Correct Tube Placement Research Articles

EP274 - A clinical audit on nasogastric tube placement documentation and adherence with NICE guidelines in general surgical patients across a district general hospital

Abstract Aims NICE provide clear guidelines on confirming correct nasogastric (NG) tube siting using pH testing of aspirates or with X-rays where indeterminate samples are drawn. We aimed to audit documentation following nasogastric tube insertion to ascertain adherence to NICE guidelines. Methods A single-cycle snapshot audit was conducted on all surgical inpatients who had nasogastric tubes inserted over their admission across a single-centre district general hospital general surgery department. Data was collected on indication for NG tube insertion (drainage or feeding), length of initial tube insertion, whether pH testing was used to confirm position, and whether correct tube placement has been confirmed by a competent person through x-ray where indeterminate samples were tested from NG aspirate (pH > 5.5). Results A total of 15 patients had an NG tube inserted over their admission with mean age 77.3 years (range 47-97). 60% of patients had correctly documented confirmation of NG tube siting. 4/15 NG tubes were inserted for feeding purposes (26.7%), all of which were documented correctly. Only 45.5% of NG tubes for drainage were documented correctly and only 33.3% of all NG tubes had length of insertion documented. Where pH testing was inconclusive, a chest X-ray was requested for all patients and sufficiently documented by a doctor qualified to confirm position. No complications relating to NG tubes occurred across the audit study. Conclusions Implementation of improvement measures are warranted to improve overall adherence with NICE guidelines and prevent risk of incorrect confirmation of NG tube siting.

Effect of patient position on the success rate of placing triple-cuffed double lumen endotracheal tubes: a two-center interventional observational study.

Double-lumen endotracheal tubes (DLT) are essential for one-lung ventilation during thoracic surgery. Bronchoscopy is crucial for correct placement of a DLT to avoid complications such as hypoxemia. This study evaluated the effectiveness of the triple-cuffed DLT (tcDLT) in the supine and lateral positions for correct placement without bronchoscopic guidance. This prospective observational study included 167 patients scheduled for elective thoracic surgery requiring one-lung ventilation. The incidence of successful placement of left-sided tcDLTs was compared between the supine and lateral decubitus positions under bronchoscopic surveillance. Successful tcDLT placement was defined as the placement of the proximal end of the bronchial cuff within 5 mm of the carina. Among 153 patients who completed the study, the successful tcDLT placement rate in the lateral position (70.6%) was significantly higher than that in the supine position (50.3%). The rate of difference was 20.3% (95% confidence interval [CI], 10.6-29.9%). The extended successful placement rate, including slightly deeper placements, showed no significant differences between the positions (88.9%; 95% CI, 83.9‒93.9% in supine, 86.3%; 95% CI, 80.8‒91.7% in lateral). tcDLT facilitates correct tube placement in both the supine and lateral positions, with a higher lateral success rate. This finding supports the idea that tcDLTs offer a reliable alternative for lung separation when bronchoscopy is not feasible.

A review of environmental and economic aspects of medical devices, illustrated with a comparative study of double-lumen tubes used for one-lung ventilation

When health care management considers implementing a new technology such as a medical device, it is crucial to take workflow, clinical outcome, economy, and environmental impacts into consideration in the decision-making process. This study outlines the knowledge status of this complex challenge via a systematic literature review (SLR). The SLR found 133 of 1570 screened publications that covered relevant frameworks for choosing hospital equipment (i.e., related economics, life cycle assessment, waste generation and health issues). Yet, just five publications addressed choosing single-use vs. reuse of tubes or similar types of equipment by economic and environmental considerations through a systematic quantitative approach. The SLR reveals few publicly available peer-reviewed studies for the optimal sustainable choice of equipment. This study assesses environmental impacts of carbon dioxide (CO2) emissions as CO2-equivalents and resource consumption of a single-use double-lumen tube (DLT) combined with a reusable bronchoscope were compared to a single-use DLT with an integrated single-use camera. Camera DLTs exclude or minimize the need for a bronchoscope to verify correct tube placement during one-lung ventilation. The life cycle assessment shows that the materials and energy used and needed for personnel protective equipment and cleaning of the reusable bronchoscope contribute significantly to CO2-equivalent emissions. To ensure the sustainable choice of equipment this aspect must not be overlooked. Secondly, future reuse of plastic waste materials from the use can contribute significantly to better environmental performance.

