Management Of Difficult Intubation Research Articles

Remimazolam for anesthesia and sedation in pediatric patients: a scoping review.

Anesthetic management of pediatric patients poses several challenges and the optimal anesthetic agent for use in this population is still a matter of debate. We systematically searched PubMed/MEDLINE and Google Scholar from their inception for studies that investigated the role and potential applications of remimazolam, a novel ultra-short-acting benzodiazepine, in pediatric patients. Furthermore, in March 2024, an update of the literature search along with an additional post-hoc search on the EMBASE database were performed. A total of fourteen pertinent studies which spanned the 2021-2023 period explored remimazolam as either the primary or adjuvant hypnotic agent for inducing and/or maintaining general anesthesia or sedation. Preliminary evidence derived from these studies highlighted that remimazolam is a safe and effective option for both sedation and general anesthesia in pediatric patients, particularly those with concurrent mitochondrial disorders, myopathic diseases, or at risk for malignant hyperthermia. Moreover, the current evidence suggested that remimazolam may contribute to reducing preoperative anxiety and postoperative delirium in children. Its favorable pharmacodynamic and pharmacokinetic profile demonstrated potential safety, effectiveness, and ease-of-use in various perioperative pediatric contexts, making it suitable for integration into specific protocols, such as intraoperative monitoring of evoked potentials and management of difficult intubation. Notwithstanding these promising findings, further research is essential to determine optimal dosages, establish conclusive evidence of its superiority over other benzodiazepines, and elucidate the impact of genetic factors on drug metabolism.

Audit of Preoperative Difficult Airway Management in Algeria: Challenges and Strategies

Most respiratory complications during intubation are unanticipated and can lead to severe injuries or even death, especially in general anesthesia. Mitigating factors include preparation, evaluation, communication, teamwork, and situational awareness. However, in the absence of national recommendations, airway management in Algeria remains a challenge. Methodology: A cross-sectional study over one year (2019-2020) was conducted by distributing a questionnaire covering demographic data, difficulties encountered during intubation and ventilation, access to specific equipment and training, and the desire for training or algorithms. Data were entered and analyzed using SPSS 18 software. Results: Out of 110 distributed questionnaires, the participation rate was 78%, covering 25 wilayas. The prevalence of intubation difficulties was 100%, with a higher prevalence among those without local protocols or specific training. Public health specialists in EPH and CHU were more likely to encounter ventilation difficulties. Discussion: This audit identifies the challenges faced by anesthesiologists in Algeria, emphasizing the importance of pre-planning and advancements in techniques to simplify the management of difficult intubations. The development of algorithms could facilitate patient care, provided that the techniques are widely known and feasible. Conclusion: Improving airway management in Algeria requires pre-planning, increased awareness, and appropriate training. Advances in techniques and the development of algorithms could help reduce complications during difficult intubations.

Content Validation of Questionnaire for Survey on Practice Preferences of Indian Anaesthesiologists in Difficult Intubation and “Cannot Intubate, Cannot Ventilate” Situations (CICV)

Introduction: American Society of Anaesthesiologists (ASA) and Difficult Airway Society (DAS) have provided guidelines on management of difficult intubation and Cannot Intubate, Cannot Ventilate (CICV) situations. There have been many advances in equipment available to anaesthesiologist in difficult airway like Supraglottic Airway Devices (SGA), VideoLaryngoscope (VL) and optical stylet. The knowledge and practice of these guidelines are important for patient safety in difficult airway scenario. Aim: To validate the questionnaire to assess practice preferences in difficult intubation and CICV in Indian anaesthesiologist. Materials and Methods: This questionnaire-based observational survey was carried out between April 2021 to June 2021 at Department of Anaesthesia, DY Patil School of Medicine, Navi Mumbai, Maharashtra, India. Nineteen questions were framed based on the literature related to difficult intubation and CICV practices. This questionnaire sent to 20 experts to grade each question on relevance, clarity, simplicity and ambiguity on a likert scale of 4 as provided in information sheet. Sixteen out of 20 experts responded. Nineteen questions were framed based on the literature related to difficult intubation and CICV practices. The questionnaire was expanded to 22 questions after pilot testing with 10 senior expert anaesthesiologists suggestion of including the question on apneic oxygenation. The collected responses were used to calculate Item-wise Content Validity Index (I-CVI), Scale-wise Content Validity Index (S-CVI) and Modified Kappa Statistics (MKS) in Microsoft excel sheet. Results: S-CVI for relevance, simplicity, clarity and ambiguity was 0.77, 0.77, 0.77 and 0.73, respectively. S-CVI/average or Average Congruency Percentage (ACP) was 0.95, 0.95, 0.95 and 0.94 for relevance, simplicity, clarity and ambiguity, respectively. Question 4, 14, 20, 22 received I-CVI of 0.75 in terms of relevance, clarity, simplicity and ambiguity and modified as per experts instructions. Conclusion: The survey questionnaire developed to assess practice preferences in difficult intubation and CICV fulfilled the content validity criteria both by qualitative and quantitative analyses.

