Airway Exchange Research Articles

Assessing the Efficacy and Safety of Extubation Protocols in the Intensive Care Unit Following Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome: A Retrospective Cohort Study

Background: There is a notable lack of protocols addressing extubation techniques in transoral robotic surgery (TORS) for obstructive sleep apnea (OSA). Methods: This retrospective cohort study enrolled patients who underwent TORS for OSA between March 2015 and December 2021 and were managed with different extubation approaches. The patients were divided into two groups: high-flow nasal cannula (HFNC) therapy and conventional oxygen therapy. The use of an airway exchange catheter (AEC) was investigated. Results: The application of HFNC use versus conventional oxygen therapy led only to a statistical reduction in extubation time (p = 0.024); length of stay in the intensive care unit (ICU) and the episodes of desaturation below 95% were reduced, but data are non-statistically significant. Similarly, the application of an AEC led to a reduction in extubation time in hours (p = 0.008) and length of stay in the ICU (p = 0.024). Conclusions: In patients with OSA who underwent TORS, the use of an HFNC, with or without an AEC, resulted in a significant reduction in extubation time without major adverse events. Additionally, HFNC utilization may decrease desaturation episodes during extubation. Despite limitations, based on the findings of this preliminary investigation, the combination of an HFNC and an AEC emerges as a promising strategy for enhancing the safety and efficacy of extubation protocols in this patient population.

Integrating the Airway Lead structure into a large healthcare system to appraise the landscape of airway management resources

Airway Leads are clinicians who guide safe airway management institutionally and act as liaisons between the evolving airway management landscape and bedside clinicians. Internationally, resources produced by Airway Leads Networks aid clinicians in establishing emergency airway management protocols and making difficult airway equipment decisions. The creation of an Airway Leads Network within the United States' multi-payer healthcare system is ongoing, spearheaded nationally by groups such as the Society for Airway Management. We aimed to build a committee of airway leaders across the Yale New Haven Health system and to leverage this committee to appraise the airway equipment and personnel resources throughout the system. We identified key stakeholders in airway management across the healthcare system and administered a quality improvement survey to members of the assembled committee querying their knowledge of the availability of airway management devices. The dataset was gathered from 14 airway management leaders identified across 4 surgical facilities, 6 emergency departments and 5 medical intensive care units at 8 hospitals and hospital campuses within the Yale New Haven Health system. Equipment available in greater than 75 % of locations included hyperangulated and standard geometry videolaryngoscopes, rigid tracheal tube stylets, tracheal tube introducers, flexible intubation scopes, scalpels and waveform capnography. Equipment available in 25 % to <75 % of locations included emergency invasive airway kits, wheeled airway towers or airway boxes, intubating oral airways, airway exchange and Aintree catheters, intubation-capable supraglottic airways, and awake intubation supplies. Glidescope (Verathon) was the most common videolaryngoscope and flexible intubation scope, and Aura (Teleflex) was the most common intubation-capable supraglottic airway available. The initiative illustrated the feasibility and utility of developing a committee of airway leaders in a large health system. While all locations had access to a requisite array of airway management devices, there was variation in the availability and brand of individual airway equipment.

Aintree Catheter Versus Gum Elastic Bougie for Airway Exchange Using the i-Gel Supraglottic Device: A Cadaver Study.

Airway compromise is the third leading cause of preventable death on the battlefield. Most combat medics carry supraglottic airway (SGA) devices for airway management. However, exchanging an SGA device for a definitive airway can be challenging, especially in austere environments. This study aims to compare the Aintree intubation catheter (AIC) to the gum elastic bougie (GEB) as adjuncts for performing airway device exchange with the i-gel SGA device in place. This randomized crossover cadaver study of 48 participants examined the success rate of two endotracheal introducers (AIC and GEB) when performing a blind airway exchange with an i-gel in place. Study participants were combat medics (MOS 68W), physician assistant students, physician assistant staff, emergency medicine (EM) physician residents, and emergency medicine attending physicians attending classes at the installation Medical Simulations Training Center. Each participant performed up to three attempts using both endotracheal tube introducers on the same cadaver. The primary outcome was successful airway exchange rate with each device, and the secondary outcome was time to successful airway exchange. Although the AIC had a slightly higher success rate of 33% compared to the GEB success rate of 30%, this result was not statistically significant, P = .56. Similarly, participants completed successful airway exchanges with the AIC faster, with a mean time of 86.5 seconds (95% CI: 71.2 to 101.9) versus 101.2 seconds (95% CI: 85.5 to 116.9) with the GEB. However, this result was also not statistically significant, P = 0.18. This study demonstrates no significant difference in success rate and time to completion of successful iterations of airway exchanges between the two devices. Although the AIC performed slightly better overall, these results are not statistically significant. Additionally, blind exchange intubations appear to be of high risk with minimal success, so we recommend against this technique in routine practice.

