notfallmedizin, Bundeswehrkrankenhaus Hamburg, Lesserstraße 180, 22049, Hamburg, Deutschland
| | - Gereon Schälte
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
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45
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Ellis R, Laviola M, Stolady D, Valentine RL, Pillai A, Hardman JG. Comparison of apnoeic oxygen techniques in term pregnant subjects: a computational modelling study. Response to Br J Anaesth 2022; 129: 581-7. Br J Anaesth 2023; 130:e429-e430. [PMID: 36754707 DOI: 10.1016/j.bja.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/07/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Reena Ellis
- Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Marianna Laviola
- Anaesthesia and Critical Care, Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Daniel Stolady
- Anaesthesia, Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Rebecca L Valentine
- Anaesthesia and Critical Care, Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Arani Pillai
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan G Hardman
- Nottingham University Hospitals NHS Trust, Nottingham, UK; Anaesthesia and Critical Care, Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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Nagaura M, Saitoh K, Tsujimoto G, Yasuda A, Shionoya Y, Sunada K, Kawai T. Usefulness of preoperative computed tomography findings for airway management in patients with acute odontogenic infection: a retrospective study. Odontology 2023; 111:499-510. [PMID: 36279070 DOI: 10.1007/s10266-022-00756-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022]
Abstract
Odontogenic infection is more likely to affect the airway and interfere with intubation than non-odontogenic causes. Although anesthesiologists predict the difficulty of intubation and determine the method, they may encounter unexpected cases of difficult intubation. An inappropriate intubation can cause airway obstruction due to bleeding and edema by damaging the pharynx and larynx. This study was performed to determine the most important imaging findings indicating preoperative selection of an appropriate intubation method. This retrospective study included 113 patients who underwent anti-inflammatory treatment for odontogenic infection. The patients were divided into two groups according to the intubation method: a Macintosh laryngoscope (45 patients) and others (video laryngoscope and fiberscope) (68 patients). The extent of inflammation in each causative tooth, the severity of inflammation (S1-4), and their influence on the airway were evaluated by computed tomography. The causative teeth were mandibular molars in more than 90%. As the severity of inflammation increased, anesthesiologists tended to choose intubation methods other than Macintosh laryngoscopy. In the most severe cases (S4), anesthesiologists significantly preferred other intubation methods (33 cases) over Macintosh laryngoscopy (9 cases). All patients with S4 showed inflammation in the parapharyngeal space, and the airway was affected in 41 patients. The mandibular molars were the causative teeth most likely to affect the airway and surrounding region. In addition to clinical findings, the presence or absence of inflammation that has spread to the parapharyngeal space on preoperative computed tomography was considered an important indicator of the difficulty of intubation.
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Affiliation(s)
- Madoka Nagaura
- Department of Oral and Maxillofacial Radiology, School of Life Dentistry at Tokyo, The Nippon Dental University, 1-9-20 Fujimi, Chiyoda-Ku, Tokyo, 102-8159, Japan.
- Division of Oral Diagnosis, Dental and Maxillofacial Radiology and Oral Pathology Diagnostic Services, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan.
| | - Keisuke Saitoh
- Division of Oral Diagnosis, Dental and Maxillofacial Radiology and Oral Pathology Diagnostic Services, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan
| | - Gentaro Tsujimoto
- Department of Dental Anesthesia, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan
| | - Asako Yasuda
- Department of Dental Anesthesia, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan
| | - Yoshiki Shionoya
- Department of Dental Anesthesia, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan
| | - Katsuhisa Sunada
- Department of Dental Anesthesiology, School of Life Dentistry at Tokyo, The Nippon Dental University, 1-9-20 Fujimi, Chiyoda-Ku, Tokyo, 102-8159, Japan
| | - Taisuke Kawai
- Department of Oral and Maxillofacial Radiology, School of Life Dentistry at Tokyo, The Nippon Dental University, 1-9-20 Fujimi, Chiyoda-Ku, Tokyo, 102-8159, Japan
- Division of Oral Diagnosis, Dental and Maxillofacial Radiology and Oral Pathology Diagnostic Services, The Nippon Dental University Hospital, 2-3-16 Fujimi, Chiyoda-Ku, Tokyo, 102-8158, Japan
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Comparison of the Effectiveness of Different Barrier Enclosure Techniques in Protection of Healthcare Workers During Tracheal Intubation and Extubation: Erratum. A A Pract 2023; 17:e01673. [PMID: 37036228 DOI: 10.1213/XAA.0000000000001673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
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Bartos JA, Clare Agdamag A, Kalra R, Nutting L, Frascone RJ, Burnett A, Vuljaj N, Lick C, Tanghe P, Quinn R, Simpson N, Peterson B, Haley K, Sipprell K, Yannopoulos D. Supraglottic Airway Devices are Associated with Asphyxial Physiology After Prolonged CPR in Patients with Refractory Out-of-Hospital Cardiac Arrest Presenting for Extracorporeal Cardiopulmonary Resuscitation. Resuscitation 2023; 186:109769. [PMID: 36933882 DOI: 10.1016/j.resuscitation.2023.109769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Multiple randomized clinical trials have compared specific airway management strategies during ACLS with conflicting results. However, patients with refractory cardiac arrest died in almost all cases without the availability of extracorporeal cardiopulmonary resuscitation (ECPR). Our aim was to determine if endotracheal intubation (ETI) was associated with improved outcomes compared to supraglottic airways (SGA) in patients with refractory cardiac arrest presenting for ECPR. METHODS We retrospectively studied 420 consecutive adult patients with refractory out-of-hospital cardiac arrest due to shockable presenting rhythms presenting to the University of Minnesota ECPR program. We compared outcomes between patients receiving ETI (n=179) and SGA (n=204). The primary outcome was the pre-cannulation arterial PaO2 upon arrival to the ECMO cannulation center. Secondary outcomes included neurologically favorable survival to hospital discharge and eligibility for VA-ECMO based upon resuscitation continuation criteria applied upon arrival to the ECMO cannulation center. RESULTS Patients receiving ETI had significantly higher median PaO2 (71 vs. 58 mmHg, p=0.001), lower median PaCO2 (55 vs. 75 mmHg, p<0.001), and higher median pH (7.03 vs. 6.93, p<0.001) compared to those receiving SGA. Patients receiving ETI were also significantly more likely to meet VA-ECMO eligibility criteria (85% vs. 74%, p=0.008). Of patients eligible for VA-ECMO, patients receiving ETI had significantly higher neurologically favorable survival compared to SGA (42% vs. 29%, p=0.02). CONCLUSIONS ETI was associated with improved oxygenation and ventilation after prolonged CPR. This resulted in increased rate of candidacy for ECPR and increased neurologically favorable survival to discharge with ETI compared to SGA. Short Title: Airway Effects in Refractory Cardiac Arrest.