Change in Mallampati Score during Pregnancy, Labour and Post Labour: An Observational Study

Background Mallampati (MP) score is used to predict the ease of endotracheal intubation. Pregnancy is often associated with failed intubation during anaesthesia for caesarean delivery and contributes majorly to maternal complications that are related to anaesthesia. This study aimed to determine the change in MP grade over the course of pregnancy (first trimester, during labour and post-delivery). Methods The study was conducted on 389 pregnant women in the first trimester. Demographic data, airway characteristics and MP score of the patients were recorded at different stages of pregnancy. Change in MP grade was assessed for those patients, who have delivered vaginally. Results The mean age of the study subjects was 25.77±3.64 years. There was a significant association of MP score with weight gain (P<0.0001) and change in neck circumference (P<0.0001). There was a significant change in the number of patients with MP grade 3 and 4 was noted from first trimester (n=14; 2.26%) to 48 hours post-delivery (n=78; 24.6%) (P<0.01), showing a strong association between change in MP score and pregnancy. Conclusion There was a significant increase in the MP score over the course of pregnancy that may be attributed to gestational weight gain along with variations in the neck circumference in pregnant women. Hence, assessment of MP score is important for proper management of difficult intubation, especially in parturient.

Difficult and failed intubation in the first 4000 incidents reported on webAIRS.

A review of the first 4000 reports to the webAIRS anaesthesia incident reporting database was performed to analyse cases reported as difficult or failed intubation. Patient, task, caregiver and system factors were evaluated. Among the 4000 reports, there were 170 incidents of difficult or failed intubation. Difficult or failed intubation incidents were most common in the 40-59 years age group. More than half of cases were not predicted. A total of 40% involved patients with a body mass index >30 kg/m2 and 41% involved emergency cases. A third of the reports described multiple intubation attempts. Of the reports, 18% mentioned equipment problems including endotracheal tube cuff rupture, laryngoscope light failure, dysfunctional capnography and delays with availability of additional equipment to assist with intubation. Immediate outcomes included 40 cases of oxygen desaturation below 85%; of these cases, four required cardiopulmonary resuscitation. The majority of the incidents resulted in no harm or minor harm (45%). However, 12% suffered moderate harm, 3.5% severe harm and there were three deaths (although only one related to the airway incident). Despite advances and significant developments in airway management strategies, difficult and failed intubation still occurs. Although not all incidents are predictable, nor are all preventable, the information provided by this analysis might assist with future planning, preparation and management of difficult intubation.

