Alternative Airway Research Articles

ANALYSIS OF THE BASKA MASK VERSUS PROSEAL LARYNGEAL MASK AIRWAY SEALING PRESSURE IN PATIENTS POSTED FOR LAPAROSCOPIC SURGERIES UNDER GENERAL ANAESTHESIA

Background: Airway management by anaesthesiologist has come a long way from the invention of endotracheal intubation. Invention of supraglottic airway devices (SAD) provided alternative airway, without hazards of direct laryngoscopy and intubation. First generation SAD was considered airway tubes, and hence modications were made to them. PLMA (Proseal laryngeal mask airway) is a second generation SAD which has a gastric port along with the airway tube. BASKA mask is a novel 3rd generation SAD. We designed this study to compare the clinical efcacy of BASKA mask and PLMA for time for insertion, ease of insertion, airway sealing pressure and complications in anaesthetised patients undergoing positive pressure ventilation under general anaesthesia. The present randomi Methodology: zed control trial was conducted in 60 ASA-1 and ASA-2, aged between 18-60 years posted for elective laparoscopic surgeries under general anaesthesia. Patients were allocated into two equal groups, Group B-BASKA mask (n=30) and Group P- PLMA (n=30). All the data Collected were analysed. The demographic data, duration of insertion and airway sealing pressure were analysed using unpaired't' test. In our study we observed that, BASKA mask took lesser time to ins Results: ert in comparison to PLMA, the mean duration of insertion was 16.77±2.14 sec in BASKA Mask and 25.40±3.04 sec in PLMA Group. This difference was statistically signicant (p < 0.0001). The Mean airway sealing pressure was 33±2.31 cm of H2O in BASKA mask group and 27.00±1.84 cm of H2O in PLMA Group, after 5 min of insertion and 31.33±2.06 cm of H20 in BASKA Mask and 26.90±1.79 cm of H2O in PLMA Group after 5 min of pneumoperitoneum. The airway sealing pressure was more in BASKA group which was statistically signicant both after 5 min insertion and 5 min of pneumoperitoneum. There were no signicant mean airway sealing pressures between 5 min after insertion and 5 min after pneumoperitoneum in both the groups. The ease of insertion was more in BASKA mask but it was statistically insignicant. The Laryngopharyngeal morbidity score between these groups were statistically insignicant. To conclude, we observed that BASKA mask took lesser time to insert Conclusion: than PLMA in anaesthetized paralysed adult patients. Mean airway sealing pressure was higher in BASKA mask than PLMA. The ease of insertion was more in BASKA mask but it was statistically insignicant. The LPM score between these groups were statistically insignicant.

The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility.

Among all the proposed predictors of difficult intubation defined by the intubation difficulty scale, head and neck movement (motility) stands out and plays as a crucial factor in determining the success rate and the degree of ease on endotracheal intubation. Aside from other airway tools (e.g., supraglottic airway devices), optical devices have been developed and applied for more than two decades and have shown their superiority to conventional direct laryngoscopes in many clinical scenarios and settings. Although awake/asleep flexible fiberoptic bronchoscopy is still the gold standard in patients with unstable cervical spines immobilized with a rigid cervical collar or a halo neck brace, videolaryngoscopy has been repeatedly demonstrated to be advantageous. In this brief report, for the first time, we present our clinical experience on the routine use of the Shikani video-assisted intubating stylet technique in patients with traumatic cervical spine injuries immobilized with a cervical stabilizer and in a patient with a stereotactic headframe for neurosurgery. Some trouble-shooting strategies for this technique are discussed. This paper demonstrates that the video-assisted intubating stylet technique is an acceptable alternative airway management method in patients with restricted or confined neck motility.

Difficult Airway Management in Pediatric Patient with Neck Contracture

Background: A specific airway evaluation and physical examination should be performed in all pediatric patients undergoing anesthesia. Pediatric difficult airway problems can occur due to congenital, inflammation, trauma, or malignant disorders. Laryngeal mask airway (LMA) is an alternative breathing device for difficult airway cases. Case: We reported a 5-year-old girl, 12 kg of weight, with a diagnosis of Colli region contracture planned for contracture release. Physical examination revealed glasgow coma scale score 15, with a pulse of 98 beats per minute, a breath rate of 22 times per minute and SpO2 of 98% on the room air. In the airway evaluation, it was found that the lower mouth was pulled down by the contracture tissue, 2-fingers-wide of mouth opening, the mallampati score was difficult to evaluate, there was no obstruction and neck motion was limited due to contractures. In this report, intubation via video laryngoscope was failed due to the severely restricted neck motion caused by the contracture. The use of LMA became an alternative difficult airway management in this patient after failed intubation with a video laryngoscope. Conclusion: Preoperative evaluation for assessing and evaluating difficult airway in pediatric patients greatly determines the success of airway management. The use of airway devices such as LMA is still very helpful in cases of pediatric difficult airway.