Diagnostic accuracy of ultrasonography for detecting gastric tube placement: an updated meta-analysis.

This study aimed at reviewing the diagnostic accuracy of ultrasonography for detecting correct nasogastric tube placement compared with X-ray imaging as the reference standard. This was a systematic review and meta-analysis of observational studies published between 1961 and 2022. We included studies that compared the diagnostic accuracy of ultrasound detection for nasogastric tube placement with that of X-ray imaging in adult patients who were undergoing nasogastric tube placement for any reason. We searched for published studies in the following electronic databases: Cochrane Library, PubMed, EMBASE, and Web of Science. The risk of bias was assessed using a standard procedure according to the Quality Assessment of Diagnostic Accuracy Studies-2 criteria. The results were analyzed using RevMan or Meta-Disc software to determine the adequacy and conclusiveness of the available evidence. Fourteen studies met our inclusion criteria. Overall, 1,812 patients were included in these studies. The results included a pooled sensitivity of 0.96 (95% confidence interval [CI] 0.94-0.97), specificity of 0.91 (95% CI 0.85-0.96), positive likelihood ratio of 5.08 (95% CI 1.49-17.39), and negative likelihood ratio of 0.08 (95% CI 0.06-0.10). This was confirmed through a summary receiver operating characteristic curve, which showed that the area under the curve was 0.96. We found evidence about validity of ultrasound as an efficient method for verifying nasogastric tube placement, although there is insufficient evidence to suggest that it can be used as a diagnostic tool for incorrect gastric tube placement.

The effectiveness of auscultatory, colorimetric capnometry and pH measurement methods to confirm placement of nasogastric tubes: A methodological study.

To determine the effectiveness of auscultatory, colorimetric capnometry and pH measurement methods for confirmation of correct nasogastric tube placement in critically ill patients. Incorrect nasogastric tube placement causes serious complications. This was a methodological and comparative study. The study sample consisted of 88 new insertions of nasogastric feeding tubes between April 2018-2019. Results from the 'auscultatory', 'pH' and 'colorimetric capnometry' methods were compared with the location of the nasogastric tube as determined through radiography. Descriptive statistics, Eta analysis and the Cohen kappa compliance test as well as sensitivity and specificity were conducted. There was a weak agreement (26.3%) between the auscultation and radiological evaluation for confirming nasogastric tube placement. The pH measurement and colorimetric capnometry methods were not correlated with radiological evaluation. Stomach pH increased as patient age increased and use of the colorimetric capnometry method failed to confirm the oesophageal and duodenal location. The specificity of the auscultation was low, and both the specificity and sensitivity pH methods were low. It was determined that auscultation, measuring pH and colorimetric capnometry were unreliable methods for confirming placement of nasogastric tubes. It is recommended to confirm initial placement of the nasogastric tube with radiography and to develop effective and reliable non-radiological measurement methods that can be performed at the bedside.

Intubation using VieScope vs. Video laryngoscopy in full personal protective equipment \u2013 a randomized, controlled simulation trial

BackgroundVieScope is a new type of laryngoscope, with a straight, transparent and illuminated blade, allowing for direct line of sight towards the larynx. In addition, VieScope is disposed of after single patient use, which can avoid cross-contaminations of contagious material. This has gained importance especially when treating patients with highly contagious infectious diseases, such as during the SARS-CoV2 pandemic. In this context, VieScope has not been evaluated yet in a clinical study.Material and methodsThis study compared intubation with VieScope to video-laryngoscopy (GlideScope) in normal and difficult airway in a standardized airway manikin in a randomized controlled simulation trial. Thirty-five medical specialists were asked to perform endotracheal intubation in full personal protective equipment (PPE). Primary endpoint was correct tube position. First-pass rate (i.e., success rate at the first attempt), time until intubation and time until first correct ventilation were registered as secondary endpoints.ResultsFor correct tracheal tube placement, there was no significant difference between VieScope and GlideScope in normal and difficult airway conditions. VieScope had over 91% fist-pass success rate in normal airway setting. VieScope had a comparable success rate to GlideScope in difficult airway, but had a significantly longer time until intubation and time until ventilation.ConclusionVieScope and GlideScope had high success rates in normal as well as in difficult airway. There was no unrecognized esophageal intubation in either group. Overall time for intubation was longer in the VieScope group, though in an acceptable range given in literature.Results from this simulation study suggest that VieScope may be an acceptable alternative for tracheal intubation in full PPE.Trial RegistrationThe study was registered at the German Clinical Trials Register www.drks.de (Registration date: 09/11/2020; TrialID: DRKS00023406).