Saber-sheath trachea as a challenge for safe surgery: A case report

Introduction. Saber-sheath trachea is a rare malformation of the trachea marked with coronal narrowing with concomitant widening of sagittal diameter, with a sagittal-to-coronal diameter ratio exceeding 2:1. As tracheal rings are stiff and do not collapse around the tube, the intubation is difficult. Case Report. A 53-year-old female was referred to our hospital due to failed intubation at the local hospital during a planned surgery of skin melanoma. The patient was scheduled for surgery in our hospital, her case was presented to a panel of anesthesiologists and she was prepared for surgery. The intubation failed again, even though a video-assisted laryngoscope and endotracheal tube with 5 mm internal diameter was used. The anesthesiologist noticed that the endotracheal tube entered the trachea only 2 cm due to strong resistance, so further intubation was not an option in order to avoid damaging the trachea. The surgery was performed in local anesthesia with analgosedation. Later on, computed tomography was done, because of suspected pathological process compressing trachea, but the radiologist described the anomaly as saber-sheath trachea. One year later, the patient presented with axillary lymph node metastases and needed another surgery. This time the anesthesiologist knew about the trachea malformation, anticipated difficult intubation and used i-gelTM for airway management. Conclusion. Despite the fact that numerous methods have been developed for the purpose of identifying patients at risk of difficult intubation, there are many unexpected airway pathologies that can lead to failed intubation. Adequate preoperative assessment, knowledge of Guidelines for Difficult Intubation Management, availability of supraglottic airway devices, and cooperation between the surgeon and anesthesiologist, are crucial to successful patient management.

A survey of practice of rapid sequence induction for caesarean section in England

BackgroundIn view of newer techniques of preoxygenation and laryngoscopy and recent obstetric guidelines concerning the management of difficult intubation, we aimed to evaluate the current practice of rapid sequence induction for caesarean section in England. MethodsIn 2017, 316 questionnaire surveys were posted to all 158 hospitals with caesarean section capabilities in England. At each hospital, one questionnaire was to be completed by the obstetric anaesthetic consultant lead and one by an anaesthetic trainee. Differences in responses between consultants and trainees, regardless of their place of work, were compared for all data using the chi-square and the Fisher’s exact tests. ResultsOne-hundred-and-eighty complete questionnaires were returned, with an overall response rate of 57%, 98 (54%) from obstetric anaesthetic consultant leads and 82 (45.6%) from trainees). Both head up (57%) and ramped (56%) were the preferred positions for preoxygenation. Less than half of respondents (43%) preoxygenated until the surgeon was scrubbed. Cricoid pressure was used by almost all respondents (98%). Thiopentone (67%) was the most commonly chosen anaesthetic induction agent and most respondents (82%) supported a change to the use of propofol. Suxamethonium (92%) was the neuromuscular blocker of choice but more than half the respondents (52%) supported a change to rocuronium. In the event of a failed intubation, the rescue supraglottic airway device of choice was the i-gel® (65%). ConclusionsOur survey demonstrated the significant variation in the practice of rapid sequence induction for caesarean section in obstetrics in the United Kingdom.

Airway management of difficult intubation in the pediatric population: A single center experience

Awareness and the management of the difficult airway in children are crucial. Although the incidence of difficult intubation in children is believed to be lower than in adults, there is insufficient data regarding it. The aim of this study was to determine what airway management techniques are being applied in the difficult airway situation, by a group of experienced Consultant Anesthetists, in a large pediatric center. The study conducted over a 2-year period, in a large pediatric hospital. For a 2-year period beginning from September 2014, consultant anesthetists completed pro-forma following all pediatric anesthesia procedures in which tracheal intubation was difficult. The collected information included: patient demographics; airway assessment; anesthetic technique and airway management strategies employed; and reasons of failure in intubation attempts. There were 50 cases which were assessed as difficult intubation, and 80% of the cases had an anticipated difficult intubation report with 40% having a history of previous difficult intubation. Fiberoptic Bronchoscope (FOB) was the first-choice rescue technique in 84% of the patients; 92% of oral FOB and 71% of nasal FOB were successful. Six cases required surgical airway as surgical tracheostomy. This study created a screenshot of the various methods used when we were faced with a difficult airway management in pediatric population. Fiberoptic intubation remains overall the best method whereas no method was 100% successful. The majority of the patients had anticipated difficult airway, which opportunely allows planning for surgical airway with other teams such as Ear-Nose Throat and pediatric surgery.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway

Background and Aims:Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements.Material and Methods:One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted.Results:Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26–80) s and 49 (range 28–83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups.Conclusion:Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.