Indications and success rate of endotracheal emergency intubation in clinical acute and emergency medicine

Securing the airway in the emergency department (ED) is ahigh-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was aretrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications. Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent asix-week training program including atwo-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with aplaced laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate. During the study period 499 patients were intubated by the core ED team and 28patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527(2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08). In clinical acute and emergency medicine, astandardized approach utilizing video laryngoscopy and a bougie following astructured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting.

A novel technique to exchange tracheal tubes using an Aintree Intubation CatheterTM over an airway exchange catheter.

A novel technique to exchange tracheal tubes using an Aintree Intubation CatheterTM over an airway exchange catheter.

Recent Advances in Paediatric Airway Management

Paediatric airway management is continuously evolving with the innovation of new devices and techniques. The paediatric airway presents notable anatomical and physiological challenges. The introduction of a wide array of videolaryngoscopes and flexible intubating video endoscopes in paediatric sizes has made airway management safer. In addition, second-generation supraglottic airways are increasingly utilised both independently and as a component of hybrid strategies. The introduction of various paediatric airway adjuncts such as Frova introducer, optical stylets and airway exchange catheters has been a valuable addition. Microcuff tubes have proven to be safe for use even in neonates and infants and reduce the number of endotracheal tube exchanges. Apnoeic oxygenation techniques using transnasal humidified rapid insufflation ventilatory exchange help in preventing desaturation during intubation. Point-of-care ultrasound has a multitude of applications in paediatric airway management and is useful technique for the identification of the cricothyroid membrane and assessment of gastric residual volume. Airway assessment and simulation in combination with three-dimensional printing can serve as useful adjuncts in difficult and complicated airways and help in training and skill development and retention. Artificial intelligence and machine learning are in the nascent stages but are continuously evolving and may revolutionise airway assessment in the near future. This narrative review describes the recent advances in airway devices and techniques that have revolutionised paediatric airway management over the past decade.

Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)-A Prospective, Randomised Controlled Study.

The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios. After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min. In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02). The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial.

High-flow Tracheal Oxygenation with Airway Exchange Catheter: A Novel Approach.

How to cite this article: Vaithialingam B, Arun BG. High-flow Tracheal Oxygenation with Airway Exchange Catheter: A Novel Approach. Indian J Crit Care Med 2023;27(6):456.

Unexpected Tension Pneumothorax after Double-Lumen Endotracheal Intubation in Patients with Pulmonary Edema: A Case Report

Tension pneumothorax is a relatively rare complication after anesthetic induction that requires prompt diagnosis and treatment. Several handling errors related to intubation procedures or equipment and vigorous positive pressure ventilation are potentially important etiologies of tension pneumothorax in patients with underlying lung disease or in mechanically ventilated patients. We describe a case of tension pneumothorax observed after double-lumen tube (DLT) insertion followed by single-lumen tube replacement using an airway exchanger catheter in a mechanically ventilated patient. An 84-year-old female on mechanical ventilation underwent minimally invasive cardiac surgery under general anesthesia. Immediately after left-sided DLT insertion using an airway exchanger catheter, oxygen saturation decreased to 89%, peak airway pressure increased to 35 cm H2O with inadequate tidal volume, and blood pressure gradually dropped to 69/41 mmHg. Breath sounds from the right hemithorax were significantly reduced. Severe collapse of the right lung, a flattened diaphragm, and compressed abdominal organs were identified on chest radiography. Therefore, a tube thoracotomy was performed based on the findings of a tension pneumothorax. Then, oxygen saturation, peak airway pressure with adequate tidal volume, and blood pressure improved, and the distended abdomen normalized. After the pneumothorax resolved, a bronchoscopy was performed. Slight redness was noted in the right bronchus, indicating that the DLT was incorrectly inserted into the right side. In conclusion, the possibility of a tension pneumothorax should be considered during DLT intubation or endotracheal tube replacement with an airway exchange catheter.