USB-endoscope laryngoscope is as effective as video laryngoscope in difficult intubation

BACKGROUND: Video laryngoscopy (VL) has recently been put into clinical use to minimize the limitations of direct laryngoscopy and assist physicians interested in airway management. However, the high cost is the biggest constraint especially in countries with limited resources. To lower the cost, a custom-made VL obtained by attaching a USB-endoscope camera ($8.5) to the Macintosh laryngoscope (USB-L) can be used. MATERIAL AND METHODS: All intubations were performed in a difficult intubation model. Intubations were carried out by two emergency physicians. A Glidescope as a VL and a custom-made USB-L were used. In addition to these devices, one bougie to facilitate the advancement of the tube was used. The total intubation time was evaluated. RESULTS: Correct tube placement for both operators was 100% for both devices. A difference between the operators in the duration of intubations could not be found. Also, there is no difference in the duration of intubations between the devices for both operators. CONCLUSION: It was concluded that the USB-L and VL are not statistically different in terms of intubation time in the difficult intubation model using bougie. For countries with limited resources, the low-cost USB-L has come to the forefront due to the high cost of VL and difficulty of access.

A Cross-sectional Survey of Enteral Feeding Tube Placement and Gastric Residual Aspiration Practices

Background: Preterm infants routinely require enteral feeding via nasogastric or orogastric tubes as an alternative to oral feeding to meet their nutritional needs. Anecdotal evidence suggests variations in practice related to correct tube placement and assessment of feed intolerance. Purpose: To determine the current practices of enteral feeding tube placement confirmation and gastric residual (GR) aspiration of neonatal clinicians in Australia. Methods: A cross-sectional online survey comprising 24 questions was distributed to nursing and medical health professionals working in Australian neonatal care units through 2 e-mail listservs made available by professional organizations. Findings: The survey was completed by 129 clinicians. A single method was practiced by 50% of the clinicians in confirming tube placement, and most common practice was assessing the pH of GR aspirate. The majority of respondents (96%) reported that they relied on GR aspiration and clinical signs to determine feeding tolerance and subsequent decisions such as ceasing or decreasing feeds. However, the frequency of aspiration, the amount and color of aspirate considered to be normal/abnormal, and decisions on whether to replace gastric aspirate or whether aspiration should be performed during continuous tube feeding varied. Implication for practice: This study demonstrated considerable variability in clinical practice for enteral feeding tube placement confirmation and GR aspiration despite most respondents reporting using a unit-based clinical practice guideline. Our study findings highlight the need for not only developing evidence-based practice guidelines for safe and consistent clinical practice but also ensuring that these guidelines are followed by all clinicians. Implication for research: Further research is needed to establish evidence-based methods both for enteral feeding tube placement confirmation and for the assessment of feeding intolerance during tube feeding. In addition, the reasons why evidence-based methods are not followed must be investigated.

Comparing the rate of fiberoptic bronchoscopy use with a video double lumen tube versus a conventional double lumen tube-a randomized controlled trial.