Airway Management of a Neck-Burned Child with Mc-Grath Series 5 Videolaryngoscope and Gum Elastic Bougie

Background: Anesthetic management of a neck-burned child presents many problems but especially airway difficulties are characteristic. In addition to differences between pediatric and adult airway, concomitant challenges of postburn sternomental contractures may lead to the catastrophic outcomes. Videolaryngoscope is an alternative intubation device which improves laryngeal view and does not require a direct glottic view. Gum elastic bougie is also a well-known and valuable aid for management of difficult intubation. Case Report: We presented a successful airway management of a 10 year old boy underwent post-burn contracture releasing surgery for his neck and left upper extremity with Mc-Grath Series 5 videolaryngoscope and gum elastic bougie. The patient had limitation in neck mobility because of severe burn contracture (patient’s neck was contracted in the flexed position, his chin and lower lip was restrained down to the anterior trunk) with lack of any respiratory disorder. After preoxygenation we administered anaesthesia induction. Mask ventilation was failed because of excessive gas leak. So we inserted laringeal mask airway without significant desaturation. After providing adequate ventilation we administered muscle relaxant. After two unsuccessful attempts we performed intubation with Mc-Grath Series 5 videolaryngoscope and gum elastic bougie. We confirmed correct tube placement via capnograph. Conclusion: Concurent use of Mc-Grath Series 5 videolaryngoscope and gum elastic bougie in management of pediatric difficult airway is suitable as an alternative technique.

The management of difficult intubation in infants: a retrospective review of anesthesia record database.

We retrospectively reviewed the anesthesia records of infants < 1 year of age for elucidating the incidence of difficult intubation and airway management in a single general hospital. The electronic data records from a total of 753 consecutive anesthesiological procedures in 513 different infants were analyzed. After excluding data with a lack of records of laryngoscopic findings, a total of 497 procedures (389 different infants) with either remarks of difficult intubation (requiring > 10 min for tracheal intubation) or records of Cormack-Lehane grade were included. Demographic data are median age 5 (range, 0–11) months, height 61 (33–84) cm, body weight 6.0 (1.1 − 11.8) kg. The number of cases with ASA physical status I, II, III and IV was 182 (36.6 %), 135 (27.3 %), 177 (35.5 %) and 3 (0.6 %), respectively. Cormack-Lehane grade 1, 2, 3 and 4 was seen in 450 (90.5 %), 32 (6.4 %), 6 (1.2 %) and 6 (1.2 %) cases, respectively.Document of difficult intubation was found in 12 cases (2.4 %, 10 different infants) with a lack of record of Cormack-Lehane grade in 3 cases. Of these 10 infants, nine had multiple congenital anomalies including heart diseases and cleft palate. Without premedication, general anesthesia was induced with intravenous midazolam or sevoflurane in the 12 cases. Tracheal intubation was performed after disappearance of spontaneous respiration except three cases who were intubated in the awake state or under sedation. Elapsed time from induction of anesthesia to intubation was 17 (14–29) min. Although mask ventilation was adequate in all cases, two cases (one infant) developed hypoxia and bradycardia during tracheal intubation. No remarkable decrease of SpO2 or bradycardia less than 100 bpm was detected in other cases. In conclusion, we found difficult intubation in 2.4 % of infants undergoing general anesthesia. Although muscle relaxants are useful for facilitating tracheal intubation, it should be carefully used with the preparation of other airway devices in infants with predicted difficult intubation.

Anticipated Difficult Airway in Ear, Nose and Throat Procedures

ABSTRACT Contrary to general and obstetric populations, where difficult airway is widely studied and well documented, it requires further research in elective and emergency ear, nose and throat (ENT) surgeries. American Society of Anesthesiologists (ASA) has published practice guidelines for the management of difficult airway, which help us deal with it perioperatively. All patients posted for ENT surgeries with difficult airway should be evaluated preoperatively and the strategy for management of difficult intubation as well as extubation chalked out. In the event, that the primary approach fails, the secondary plan should always be clear preoperatively, to reduce morbidity and mortality. How to cite this article Baldwa NM. Anticipated Difficult Airway in Ear, Nose and Throat Procedures. Int J Otorhinolaryngol Clin 2015;7(1):10-16.