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.

Laryngeal Masks in Neonatal Resuscitation-A Narrative Review of Updates 2022.

Positive pressure ventilation (PPV) is crucial to neonatal cardiopulmonary resuscitation because respiratory failure precedes cardiac failure in newborns affected by perinatal asphyxia. Prolonged ineffective PPV could lead to a need for advanced resuscitation such as intubation, chest compression, and epinephrine. Every 30 s delay in initiation of PPV increased the risk of death or morbidity by 16%. The most effective interface for providing PPV in the early phases of resuscitation is still unclear. Laryngeal masks (LMs) are supraglottic airway devices that provide less invasive and relatively stable airway access without the need for laryngoscopy which have been studied as an alternative to face masks and endotracheal tubes in the initial stages of neonatal resuscitation. A meta-analysis found that LM is a safe and more effective alternative to face mask ventilation in neonatal resuscitation. LM is recommended as an alternative secondary airway device for the resuscitation of infants > 34 weeks by the International Liaison Committee on Resuscitation. It is adopted by various national neonatal resuscitation guidelines across the globe. Recent good-quality randomized trials have enhanced our understanding of the utility of laryngeal masks in low-resource settings. Nevertheless, LM is underutilized due to its variable availability in delivery rooms, providers’ limited experience, insufficient training, preference for endotracheal tube, and lack of awareness.

Combination Therapy of High-flow Nasal Cannula and Upper-body Elevation for Postoperative Sleep-disordered Breathing: Randomized Crossover Trial.

The low acceptance rate of continuous positive airway pressure therapy in postoperative patients with untreated obstructive sleep apnea (OSA) indicates the necessity for development of an alternative postoperative airway management strategy. The authors considered whether the combination of high-flow nasal cannula and upper-body elevation could improve postoperative OSA. This nonblinded randomized crossover study performed at a single university hospital investigated the effect on a modified apnea hypopnea index, based exclusively on the airflow signal without arterial oxygen saturation criteria (flow-based apnea hypopnea index, primary outcome), of high-flow nasal cannula (20 l · min-1 with 40% oxygen concentration) with and without upper-body elevation in patients with moderate to severe OSA. Preoperative sleep studies were performed at home (control, no head-of-bed elevation) and in hospital (30-degree head-of-bed elevation). On the first and second postoperative nights, high-flow nasal cannula was applied with or without 30-degree head-of-bed elevation, assigned in random order to 23 eligible participants. Twenty-two of the 23 (96%) accepted high-flow nasal cannula. Four participants resigned from the study. Control flow-based apnea hypopnea index (mean ± SD, 60 ± 12 events · h-1; n = 19) was reduced by 15 (95% CI, 6 to 30) events · h-1 with head-of-bed elevation alone (P = 0.002), 10.9 (95% CI, 1 to 21) events · h-1 with high-flow nasal cannula alone (P = 0.028), and 23 (95% CI, 13 to 32) events · h-1 with combined head-of-bed elevation and high-flow nasal cannula (P < 0.001). Compared to sole high-flow nasal cannula, additional intervention with head-of-bed elevation significantly decreased flow-based apnea hypopnea index by 12 events · h-1 (95% CI, 2 to 21; P = 0.022). High-flow nasal cannula, alone or in combination with head-of-bed elevation, also improved overnight oxygenation. No harmful events were observed. The combination of high-flow nasal cannula and upper-body elevation reduced OSA severity and nocturnal hypoxemia, suggesting a role for it as an alternate postoperative airway management strategy.

Supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest: the AIRWAYS-2 cluster RCT.