No: 7331 An airway exchange catheter: a beneficial approach for a difficult airway in the intensive care unit

No: 7331 An airway exchange catheter: a beneficial approach for a difficult airway in the intensive care unit

Comparison of conventional awake extubation with endotracheal tube – laryngeal mask airway exchange extubation for evaluation of respiratory and hemodynamic parameters during emergence in neurosurgical patients

Background: Emergence from general anesthesia and tracheal extubation may be associated with tremendous physiological and metabolic stress in patients which could be major concern for the anesthesiologist in patients especially with neurosurgical patients. Aims and Objectives: The study was designed to find a novel method to achieving a smooth extubation in neurosurgery by compare the respiratory complications and hemodynamic stress response between conventional awake extubation of an endotracheal tube (ETT) and that following exchange extubation of ETT using a laryngeal mask airway (LMA) in craniotomy surgeries. Materials and Methods: A total of 60 patients of American Society of Anesthesiologists physical status I and II between ages 18 and 60 years undergoing neurosurgery were evaluated for respiratory events such as bucking, coughing, desaturation, and hemodynamic changes due to sympathetic stimulation such as tachycardia, hypertension, and any other complications that have occurred in any of the two extubation methods. Results: In Group A, 86.67% patients have shown significant events of bucking and coughing while desaturation events were comparable between two groups. Manipulation events, that is, chin lift and jaw thrust had to perform in 66.67% and 21.67%, respectively, in patients of Group A compared to only 03.33% patients in Group L. (P&lt;0.05). In Group A, 97.33% patients shown tachycardia compared to 30% in Group L where only 30%. Similarly, mean arterial pressure after extubation found to be significantly high in 63.33% of the patients in Group A with 63.33% as compared to13.33% of patients in Group L (P&lt;0.05). Conclusion: ETT/LMA exchange is the most effective technique for achieving the clinical endpoints of the study, that is, prevention of emergence hypertension and respiratory complications compared to awake extubation methods. The exchange of ETT with LMA in deeper plane of anesthesia significantly reduces emergence related the hemodynamic and respiratory unwonted events.

USE OF VIDEO LARYNGOSCOPE FOR DIFFICULT AIRWAY MANAGEMENT IN THORACIC SURGERY: A CASE STUDY

We present the clinical case of a 76-year-old male with the following medical history: Active smoker (2 packs/day),moderate obesity, moderate COPD. arterial hypertension, mellitus diabetes 2, dyslipidemia. Lacunar stroke without neurological damage, infrarenal abdominal aortic aneurysm of 40 mm, under follow-up in policlinic of Vascular Surgery, 1st degree atrioventricular block, under follow-up by Cardiology. Normal Echocardiography. PET-CT: Hypermetabolic pulmonary nodule in RUL, suggestive of cancer. FUNCTIONAL TESTS: Moderate obstructive pattern. FEV1 2.20 (72%), FEV1/FVC 58. DLCO 5.80 (64%). AIRWAY EXPLORATION: Retrognatia, Mallampati III, significant cervical stiffness, thick neck and degree of movement of head and neck < 80°. Case Management: Placement of thoracic epidural catheter (T5-T6) prior to induction for analgesic control during intraoperative and postoperativeperiod. Non-invasive blood pressure monitoring, 5-lead ECG, temperature, peripheral oxygen saturation (SpO2), Bispectral Index (BIS) and Train-of-four (TOF). In the presence of predictors of possible difficult airway and ventilation, material is prepared for management of possible difficult airway Pre-oxygenation with face mask and FiO2 1 until EtO2 85 mmHg is reached. Rapid sequence induction was performed with intravenous midazolam, fentanyl, propofol and 1,2 mg/kg of rocuronium. After reaching TOF 0, direct laryngoscopy was initially performed but a Cormark-Lehane (CL) III was observed.Indirect laryngoscopy was then performed with a McGrath video laryngoscope with a n°4 disposable blade, showing a CL I. Subsequently, an 11 Fr airway exchange catheter was introduced through the vocal cords into the trachea; then, the proximal end of the airway exchange catheter was inserted into the endobronchial lumen of the 37Fr Vivasight DL, to permet its insertion into the trachea guided by this airway exchange catheter under the vision of the McGrath videolaryngoscope. Once the VivaSight DL was inserted into the trachea, the airway exchange catheter was removed and the VivaSight DL tube was turned left 90° and was inserted successful into the left main bronchus guided by embedded camera of this special type of DLT. Anesthesia maintenance was performed with inhalated sevoflurane and continuous intravenous infusion of remifentanil and rocuronium. Epidural elastomer of levobupivacaine 0.125% at 7 ml/h. Controlled ventilation is maintained in volume control mode, with Tidal Volume (TV) at 7 ml/kg ideal weight in two-lung ventilation and 5 ml/kg ideal weight in one-lung ventilation. Alveolar Recruitment Maneouvres (ARM) after intubation and at start of one-lung ventilation (OLV) were performed. Good mechanics and adequate gas exchange throughout the procedure, with no episodes of desaturation. After completion of surgery, reversal of neuromuscular blockade was achieved with sugammadex at 2 mg/kg. After checking TOF ratio> 90% and adequate level of consciousness, optimal respiratory mechanics and a 100% SpO2, extubation was performed without incident. He was transferred to the intensive care unit for post-surgical control during the first 24 hours.