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Affiliation(s)
- Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - Arianne Clare Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Lindsay Nutting
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - R J Frascone
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Aaron Burnett
- Woodbury and Cottage Grove, Emergency Medical Services, MN, USA
| | - Nik Vuljaj
- M Health Fairview Emergency Medical Services, Minneapolis, MN, USA
| | - Charles Lick
- Allina Health Emergency Medical Services, Minneapolis, MN, USA
| | - Peter Tanghe
- Department of Emergency Medicine, North Memorial Health Ambulance Service, North Memorial Health Medical Center, Robbinsdale, MN, USA
| | | | | | - Bjorn Peterson
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Kari Haley
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Kevin Sipprell
- Department of Emergency Medicine, Ridgeview Medical Center, Waconia, MN, USA
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
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Smith S, Liu M, Ball I, Meunier B, Hilsden R. A Systematic Review of Prehospital Combat Airway Management. J Spec Oper Med 2023; 23:31-37. [PMID: 36753714 DOI: 10.55460/s3mi-tfx5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 02/10/2023]
Abstract
Medical leadership must decide how prehospital airways will be managed in a combat environment, and airway skills can be complicated and difficult to learn. Evidence informed airway strategies are essential. A search was conducted in Medline and EMBASE databases for prehospital combat airway use. The primary data of interest was what type of airway was used. Other data reviewed included: who performed the intervention and the success rate of the intervention. The search strategy produced 2,624 results, of which 18 were included in the final analysis. Endotracheal intubation, cricothyroidotomy, supraglottic airways, and nasopharyngeal airways have all been used in the prehospital combat environment. This review summarizes the entirety of the available combat literature such that commanders may make an evidence-based informed decision with respect to their airway management policies.
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Schauer SG, Hudson IL, Fisher AD, Dion G, Long B, Blackburn MB, De Lorenzo RA, Shaw TA, April MD. Improving Outcomes Associated with Prehospital Combat Airway Interventions: An Unrealized Opportunity. J Spec Oper Med 2023; 23:23-29. [PMID: 36853854 DOI: 10.55460/sji5-vwjh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Airway obstruction is the second leading cause of potentially survivable death on the battlefield. Assessing outcomes associated with airway interventions is important, and temporal trends can reflect the influence of training, technology, the system of care, and other factors. We assessed mortality among casualties undergoing prehospital airway intervention occurring over the course of combat operations during 2007-2019. METHODS This is a retrospective analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included only casualties with documented placement of an endotracheal tube, cricothyrotomy, or supraglottic airway (SGA) in the prehospital setting. RESULTS Within the DODTR from January 2007 to December 2019, there were 25,849 adult encounters with documentation of any prehospital activity. Within that group, there were 251 documented cricothyrotomies, 1,147 documented intubations, and 35 documented supraglottic airways placed. Cricothyrotomy recipients had a median age of 25. Within this group, the largest proportion were non-North Atlantic Treaty Organization (NATO) military personnel (35%), were injured by explosives (54%), had a median injury severity score (ISS) of 24, and 60% survived to hospital discharge. Intubation recipients had a median age of 24. Within this group, the largest proportion were non-NATO military personnel (37%), were injured by explosives (57%), had a median ISS of 18, and 76% survived to hospital discharge. SGA recipients had a median age of 28. Within this group, the largest proportion were non-NATO military (37%), were injured by firearms (48%), had a median ISS of 25, and 54% survived to hospital discharge. A downward trend existed in the quantity of all procedures performed during the study period. In both unadjusted and adjusted regression models, we identified no year-to-year differences in survival after prehospital cricothyrotomy or SGA placement. In the unadjusted and adjusted models, we noted a decrease in mortality during the 2007-2008 (odds ratio [OR] for death 0.47, 95% CI 0.26-0.86) and an increase from 2012-2013 (OR 2.10, 95% CI 1.09-4.05) for prehospital intubation. CONCLUSION Mortality among combat casualties undergoing prehospital or emergency department airway interventions showed no sustained change during the study period. These findings suggest that advances in airway resuscitation are necessary to achieve mortality improvements in potentially survivable airway injuries in the prehospital setting.
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