When a cardiac arrest occurs, cardiopulmonary resuscitation should be started immediately. However, there is limited evidence about the best approach to airway management during cardiac arrest. The objective was to determine whether or not the i-gel® (Intersurgical Ltd, Wokingham, UK) supraglottic airway is superior to tracheal intubation as the initial advanced airway management strategy in adults with non-traumatic out-of-hospital cardiac arrest. This was a pragmatic, open, parallel, two-group, multicentre, cluster randomised controlled trial. A cost-effectiveness analysis accompanied the trial. The setting was four ambulance services in England. Patients aged ≥ 18 years who had a non-traumatic out-of-hospital cardiac arrest and were attended by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017. Follow-up ended in February 2018. Paramedics were randomised 1 : 1 to use tracheal intubation (764 paramedics) or i-gel (759 paramedics) for their initial advanced airway management and were unblinded. The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred earlier, collected by assessors blinded to allocation. The modified Rankin Scale, a measure of neurological disability, was dichotomised: a score of 0-3 (good outcome) or 4-6 (poor outcome/death). The primary outcome for the economic evaluation was quality-adjusted life-years, estimated using the EuroQol-5 Dimensions, five-level version. A total of 9296 patients (supraglottic airway group, 4886; tracheal intubation group, 4410) were enrolled [median age 73 years; 3373 (36.3%) women]; modified Rankin Scale score was known for 9289 patients. Characteristics were similar between groups. A total of 6.4% (311/4882) of patients in the supraglottic airway group and 6.8% (300/4407) of patients in the tracheal intubation group had a good outcome (adjusted difference in proportions of patients experiencing a good outcome: -0.6%, 95% confidence interval -1.6% to 0.4%). The supraglottic airway group had a higher initial ventilation success rate than the tracheal intubation group [87.4% (4255/4868) vs. 79.0% (3473/4397), respectively; adjusted difference in proportions of patients: 8.3%, 95% confidence interval 6.3% to 10.2%]; however, patients in the tracheal intubation group were less likely to receive advanced airway management than patients in the supraglottic airway group [77.6% (3419/4404) vs. 85.2% (4161/4883), respectively]. Regurgitation rate was similar between the groups [supraglottic airway group, 26.1% (1268/4865); tracheal intubation group, 24.5% (1072/4372); adjusted difference in proportions of patients: 1.4%, 95% confidence interval -0.6% to 3.4%], as was aspiration rate [supraglottic airway group, 15.1% (729/4824); tracheal intubation group, 14.9% (647/4337); adjusted difference in proportions of patients: 0.1%, 95% confidence interval -1.5% to 1.8%]. The longer-term outcomes were also similar between the groups (modified Rankin Scale: at 3 months, odds ratio 0.89, 95% confidence interval 0.69 to 1.14; at 6 months, odds ratio 0.91, 95% confidence interval 0.71 to 1.16). Sensitivity analyses did not alter the overall findings. There were no unexpected serious adverse events. Mean quality-adjusted life-years to 6 months were 0.03 in both groups (supraglottic airway group minus tracheal intubation group difference -0.0015, 95% confidence interval -0.0059 to 0.0028), and total costs were £157 (95% confidence interval -£270 to £583) lower in the tracheal intubation group. Although the point estimate of the incremental cost-effectiveness ratio suggested that tracheal intubation may be cost-effective, the huge uncertainty around this result indicates no evidence of a difference between groups. Limitations included imbalance in the number of patients in each group, caused by unequal distribution of high-enrolling paramedics; crossover between groups; and the fact that participating paramedics, who were volunteers, might not be representative of all paramedics in the UK. Findings may not be applicable to other countries. Among patients with out-of-hospital cardiac arrest, randomisation to the supraglottic airway group compared with the tracheal intubation group did not result in a difference in outcome at 30 days. There were no notable differences in costs, outcomes and overall cost-effectiveness between the groups. Future work could compare alternative supraglottic airway types with tracheal intubation; include a randomised trial of bag mask ventilation versus supraglottic airways; and involve other patient populations, including children, people with trauma and people in hospital. This trial is registered as ISRCTN08256118. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and supported by the NIHR Comprehensive Research Networks and will be published in full in Health Technology Assessment; Vol. 26, No. 21. See the NIHR Journals Library website for further project information.

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care.

Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings. We conducted a market review of 25 SGA devices that may meet inclusion into the medics' aid bag. The company's official "Instructions for Use" document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device. Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device's features, indications, and contraindications based on the manufacturer's product information documentation. There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

Apneic Technique in Laryngotracheal Surgery.