BackgroundDouble lumen endotracheal tubes (DLT) are commonly used to provide single lung ventilation during thoracic surgery. A fiberoptic bronchoscope (FOB) is typically used to confirm accurate DLT placement. Accounting for initial purchase, maintenance, repair and cleaning, the use of an FOB can cost as much as $312 per procedure. The VivaSight DLT (VS-DLT) incorporates a built-in camera, which is aimed at reducing FOB use and its associated costs. In this study, we compared the rate of FOB use when intubating using either a VS-DLT or a conventional DLT (c-DLT).MethodsThis is a randomized controlled comparative study performed at a public county teaching hospital. A total of 50 patients were enrolled and randomly assigned to either a c-DLT (n=25) or a VS-DLT (n=25). The primary outcome was the rate of FOB use. Secondary outcomes included time to correct tube placement and incidence of malposition during surgery.ResultsUse of the VS-DLT required significantly less FOB use (28%) compared to use of the c-DLT (100%). While there was no difference in the ease of intubation, the time to correct tube placement was significantly faster using a VS-DLT (54 vs. 156 s, P<0.001). Additionally, the incidence of tube malposition was significantly reduced in the VS-DLT group.ConclusionsThis study demonstrated a significantly lower rate of FOB use when using a VS-DLT compared to a c-DLT. Placement of the VS-DLT was significantly quicker and malposition during surgery occurred significantly less than with the c-DLT. While intubating with a VS-DLT provides clinical benefits, it may not result in significant cost reductions when compared to a c-DLT.

Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study.

IntroductionPatients using a nasogastric tube (NGT) are vulnerable to adverse events, therefore proper assessment of these patients, verification of the correct tube placement and constant monitoring by the nursing staff are strategies that can reduce adverse events and risks associated with the care. The aim of this study will be to assess the accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement compared with the X-ray method. A further aim will be to measure and provide evidence for the direct costs of each method of confirming NGT placement and to evaluate the impact of each method on the mean direct cost of the patient.Methods and analysisThis is a prospective, single-centre study of diagnostic accuracy. Data will be collected in the clinical and surgical wards, intensive care unit and coronary care unit of a Brazilian teaching hospital. The sample will consist of 385 assessments, performed in adult patients that agree to participate in the study and that receive an NGT. The combined method and the ultrasound will be the index tests and will be performed on all study participants for later comparison with an X-ray examination, considered the reference standard and the gold standard to distinguish between gastric and pulmonary placement. Sensitivity, specificity, positive predictive value and negative predictive value will be calculated to assess the diagnostic accuracy of the methods investigated in this study, with Cohen’s kappa analysis used to evaluate the degree of concordance.Ethics and disseminationThe study was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, registration number: 83087318.4.0000.5393. The findings will be reported through academic journals, seminars and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.

Tracheal intubation in microgravity: a simulation study comparing direct laryngoscopy and videolaryngoscopy†

BackgroundThe risk of severe medical and surgical events during long-duration spaceflight is significant. In space, many environmental and psychological factors may make tracheal intubation more difficult than on Earth. We hypothesised that, in microgravity, tracheal intubation may be facilitated by the use of a videolaryngoscope compared with direct laryngoscopy. MethodsIn a non-randomised, controlled, cross-over simulation study, we compared intubation performance of novice operators and experts, using either a direct laryngoscope or a videolaryngoscope, in weightlessness and in normogravity. The primary outcome was the success rate of tracheal intubation. Time to intubation and the confidence score into the success of tube placement were also recorded. ResultsWhen novices attempted to intubate the trachea in microgravity, the success rate of tracheal intubation using a videolaryngoscope was significantly higher (20/25 [80%]; 95% confidence interval [CI], 64.3–95.7 vs eight/20 [40%]; 95% CI, 18.5–61.5; P=0.006), and intubation time was shorter, compared with using a direct laryngoscope. In normogravity, the success rate of tracheal intubation by experts was significantly higher than that by novices (16/20 [80%]; 95% CI, 62.5–97.5 vs seven/25 [28%]; 95% CI, 10.4–45.6; P=0.001), but in microgravity, there was no significant difference between the experts and novices (19/20 [95%]; 95% CI, 85.4–100 vs 20/25 [80%]; 95% CI, 64.3–95.7; P=0.113). Higher confidence scores were achieved with videolaryngoscopy compared with direct laryngoscopy by both experts and novices in both microgravity and normogravity. ConclusionsVideolaryngoscopy was associated with higher intubation success rate and speed, and higher confidence for correct tube placement by novice operators in microgravity, and as such may represent the best technique for advanced airway management during long-duration spaceflight.