Comparative study between a sensascope and a flexible fiberoptic in head and neck cancer surgeries with difficult airways

Background Many devices have been become widely available for managing difficult airways, including rigid fiberscopes and flexible fiberoptic bronchoscopes. The sensascope is different from the flexible fiberoptic in that it can be used with one hand (preferably the right hand) while the left hand is used to insert the laryngoscope as recommended by experienced users. The objective of this study was to evaluate the efficacy of a sensascope in the management of difficult airways in patients scheduled for head and neck cancer surgeries. Patients and methods This study was conducted at the National Cancer Institute on 60 patients. The patients were divided into two equal groups, group F (FOB) and group S (sensascopes), each comprising 30 patients. The following parameters were measured: patient characteristics including age, sex, weight, and ASA classification, airway assessment, hemodynamic changes, number of failures of intubation, duration of intubation, number of attempts, and complications that may occur during manipulation of the airway. Results The success rate of intubation and the number of failures were statistically comparable between the two groups. The mean time taken to complete successful intubation was significantly shorter in group F compared with group S. The number of patients successfully intubated at first attempt was significantly higher in group F than in group S. The number of patients successfully intubated at second attempt was significantly higher in group S than in group F. The number of patients who needed three attempts to be successfully intubated was statistically comparable between the two groups. There was statistically significant increase in pulse rate and mean arterial blood pressure immediately after successful intubation in group S compared with baseline and with group F. There was a significantly higher incidence of staining of the fiberscope blade with blood and transient change in voice in group S compared with group F. Conclusion The sensascope can be a valuable aid in the management of difficult intubation in a spontaneously breathing anesthetized patient, and should be added to backup devices in the event of difficult intubation.

Comparison of the single‐use Ambu® aScope™ 2 vs the conventional fibrescope for tracheal intubation in patients with cervical spine immobilisation by a semirigid collar*

Fibreoptic intubation remains a key technique for the management of difficult intubation. We randomly compared the second generation single-use Ambu(®) aScope™ 2 videoscope with a standard re-usable flexible intubating fibrescope in 50 tracheal intubations in patients with a difficult airway simulated by a semirigid collar. All patients' tracheas were intubated successfully with the aScope 2 or the re-usable fibrescope. The median (IQR [range]) time to intubate was significantly longer with the aScope 2 70 (55-97 [41?-226]) s vs 50 (40-59 [27-175]) s, p = 0.0003) due to an increased time to see the carina. Quality of vision was significantly lower with the aScope 2 (excellent 24 (48%) vs 49 (98%), p = 0.0001; good 22 (44%) vs 1 (2%), p = 0.0001; poor 4 (8%) vs 0, p = 0.12) but with no difference in the subjective ease to intubate (easy score of 31 (62%) vs 38 (76%), p = 0.19; intermediate 12 (24%) vs 7 (14%), p = 0.31; difficult 7 (14%) vs 5 (5%), p = 0.76). The longer times to intubate and the poorer scores for quality of vision do not support the use of the single-use aScope 2 videoscope as an alternative to the re-usable fibrescope.

Efficacy of Discoscope endoscope versus GlideScope video laryngoscope for difficult glottis exposure

Objective To compare the efficacy of Discoscope endoscope and GlideScope video laryngoscope for difficult glottis exposure.Methods Forty adult patients of both sexes scheduled for elective surgery under general anesthesia whose glottis was not visible at laryngoscopy (grade Ⅲ or Ⅳ according to Cormach-Lehane Grading of laryngoscopic view) were randomized into 2 groups (n =20 each):group GlideScope video laryngoscope (group G) and group Discoscope endoscope (group D).The glottis exposure time,intubating conditions,time from exposure of glottis to completion of tracheal intubation and incidence of postoperative sore throat and throat bleeding were recorded and compared between the 2 groups.Results Compared with group G,the glottis exposure time was significantly longer,the rate of backward pressure of cricoid cartilage lower,the time from exposure of glottis to completion of tracheal intubation shorter and the success rate of tracheal intubation at first attempt higher (P ＜ 0.05).There was no significant difference in the success rate of tracheal intubation at second attempt and postoperative incidence of sore throat and throat bleeding between the 2 groups(P ＞ 0.05).Conclusion DiscoScope endoscope is superior to GlideScope video laryngoscope in the management of difficult intubation in term of glottis exposure and success rate of tracheal intubation at first attempt. Key words: Endoscopy; Laryngoscopy ; Intubation, intratracheal ; Glottis