The Role of Pulmonary Function Test for Pulmonary Arterial Hypertension in Patients with Connective Tissue Disease.

Objective: The study aimed to investigate the value of pulmonary function test (PFT) in evaluating and predicting pulmonary arterial hypertension (PAH) in patients with connective tissue disease (CTD). Methods: This was a prospective observational study recruiting patients diagnosed with CTD-PAH. Patients with interstitial lung disease and pulmonary hypertension induced by other causes were not eligible for enrollment. All patients were assessed for PAH every 1–3 months. A patient was considered to have clinical improvement if the grade of risk stratification declined or at least two parameters improved during follow-up, otherwise no improvement. Results: A total of 31 patients with CTD-PAH were recruited in this study. Nearly 70% of patients had declined forced vital capacity (FVC), 60% had declined total lung capacity and maximum expiratory flow at 50% of vital capacity, and 95% had normal or mild decline in forced expiratory volume in 1 second (FEV1)/FVC. A decline in diffusing capacity of the lung for carbon monoxide (DLCO) was present in 96% of patients, and 60% were moderate to severe. Furthermore, 50% of patients had an FVC/DLCO ratio of less than 1.4. Univariate analysis showed that FEV1/FVC, DLCO, and FVC/DLCO were associated with disease prognosis. After adjusting for age as a confounding factor, multivariate logistic regression analysis revealed that DLCO was an independent predictive factor for the prognosis of CTD-PAH. Conclusion: The pulmonary function of patients with CTD-PAH is abnormal in parameters such as lung volume, small airway, and gas exchange. PFT can reveal complex pathophysiological changes in the lungs of CTD-PAH patients and predict prognosis.

Recent Advances in Videolaryngoscopy for One-Lung Ventilation in Thoracic Anesthesia: A Narrative Review.

Since their advent, videolaryngoscopes have played an important role in various types of airway management. Lung isolation techniques are often required for thoracic surgery to achieve one-lung ventilation with a double-lumen tube (DLT) or bronchial blocker (BB). In the case of difficult airways, one-lung ventilation is extremely challenging. The purpose of this review is to identify the roles of videolaryngoscopes in thoracic airway management, including normal and difficult airways. Extensive literature related to videolaryngoscopy and one-lung ventilation was analyzed. We summarized videolaryngoscope-guided DLT intubation techniques and discussed the roles of videolaryngoscopy in DLT intubation in normal airways by comparison with direct laryngoscopy. The different types of videolaryngoscopes for DLT intubation are also compared. In addition, we highlighted several strategies to achieve one-lung ventilation in difficult airways using videolaryngoscopes. A non-channeled or channeled videolaryngoscope is suitable for DLT intubation. It can improve glottis exposure and increase the success rate at the first attempt, but it has no advantage in saving intubation time and increases the incidence of DLT mispositioning. Thus, it is not considered as the first choice for patients with anticipated normal airways. Current evidence did not indicate the superiority of any videolaryngoscope to another for DLT intubation. The choice of videolaryngoscope is based on individual experience, preference, and availability. For patients with difficult airways, videolaryngoscope-guided DLT intubation is a primary and effective method. In case of failure, videolaryngoscope-guided single-lumen tube (SLT) intubation can often be achieved or combined with the aid of fibreoptic bronchoscopy. Placement of a DLT over an airway exchange catheter, inserting a BB via an SLT, or capnothorax can be selected for lung isolation.

Medication-Facilitated Advanced Airway Management with First-Line Use of a Supraglottic Device - A One-Year Quality Assurance Review.