BackgroundApneic oxygenation can be applied to select laryngotracheal procedures to improve operative visualization and avoid potential complications associated with intubation and jet ventilation. Aims/objectivesThe authors sought to determine if apneic oxygenation using a high-flow nasal cannula could be used as a safe alternative airway management strategy for the duration of select laryngotracheal procedures.MethodsSingle institution, multi-site retrospective review of 38 adult (>18 years old) patients undergoing apneic oxygenation in the setting of various laryngotracheal procedures from January 2017 through January 2018. Humidified oxygen was delivered via a high-flow nasal cannula. The data was collected and analyzed using SAS version 9.4 (SAS Institute, Cary, NC).ResultsTwenty-four women and 14 men, mean age 60.0 years (SD 16.1; 36-89) and 70.1 years (SD 7.2; 56-81), respectively, underwent a mean total apneic time of 23.9 minutes (13-40). A statistically significant correlation existed between apneic time and minimum oxygen saturation (Pearson correlation coefficient 0.38; p=0.018). Twenty-one patients resumed spontaneous ventilation without the need for jet ventilation, mask ventilation, or placement of a definitive airway during the procedure. Conclusions and significanceApneic oxygenation allows for extended periods of operating without the need for the placement of an endotracheal tube in patients undergoing general anesthesia for select laryngotracheal procedures.

CA N'EST PAS DU GÂTEAU: CHALLENGES OF MECHANICAL VENTILATION IN A PATIENT WITH ARDS DUE TO COVID-19 INFECTION AND TRACHEOMEGALY

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Mechanical ventilation for Covid-19 – acute respiratory distress syndrome (ARDS) is challenging due to poor lung compliance and high airway pressures for a prolonged period. Under these circumstances, physicians have limited means to control air leaks when they occur. We discuss a case of severe Covid-19 ARDS complicated by early air-leak which was attributed to idiopathic tracheomegaly, and the associated challenges in the patients' care. CASE PRESENTATION: 60-year-old African American man with polymyositis and diabetes mellitus was intubated with a size 8.0 endotracheal tube (ET) for hypoxemic respiratory failure due to Covid-19 infection. Lung protective ventilation was utilized. He was extubated on day three, but he required re-intubation the following day for worsening mental status and hypoxemia. A significant cuff leak (> 400 ml) on a PEEP of 5 cm H2O was noted. Ppeak and Pplat were 42cm H20 and 39 cm H2O respectively. Arterial blood gas: pH 7.129, PCO2 79.6, PaO2 72. The air leak only resolved when cuff pressures exceeded 70 cm H2O. A chest x-ray confirmed adequate ET tube positioning. Tube exchange with another size 8.0 tube was performed, but the balloon was found to be intact. The ET tube was upsized to size 9.0, yet cuff-pressures as high as 70-80 cm H2O were needed to maintain a leak of 35cm H2O) and airway pressures, steroid use, connective tissue diseases, and systemic shock. Our patient had a history of polymyositis but no other risk factors for early tracheomalacia. This case highlights the challenge of overcoming a life-threatening air leak that was likely exacerbated by elevated airway pressures in a patient with idiopathic tracheomegaly. The cuff leak improved after one week with the recovery of lung compliance. After 45 days in the medical intensive care unit, the patient was discharged to an LTACH with a size 8.0 Shiley tube. CONCLUSIONS: Developing alternative endotracheal airway products should be considered to account for these rare patients. REFERENCE #1: Everson DM. Tracheobronchomegaly causing endotracheal tube cuff leak. Trends in Anaesthesia and Critical Care. 2019;25:46-7. DISCLOSURES: No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Faiza Khalid, source=Web Response No relevant relationships by Ismini Kourouni, source=Web Response No relevant relationships by Yasir Tarabichi, source=Web Response