Correct Gastric Tube Placement in Very Low Birth Weight Neonates

Correct Gastric Tube Placement in Very Low Birth Weight Neonates

A Cost-Effectiveness Analysis Comparing the VivaSight Double-Lumen Tube and a Conventional Double-Lumen Tube in Adult Patients Undergoing Thoracic Surgery Involving One-Lung Ventilation.

BackgroundOne-lung ventilation (OLV) procedures are essential for most thoracic surgeries, and the most common method is intubation with a conventional double-lumen tube (cDLT) and bronchoscopy to verify correct tube placement.ObjectiveThe objective of this study was to conduct a cost-effectiveness analysis comparing the VivaSight double-lumen tube (DL) and a cDLT for OLV procedures.MethodsA cost-effectiveness analysis was conducted from a healthcare sector perspective in Denmark using a decision analytic model to assess the potential effects and costs of using VivaSight-DL as an alternative to a cDLT with a reusable bronchoscope. Costs were determined using a micro-costing approach. The effectiveness measure was the number of times that fiberoptic confirmation of the tube placement during intubation or surgery was unnecessary and thus avoided. The effectiveness input was from a randomized controlled trial (n = 52). Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the results.ResultsFiberoptic confirmation of tube placement was only necessary in two (6.66%) procedures using VivaSight-DL. The cost of using VivaSight-DL was $US299.96 per procedure versus $US347.61 for a cDLT with a reusable bronchoscope. The incremental cost-effectiveness ratio was − $US51.06 per bronchoscopy avoided. The base-case analysis indicated that the use of VivaSight-DL was cost effective compared with the use of a cDLT with reusable bronchoscope. Sensitivity analyses showed that the results were robust and that VivaSight-DL was more effective and less costly.ConclusionThis study suggests that VivaSight-DL is associated with cost savings and reductions in bronchoscope use to verify correct tube placement. The conclusion is based on the results from a single institution. To clarify whether VivaSight-DL is cost effective in larger or global clinical settings, further economic evaluations should be performed.

Improving Success of Orotracheal Intubation by Novice Operators in Microgravity with Video-Laryngoscopy

Background: The risk of severe medical and surgical events during long-duration spaceflight is significant. Orotracheal intubation, which may be required for a range of medical and surgical conditions, is a technically challenging procedure, especially in novice hands. We hypothesized that the procedure may be facilitated by the use of a video-laryngoscope (VL), and compared intubation success rates of experts and novices under normogravity or simulated microgravity in parabolic flights. Methods: Six subjects (3 experts and 3 novices) performed 180 orotracheal intubations on a mannequin, with half during simulated microgravity and half on the ground (normogravity condition). Half of the attempts used direct laryngoscopy (DL) and half VL. The primary outcome was intubation success rate. We also recorded intubation time and the confidence score into the success of tube placement. Findings: Using DL, the intubation success rate was higher in experts than novices regardless of gravity condition. The success rate for intubation with VL was significantly higher for experts than novices in normogravity (80% versus 28%, p<0·001), but not in microgravity (95% versus 80%, p=0·14). When novices used VL in microgravity, intubation success rates (80% versus 40%, p<0·006) were higher and intubation time shorter than when using DL. Better confidence scores were achieved with VL compared with DL. Interpretation: VL was associated with higher intubation success rate and speed and higher confidence for correct tube placement by novice operators in microgravity, and as such may represent the best technique for advanced airway management during long duration spaceflight. Funding: This work was supported by the French National Space Agency (CNES). Declaration of Interest: The authors declare that they have no competing interest. The medical equipment was graciously made available by their respective manufacturers. Ethical Approval: This study was authorized by the CNES ethical committee. All participants were volunteers and provided written informed consent for the research

257 Use of a Suprapubic Tube at the Time of Artificial Urinary Sphincter Placement: A Strategy to Avoid Urethral Catheterization in the “at risk” Patient