Airway management is a controversial topic in modern Emergency Medical Services (EMS) systems. Among many concerns regarding endotracheal intubation (ETI), unrecognized esophageal intubation and observations of unfavorable neurologic outcomes in some studies raise the question of whether alternative airway techniques should be first-line in EMS airway management protocols. Supraglottic airway devices (SADs) are simpler to use, provide reliable oxygenation and ventilation, and may thus be an alternative first-line airway device for paramedics. In 2019, Alachua County Fire Rescue (ACFR; Alachua, Florida USA) introduced a novel protocol for advanced airway management emphasizing first-line use of a second-generation SAD (i-gel) for patients requiring medication-facilitated airway management (referred to as "rapid sequence airway" [RSA] protocol). This was a one-year quality assurance review of care provided under the RSA protocol looking at compliance and first-pass success rate of first-line SAD use. Records were obtained from the agency's electronic medical record (EMR), searching for the use of the RSA protocol, advanced airway devices, or either ketamine or rocuronium. If available, hospital follow-up data regarding patient condition and emergency department (ED) airway exchange were obtained. During the first year, 33 advanced airway attempts were made under the protocol by 23 paramedics. Overall, compliance with the airway device sequence as specified in the protocol was 72.7%. When ETI was non-compliantly used as first-line airway device, the first-pass success rate was 44.4% compared to 87.5% with adherence to first-line SAD use. All prehospital SADs were exchanged in the ED in a delayed fashion and almost exclusively per physician preference alone. In no case was the SAD exchanged for suspected dislodgement evidenced by lack of capnography. First-line use of a SAD was associated with a high first-pass attempt success rate in a real-life cohort of prehospital advanced airway encounters. No SAD required emergent exchange upon hospital arrival.

Redefining Exchange of Tracheal Tube from Nasal to Oral in High Risk Sepsis Patient

A 35-year-old male weighing 94 kg developed significant oropharyngeal and perilaryngeal oedema with sepsis in the postoperative period following mandibular advancement surgery. He needed change of an existing nasotracheal tube to the orotracheal route in the intensive care unit (ICU). The procedure had to be abandoned in the ICU for fear of losing the airway in this patient requiring high inspired oxygen concentration of 60% and positive end expiratory pressure of 8.0 cm H2O. The changeover of tube was safely achieved in the operation theatre by utilising the splinting effect of the existing nasotracheal tube that helped to keep the oedematous epiglottis lifted while an airway exchange catheter (AEC) was placed by its side under videolaryngoscopic guidance. Railroading the new orotracheal tube over the preplaced AEC after withdrawing the nasal tube while receiving oxygen at 4 litres per minute helped to accomplish the safe exchange of the tracheal tube.

99 A Fresh Model in the Vehicles for Learning: Redesigning an Established, Traditional Airway Course to be Delivered in a Multi-Site Hybrid Format in the COVID-19 Era

The Royal College of Anaesthetists (RCOA) stipulates that anaesthetists should be able to use advanced/novel airway management techniques. The RCOA-accredited annual Challenging Airway Course in Northern Ireland is a staple of the calendar, providing an opportunity for all those involved in airway management to gain, refresh and replenish skills. Having already been cancelled in 2020 due to the pandemic, there was a strong appetite, particularly within the trainee body, that it should be staged in some form this year.The aim of the study was to deliver a high-quality course that outlined the theory behind airway management, without loss of the hands-on aspects of equipment/techniques, to a large candidate group in a COVID-19 safe environment.Alteration of the face-to-face course to run in a hybrid multi-site format with both online components and practical workstations.The course was delivered simultaneously in real time across the multiple deanery teaching hospitals. There was a central hub from which the course lead could synchronize timings/broadcast recorded material. As part of contingency plans for any unanticipated technical difficulties, lectures were pre-recorded and played for candidates on the day. These were punctuated with four practical workstations that mandated two delegates per station. Additionally, some content was recorded for viewing online as pre-course material and new simulation videos of a failed intubation drill and the subsequent debrief were also created. For some unable to attend site locations, a fully virtual experience was also an option. These modifications allowed us to: maximize attendance without breaching social distancing guidelines; retain the hands-on aspect of using equipment/techniques and also maintain an excellent faculty to candidate ratio to allow ample time for practising/asking questions. The pre-course material also empowered the candidates to feel better prepared for the day. Post-course anonymous feedback was completed by the vast majority of delegates and was overwhelmingly positive. Pre-course material, facilities, content, lectures, simulations and workshops were rated highly. The use of airway exchange catheters was mentioned as the introduction of a new skill for many delegates. Apart from one candidate, no one had attended any RCOA-accredited airway events in the preceding year but 100% of the candidates would recommend this course to their peers. Amidst challenging times, we successfully restyled an established and respected course. The novel hybrid multi-site format allowed a larger number of candidates to network face-to-face and gain knowledge/practical skills within a COVID-safe environment. Until such times as ‘normality’ and perhaps beyond, this may be a new formula for learning.