Submental Intubation for LeFort Type III Fracture

Introduction: This case report describes the use of submental intubation for an open reduction internal fixation (ORIF) LeFort Type III fracture encountered at Methodist Dallas Medical Center operating room (OR). Other airway management options in maxillofacial fractures include nasotracheal intubation or tracheostomy, however, these options come with complications and may be contraindicated in certain cases. Case description: This case involved a 51-year-old male who came in from an automobile vs pedestrian type accident who underwent an open reduction internal fixation of a LeFort Type III fracture with hip graft. The patient was intubated orally first for general anesthesia and then converted to submental intubation by the oral/maxillofacial surgeon to allow for surgical access. Discussion: Submental intubation is an alternative airway route for oral/maxillofacial surgeries when nasotracheal intubation or tracheostomies are not indicated. While submental intubations are low-risk, low-cost, simpler, and faster, it still comes with its list of complications. These complications rates are low, minimal scarring is reported, and no special equipment is needed. Conclusions: Submental intubation is the preferred airway route with oral/maxillofacial trauma when nasotracheal intubation or tracheostomy is not indicated. If there are no contraindications to submental intubation, it allows advantageous intraoperative airway access in patients requiring surgical fixation of oral/maxillofacial fractures.

Efficacy of Baska mask as an alternative airway device to endotracheal tube in patients undergoing laparoscopic surgeries under controlled ventilation.

Background and Aims:Newer supraglottic devices with an additional gastric channel offer greater protection from aspiration and avoidance of laryngoscopy for their insertion would result in attenuated hemodynamic responses.The primary objective was to assess hemodynamic responses to insertion of Baska mask as compared to tracheal intubation. The time and attempts taken to secure airway and evidence of regurgitation and pulmonary aspiration of gastric contents were also assessed.Material and Methods:This prospective, randomized study was conducted in 80 patients undergoing laparoscopic cholecystectomy. All patients received standardized anaesthesia protocol. Baska mask was used to secure airway in Group B, while tracheal intubation was done in group T. Methylene blue was injected through Ryle's tube into stomach in both groups. At end of surgery, fibreoptic bronchoscopy was performed to detect bluish staining of trachea and/or main bronchi as evidence of aspiration of gastric contents and bluish staining in oropharynx as evidence of regurgitation. Chi-square test and Independent sample t-test were applied.Results:The time taken to secure airway was significantly longer in Group B as compared to Group T (45.3 ± 12.6 vs. 24.3 ± 9.1 sec) Percentage of patients who had oropharyngeal blue stain was comparable in both groups. No patient in both groups had tracheal blue stain. Group T had significantly higher HR and MAP after intubation till 10 min later.Conclusion:Baska mask insertion was associated with attenuated hemodynamic responses, though more time and attempts were required for securing the airway. It could be considered as an alternative to tracheal intubation during laparoscopic surgeries.

Effectiveness of selected alternative methods of airway management by the nursing staff

Abstract Aim. The aim of the study was to assess the effectiveness of selected methods of alternative airway management by nursing staff. Material and methods. A prospective, pilot observational study was conducted on a group of 51 nurses undergoing specialization training or with specialty. Each nurse managed the airway with a laryngeal mask (LMA-Laryngeal Mask) and a laryngeal tube (LT-D-Laryngeal Tube) on a BT-CSIE trainer, and then carried out one minute ventilation using a bag valve mask, according to possessed knowledge and skills. The obtained parameters (time, pressure on the incisors, head tilt, ventilation quality) were recorded using a dedicated tablet. Statistical analysis was performed using the IBMSPSS Statistics 20 package. Results. No statistically significant differences were observed between the trials to open the airway using LMA and LT-D. Higher efficiency of LMA airway opening was demonstrated in the first trial and the average tidal volume during ventilation in relation to LT-D (LMA 547.84ml vs. LT-D 522.63ml). In addition, there was a significant difference in pressure on the incisors (LMA 6.82N vs. LT-D 4.12N). Conclusions. The effectiveness of LMA and LT-D insertion was assessed at a high level, with no significant differences between them. Variables: age, seniority, education level and type of specialization did not significantly differentiate the results obtained.

"A Systematic Review on Guidelines and Recommendations for Tracheostomy During COVID-19 Pandemic".

World is under threat of COVID-19 pandemic, associated with many numbers of critically ill patients. To manage these intubated patients there are need of more ventilators but world is not prepared for this type of situation and there are lacunae of such arrangements in most of the countries. As we know patients cannot be intubated for long time and they should be given preference to alternative airway in the form of tracheostomy. COVID-19 is aerosol transmitted disease which lead to indeed challenge to health care providers to safely perform tracheostomy and provide post tracheostomy care to these patients with minimising risks of nosocomial transmission to themselves and accompanying nursing staff. There are so many guidelines and recommendations for the timing, desired place of tracheostomy, change in tracheostomy steps related to conventional method and the subsequent management of patients. So, the aim of this systematic review is to give a brief review of available data on COVID-19 related to the timing, personal protections, operative steps modifications, and subsequent post tracheostomy care during this pandemic.