Prolonged urethral catheterization in a patient with an artificial urinary sphincter (AUS) is problematic. In this situation, cuff erosion is not unusual. Also, though most men will have no difficulty voiding in the first 24 hours after AUS placement, the patient who does presents the surgeon with a dilemma: place a urethral catheter with it’s inherent risks, or place a surprapubic tube (SPT). In an effort to avoid this scenario, those patients who seemed most at risk for urinary retention or cuff erosion following AUS placement had a SPT placed while under anesthesia. We report a single center experience with placement of a SPT at the time of AUS surgery. From July 1, 2017 to July 1, 2018 fifty-eight (58) men underwent surgery to place an AUS. Three (3) of those patients were felt to be at increased risk of post-surgical urinary retention or cuff erosion: 1 patient had had a prior AUS and experienced cuff erosion; 1 patient had a prior transobturator sling and the dissection to place the occlusive cuff was more difficult raising the concern of a post-operative cuff site hematoma; 1 patient has prior episodes of urinary retention related to recurrent bladder neck contractures. While still under anesthesia, these 3 men had a 10Fr SPT placed via percutaneous punch using flexible cystoscopy to fill the bladder and confirm correct tube placement. The SPTs were capped, to be opened if the patient experienced symptoms of urinary retention. All patients were discharged from the hospital on the day of surgery.

WITHDRAWN: Techniques to ascertain correct endotracheal tube placement in neonates.

The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. We did not identify any studies meeting the criteria for inclusion in this review. There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.

Diagnostic Value of Sonography for Confirmation of Endotracheal Intubation in the Emergency Department.

BackgroundIntubation and maintaining airway are crucial in the management of critically ill patients in the emergency department. Correct tracheal intubation should be confirmed by the physician, otherwise oesophageal intubation could lead to hypoxia with detrimental consequences and even death. Sonography can be used to determine proper placement of the tracheal tube.MethodsIn this study, 75 patients, with an indication of intubation and age older than 18 years entered the study. An emergency medicine performed real-time sonography of the trachea to evaluate the correct placement of endotracheal tube. Tube passage (snowstorm) and vocal cord angel widening (bullet sign) were evaluated, and then both lungs sliding and diaphragm movement were evaluated to confirm correct tube placement and ventilation.ResultsIn this study, 75 patients entered the study. The mean age of the patients was 61.12; 47 patients (62.7%) were male and 28 (37.3%) were female. The reason of intubation was the decreased level of consciousness in 22 cases (29.3%), cardiopulmonary arrest in 22 patients (29.3%), respiratory distress in 9 patients (12%), shock in 10 patients (13.3%), and seizure in 1 case. Snowstorm sign was seen in 72 patients (96%). Bullet sign was objected in 24 cases (32%). Lung sliding was seen bilaterally in 63 patients (84%) and unilaterally in 7 patients (9.3 %), but it was not noticed in 6.7% of the patients (5 patients).ConclusionsTransverse tracheal and lung sonography in the emergency department can be a fast measure to confirm correct endotracheal intubation.

Ventilation modes and factors influencing tidal volume in nonventilated lung during one-lung ventilation in patients undergoing thorascopic surgery: monitoring using electrical impedance tomography