Role of endotracheal tube size on nasal and laryngeal morbidity during awake fiberoptic nasotracheal intubation: A Randomized controlled trial.

Background and Aims:Awake fibreoptic nasotracheal intubation is associated with adverse airway and hemodynamic complications. The aim of this study was to evaluate the role of endotracheal tube size on nasal and laryngeal morbidity during awake fibreoptic-guided nasotracheal intubation.Material and Methods:Eighty patients recruited to undergo awake fibreoptic intubation were randomly allocated to Group C (standard size endotracheal tube) and Group S (small size endotracheal tube followed by exchange to standard size using Airway Exchange Catheter under general anesthesia). Nasal morbidity was assessed by incidence of epistaxis, olfactory acuity, and mucociliary clearance. Patient discomfort during intubation was assessed using grimace score and hemodynamic parameters were recorded. Postoperatively, the incidence of nasal and laryngeal injury was recorded using nasendoscopy and telelaryngoscopy, respectively.Results:Demographic profile between the two groups was comparable. Epistaxis was noted in 47.5% of patients in group C as compared to 12.5% in group S. Postoperative olfactory acuity was decreased [2 (1-4) vs 4 (2-5)] and saccharin clearance time was prolonged (314 s vs 134 s) in Group C as compared to Group S. (P-value <0.001) Higher grimace score [2 (1-3) vs 1 (0-2)] and increased hemodynamic response was demonstrated in Group C. (P-value <0.001) Incidence of nasal injury [2 (1-4) vs 1 (0-2)] and laryngeal injury [1 (0-2) vs 0 (0-2)] was more in Group C as compared to Group S.Conclusion:Awake fibreoptic nasotracheal intubation with small size endotracheal tube followed by exchange to standard size under general anesthesia reduces nasal, laryngeal, and hemodynamic complications.

Comparative evaluation of Intubating Laryngeal Mask Airway (ILMA), I-gel and Ambu AuraGain for blind tracheal intubation in adults.

Background and Aims:The supraglottic airway devices (SADs) that allow direct (without an intermediary device like Aintree or airway exchange catheters) tracheal intubation can be invaluable for field use in conditions ideally managed by intubation. Whilst fiberscope-guided intubation is the method of choice, if these ‘direct-intubation’ SADs could provide high success rates for blind tracheal intubation, their scope of use can increase tremendously. Our study assesses intubating laryngeal mask airway (ILMA), i-gel and Ambu AuraGain for blind tracheal intubation in adults.Material and Methods:Ninety adults undergoing elective surgery were randomized into three equal groups. After induction of anesthesia, the group-specific SAD was inserted and on achieving adequate ventilation, blind tracheal intubation was attempted over two attempts. Success rates and time of achieving adequate device placement and tracheal intubation through these were evaluated. Data were analyzed using SPSS version 17.0 and P < 0.05 was considered statistically significant.Results:All three devices could achieve adequate ventilation within two allowed attempts. Successful tracheal intubation rates were significantly better with ILMA than i-gel on first attempt (87% vs. 27%, P < 0.001) and after second attempt that was supplemented with optimization maneuvers (100% vs. 40%, P < 0.001). No patient could be intubated through Ambu AuraGain within two attempts. Time taken for successful tracheal intubation did not differ significantly (P = 0.205) with ILMA or i-gel.Conclusion:Out of ILMA, I-gel and Ambu AuraGain, ILMA is the best device for blind tracheal intubation in adults with normal airways.

Airway and Ventilation Management for Excision of Recurrent Bronchogenic Cyst Followed by Removal of Metallic Bronchial Stent in a Child

Conventional lung isolation is at times not possible as was the case with our child who had a migrated bronchial stent. The Cook® airway exchange catheter was used as a backup for oxygenation/ventilation in case of the stent getting stuck during its removal. A specially designed device for facilitating egress of air during jet ventilation was indigenously created and held as a backup plan.