Use of second generation supraglottic airway device for endovascular treatment of unruptured intracranial aneurysms: a retrospective cohort

BackgroundWe aimed to assess the feasibility of using supraglottic devices as an alternative to orotracheal intubation for airway management during anesthesia for endovascular treatment of unruptured intracranial aneurisms in our department over a nine-year period. MethodsRetrospective single center analysis of cases (2010–2018). Primary outcomes: airway management (supraglottic device repositioning, need for switch to orotracheal intubation, airway complications). Secondary outcomes: aneurysm complexity, history of subarachnoid hemorrhage, hemodynamic monitoring, and perioperative complications. ResultsWe included 187 patients in two groups: supraglottic device 130 (69.5%) and orotracheal intubation 57 (30.5%). No adverse incidents were recorded in 97% of the cases. Three supraglottic device patients required supraglottic device repositioning and 1 supraglottic device patient required orotracheal intubation due to inadequate ventilation. Three orotracheal intubation patients had a bronchospasm or laryngospasm during awakening. Forty-five patients (24.1%) had complex aneurysms or a history of subarachnoid hemorrhage. Thirty-three of them (73.3%) required orotracheal intubation compared to 24 of the 142 (16.9%) with non-complex aneurysms. Two patients in each group died during early postoperative recovery. Two in each group also had intraoperative bleeding. A post-hoc analysis showed that orotracheal intubation was used in 55 patients (44%) in 2010 through 2014 and 2 (3.2%) in 2015 through 2018, parallel to a trend toward less invasive blood pressure monitoring from the earlier to the later period from 34 (27.2%) cases to 5 (8.2%). ConclusionSupraglottic device, like other less invasiveness protocols, can be considered a feasible alternative airway management approach in selected patients proposed for endovascular treatment of unruptured intracranial aneurisms.

Analysis of endotracheal intubation-related judicial precedents in South Korea

BackgroundMedical malpractice during endotracheal intubation can result in catastrophic complications. However, there are no reports on these severe complications in South Korea. We aimed to investigate the severe complications associated with endotracheal intubation occurring in South Korea, via medicolegal analysis.MethodsWe retrospectively analyzed the closed judicial precedents regarding complications related to endotracheal intubation lodged between January 1994 and June 2020, using the database of the Supreme Court of Korea. We collected clinical and judicial characteristics from the judgments and analyzed the medical malpractices related to endotracheal intubation.ResultsOf 220 potential cases, 63 were included in the final analysis. The most common event location was the operating room (n = 20, 31.7%). All but 3 cases were associated with significant permanent or more severe injury, including 31 deaths. The most common problems were failed or delayed intubation (n = 56, 88.9%). Supraglottic airway device was used in 5.2% (n = 3) cases of delayed or failed intubation. Fifty-one (81%) cases were ruled in favor of the plaintiff in the claims for damages, with a median payment of Korean Won 133,897,845 (38,000,000, 308,538,274). The most common malpractice recognized by the court was that of not attempting an alternative airway technique (n = 32, 50.8%), followed by violation of the duty of explanation (n = 10, 15.9%).ConclusionsOur results could increase physicians’ awareness of the major complications related to endotracheal intubation and help ensure patient safety.

Awake intubation with C-MAC videolaryngoscope in a patient with difficult airway.