Objective To evaluate the ventilation modes and factors influencing the tidal volume(VT)in the nonventilated lung during one-lung ventilation(OLV)in patients undergoing thorascopic surgery using electrical impedance tomography. Methods Thirteen American Society of Anesthesiologists physical statusⅠ or Ⅱ patients of both sexes, aged 45-64 yr, weighing 45-80 kg, undergoing elective pulmonary surgery performed via video-assisted thoracoscope, were enrolled in the study.After anesthesia induction, a double lumen tube was placed, and correct tube placement was confirmed with a fiberoptic bronchoscope.Two-lung ventilation and OLV were performed sequentially when in supine position with a fixed VT of 8 ml/kg and respiratory rate(RR)of 12 breaths/min.When the patients were turned to lateral position(with the operated lung on the upper side), correct placement of the tube was reconfirmed with a fiberoptic bronchoscope.Bilateral lungs were ventilated with VT of 8 ml/kg and RR of 12 breaths/min, and unilateral lungs were then ventilated in the following modes in sequence: VT 8 ml/kg and RR 12 breaths/min for the lung on the upper side; VT 8 ml/kg and RR 12 breaths/min for the lung on the lower side; VT 8 ml/kg, RR 12 breaths/min and positive end-expiratory pressure(PEEP)4 cmH2O for the lung on the lower side; VT 6 ml/kg and RR 16 breaths/min for the lung on the lower side; VT 4 ml/kg and RR 24 breaths/min for the lung on the lower side.Each ventilation mode stabilized for 2 min.At 2 min of OLV in each mode, electrical impedance tomography was used to record the ventilation mode in the nonventilated lung, anesthesia machine was used to record VT in the nonventilated lung, and the percentage of VT on nonventilated side in VT on ventilated side(VT-non/VT-ven%)was calculated.When the unilateral lung on the lower side was ventilated in lateral position, logistic regression analysis was used to analyze the correlation between VT on ventilated side(no PEEP)and that on nonventilated side. Results Opposite ventilation was found in the nonventilated lung during OLV.VT-non/VT-ven% was significantly higher in lateral position than in supine position(P<0.05). VT-non/VT-ven% was significantly higher when the lung on the lower side was ventilated than that when the lung on the upper side was ventilated(P<0.05). Four cmH2O PEEP exerted no effect on VT-non/VT-ven%.When the lung on the lower side was ventilated in lateral position, there was a linear positive correlation between VT on ventilated side(no PEEP)and that on nonventilated side(r=0.899, P<0.05). Conclusion During OLV in patients undergoing thorascopic surgery, there is opposite ventilation in the nonventilated lung, and VT is influenced by body positions and VT in contralateral lungs. Key words: Respiration, artificial; Pulmonary ventilation; Thoracoscopy

Role of electromyography endotracheal tube in preventing recurrent laryngeal nerve injury during thyroid surgery: A case reportAirway trauma during difficult intubation… from the frying pan into the fire?

Role of electromyography endotracheal tube in preventing recurrent laryngeal nerve injury during thyroid surgery: A case reportAirway trauma during difficult intubation… from the frying pan into the fire?

Recommended practice for out-of-hospital emergency anaesthesia in adults: Statement from the Out-of-Hospital Emergency Anaesthesia Working Group of the Emergency Medicine Research Group of the German Society of Anaesthesiology and Intensive Care.

Emergency anaesthesia is an important therapeutic measure in out-of-hospital emergency medicine. The associated risks are considerably higher than those of in-hospital anaesthesia. The primary objectives of emergency anaesthesia are hypnosis, analgesia, oxygenation and ventilation through airway management. The secondary objectives of emergency anaesthesia are amnesia, anxiolysis, the reduction of oxygen consumption and respiratory work, the protection of vital organs and the avoidance of secondary myocardial and cerebral damage. A critical evaluation of the indications for outof- hospital emergency anaesthesia must take into consideration patient, case and provider-related factors. Rapid sequence induction of emergency anaesthesia includes standard monitoring, preoxygenation, standardised preparation of emergency anaesthesia, drug administration, manual in-line stabilisation during intubation (if necessary), airway management and checking of correct tube placement. Spontaneously breathing casualties should receive preoxygenation for at least 3 to 4 min with a tight-fitting facemask with reservoir using 12 to 15 l min_1 of oxygen or with a demand valve providing 100% oxygen. As an alternative, preoxygenation may be performed as noninvasive ventilation with 100% oxygen. Standardised anaesthesia preparation comprises filling drugs into syringes and labelling them, checking ventilation equipment, preparing endotracheal tube and syringe for inflating the cuff and the introducer, stethoscope and fixation material, preparing alternative instruments for airway management as well as checking suction, ventilation and standard monitoring devices, including capnography. Standard monitoring for out-of-hospital emergency anaesthesia comprises ECG, blood pressure measurement and pulse oximetry. Continuous capnography is always and exclusively performed to check the placement of airway devices, as well as to indirectly monitor haemodynamics.