Sir, The role of videolaryngoscopy has increased in the management of the difficult airway in recent times. We report a case where C-MAC D-blade videolaryngoscope (VL) was used in the airway management of a patient with cervico-facial necrotising fasciitis scheduled for surgical debridement. A 28-year-old male patient was posted for surgical debridement of cervico-facial necrotising fasciitis with multi-organ dysfunction. He was a known case of type 1 diabetes mellitus (DM). On examination, the patient was irritable and disoriented due to sepsis-induced encephalopathy (GCS-E3V3M5). He had a swollen and blackened right cheek due to necrosis with extension to the neck [Figure 1]. The mouth opening of the patient was around 1.6cm with restricted neck mobility, eliminating the possibility of neck extension. Our primary airway management plan was awake intubation via C-MAC VL (Karl Storz) blade D. A fibre-optic bronchoscope with an endoscopic mask was readily available as an alternative airway management plan. A skilled ear-nose-throat (ENT) surgeon was also requested to be standby for the emergency tracheostomy.Figure 1: Cervico-facial necrotising fasciitis involving the entire right cheek and extending to the neckIn the preoperative room, the patient's airway was prepared by nebulisation with 4mL of 4% lignocaine. In the operating room, standard American Society of Anesthesiologists (ASA) monitors such as electrocardiogram, non-invasive blood pressure and pulse oximeter were attached to the patient. The patient was sedated with 50 μg fentanyl and dexmedetomidine (loading dose of 1 μg/kg, followed by the infusion of 0.5 μg/kg/h). The patient received continuous oxygen via a nasal catheter with a flow of 3 L.min−1. Topical anaesthesia was supplemented with two puffs of lidocaine 10% metered spray applied directly on the surface of the tongue and oropharynx. Videolaryngoscopy was done using an adult D-blade of C-MAC and the percentage of glottic opening (POGO) score was found to be zero. Simultaneously, the posterior pharyngeal wall was anaesthetised with two puffs of 10% lignocaine spray to blunt the reflexes during insertion of the endotracheal tube (ETT). The patient was then intubated with a 7.5 mm internal diameter (ID) ETT with the aid of Eschmann stylet (Portex; Smiths Medical). After confirmation of the capnography waveform, general anaesthesia was induced with propofol and rocuronium. The surgery lasted uneventfully for around 100 min after which the patient was shifted to the intensive care unit, and was extubated the same day. Cervico-facial necrotising fasciitis is a soft tissue infection that spreads along with the superficial musculoaponeurotic system and early aggressive surgical debridement is the mainstay in achieving a successful outcome.[1] Anaesthetic management of such patients is challenging as the pain, swelling and oedema due to inflammatory processes restrict the facial and cervical movements, making the airway potentially difficult. Awake fibre-optic intubation (AFOI) is considered the technique of choice in predicted difficult airway. AFOI has a steep learning curve and requires patient cooperation. Recently, VLs have gained immense popularity as the first-line devices in adult and paediatric difficult airways due to feasibility of orotracheal intubation in a restricted mouth opening.[23] Karmer et al. described C-MAC VL as superior to fibre-optic intubation (FOI) in terms of faster intubation time in limited mouth opening patients(>1.3cm).[4] Alhomary in a systematic review also confirmed that awake video laryngoscopy has a shorter intubation time compared to AFOI.[5] In our institute, we frequently use D-blade of C-MAC for difficult intubations and so are well versed with it. Hence, C-MAC was chosen as a primary airway management plan to quickly secure the airway. Since the D-blade has a thickness of around 1 cm, it can be easily accommodated in the limited mouth opening patient and has a better field of vision (60 degrees angle of view) with the requirement of less lifting force to visualise the glottis, especially in patients who are not fully anaesthetised.[6] To conclude, we suggest that awake videolaryngoscopy using D-blade of C-MAC VL can be considered as an alternative for tracheal intubation in difficult airway scenarios where AFOI is difficult or not possible. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement We would like to acknowledge the support and guidance of Dr Rakesh Kumar, M.D, Associate Professor, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur in helping me write this article.

A clinical study on laryngotracheal injuries following endotracheal intubation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Despite major advances in the design of endotracheal tubes and developments in the management of difficult airways, endotracheal intubation remains by far the most common cause of laryngotracheal injuries (LTI). These LTI are challenging to manage and are associated with significant morbidity and mortality. Hence, the present study was done to find out the incidence, types of LTI and to study the factors affecting the same.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study was conducted on patients who were intubated for more than 48 hours and admitted in medical intensive care units in a tertiary referral hospital, for a period of 1 year. All patients following extubation were evaluated for LTI by x-ray neck (antero-posterior and lateral view), rigid endoscopy and flexible naso-pharyngo-laryngoscopy. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Thirty patients were included in the study. Majority of the patients (56.6%) were found normal while 43.2% patients were having LTI following extubation in the form of bilateral vocal cord fixation, subglottic stenosis, granulation tissue in the posterior commissure and in the trachea. Majority of these patients were aged less than 45 years, with duration of intubation for more than 10 days, with tube size more than 7 mm. Organo-phosphourous (OP) poisoning was the etiology for LTI in 69.2% cases.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; A high incidence of LTI especially in cases of OP poisoning warrants one to be cautious in managing these intubated patients. Those patients requiring prolonged intubation should be considered for other alternative airway managements like tracheostomy in addition to using low pressure, high volume cuffed tubes. Adequate training of the emergency personnel in the intubation technique and its subsequent care is important especially in a tertiary referral center.&lt;/p&gt;

Effectiveness of the Use of Augmented Reality in Teaching the Management of Anaphylactic Shock at the Primary Care Level: Protocol for a Randomized Controlled Trial.

BackgroundAugmented reality (AR) has benefits and feasibility in emergency medicine, especially in the clinical care of patients, in operating rooms and inpatient facilities, and in the education and training of emergency care providers, but current research on this topic is sparse.ObjectiveThe primary objective is to evaluate the short-term and long-term effectiveness of the use of AR in the treatment of patients with anaphylactic shock. The secondary objectives are to evaluate the safety in the treatment of patients with anaphylactic shock, evaluate the short-term and long-term effectiveness of stress management in this process, and determine the experiences and attitudes towards the use of AR in education.MethodsThe study will be conducted in 3 phases. In the first phase, we will develop and test the scenario for simulation of anaphylactic shock and the evaluation scale for assessing the effect of the intervention. In the second phase, a single-blinded, randomized controlled trial will be conducted. In the third phase, the use of AR in teaching the management of anaphylactic shock using focus groups will be evaluated qualitatively. All participants will participate in a 1-day training program consisting of a lecture on emergency care and anaphylactic shock as well as exercises in manual dexterity (aspiration, airway management, alternative airway management, artificial respiration, chest compressions, safe defibrillation, oxygen application, use of medication during emergency care). The test group will also focus on education about anaphylactic shock in AR (the intervention). The main outcome will be the evaluation of the participants' performance in coping with a simulated scenario of anaphylactic shock using a high-fidelity simulator (simulator with high levels of realism) and a standardized patient in an educational and clinical environment. The study will be conducted with primary care physicians.ResultsA scenario for the simulation with a high-fidelity simulator and standardized patient has already been developed. For the time being, we are developing an evaluation scale and starting to recruit participants. We plan to complete the recruitment of participants by the end of December 2020, start the randomized controlled trial in January 2021, and finish 1 year later. The first results are expected to be submitted for publication in 2021.ConclusionsThis will be the first study to evaluate the effectiveness of the use of AR in medical teaching. Specifically, it will be based on a clinical case of anaphylactic shock at the primary care level. With our study, we also want to evaluate the translation of these educational results into clinical practice and assess their long-term impact.Trial RegistrationISRCTN Registry ISRCTN58047410; http://www.isrctn.com/ISRCTN58047410International Registered Report Identifier (IRRID)PRR1-10.2196/22460

A Comparative Evaluation of Respiratory Parameters Spo2 and Etco2 with Paediatric I-Gel, Proseal LMA Vs Endotracheal Tube

Introduction: Supra Glottic Airway devices have set a new trend in airway maintenance since their invention. Availability of these devices in the paediatric sizes has revolutionized their use. Endo Tracheal Tubes have always been considered “Gold Standard” owing to their ability of maintaining stable respiratory parameters and in prevention of aspiration. We have compared the repiratory parameters achieved with Paediatric I-Gel, Proseal -LMA and Endo Tracheal Tube. Description: 120 children aged 2 to 12 years, both sex, ASA 1 and 2, posted for elective surgery were included in the study. They were divided into 3 groups of 40 each - Endo Tracheal Tube (E), Proseal LMA (P-LMA) and I-GEL respectively. The device was inserted after induction of anaesthesia and the respiratory parameters namely SpO2 and EtCO2 were recorded at various time intervals. Result: All values were analysed and expressed as mean +/– SD. Statistical comparison was done by unpaired student “t”- test and chi square test. The values obtained for various time intervals were found to be statistically insignificant for all the three devices. Conclusion: PaediatricProseal LMA (P-LMA) and I-GEL are very much comparable with Endo Tracheal Tube (E) with regard to respiratory parameters and hence can be safely used as an alternative airway in the paediatric population.