Längenverhältnis von Trachealtubus zur Larynxmaske

Management of difficult airways and difficult intubation differs in pediatric and in adult patients. In conscious children, fiberoptic intubation is not feasible because of limited compliance. The specially designed laryngeal mask for blind tracheal intubation, LMA Fastrach™, is available for adolescents and adults only. Therefore, fiberoptic-guided intubation through a supraglottic airway device (SAD) is a standard technique for the management of difficult intubation in children. While performing the procedure, stabile positioning of the endotracheal tube (ETT) and prevention of dislodgement are critical issues. The relationship between the length of the ETT and the SAD is highly important and was investigated in this in vitro study.In this study 6 different brands of SAD in the pediatric sizes 1-3 and 2 different ETT brands (cuffed, Microcuff(®), uncuffed, Sheridan PED-SOFT™) were investigated. Using pediatric growth tables, the recommended patient weight for each SAD size was correlated to patient age and then to appropriately sized cuffed and uncuffed ETTs. The ETT size was chosen according to the manufacturer's recommendations (cuffed ETT) and according to the literature (uncuffed ETT). The various SAD-ETT pairs were assessed with regard to differences in their length. After lubrication with silicone the ETT with a firmly attached 15 mm tube adapter was maximally inserted into the SAD and the ETT tip overlapping the SAD cuff was measured. Secondarily, an adapter for fiberoptic procedures was interposed and the measurements repeated.For a defined patient uncuffed ETTs were usually selected with a larger internal diameter (ID) compared to cuffed ETTs. Therefore, the uncuffed ETT is the longer one and will overlap the SAD by a longer tip. Comparing the curved SAD brands AuraOnce™ and Aura-i™, the Aura-i™ devices generally showed shorter tubes resulting in a longer protruding ETT tip (median 1.5 cm, minimum-maximum 1.0-2.4 cm). The straight brands LMA classic™, AuraStraight™ and LMA Unique™ showed similarity in tube length. In comparison with i-gel(®), for the SAD sizes 1-2.5 the former provide a longer projecting ETT tip. Only i-gel(®) together with AuraStraight™ showed the longest overlapping ETT tip for SAD size 3. If a swivel adapter was used during the fiberoptic intubation procedure, the length of the ETT could be critically reduced in relation to the length of the SAD. Using a swivel adapter from VBM Medizintechnik, (Sulz a. N., Germany) a relative reduction in ETT length of 2.3 or 3.2 cm has to be taken into account.For fiberoptic-guided endotracheal intubation through an SAD, sufficient length of the ETT in relation to the SAD is mandatory. Differences in geometry between SAD and ETT brands have to be considered. The selection of a relatively small SAD in combination with an uncuffed ETT might be advantageous. Redesigned extra long ETTs would be desirable to decrease the risk for ETT dislocation and to increase the safety of the technique. Restrictive use of a swivel adapter during the procedure is important because of further and potentially critical decreases in ETT length. In addition, after successful intubation of the trachea, removal of the SAD via an airway exchange catheter and replacement of the cuffed ETT of choice in the correct position is recommended to secure the airway and provide unimpaired ventilation and oxygenation.

Intérêt de la simulation haute-fidélité dans l’évaluation de l’application de procédures de soins par les médecins urgentistes

AimHigh-fidelity simulation is increasingly used as a teaching tool. The aim of this study was to assess the impact of high-fidelity simulation in helping emergency physicians to better implement standard care protocols.ProcedureIt is a prospective study assessing the performance of physicians in applying the correct procedures for the management of difficult intubation, severe traumatic brain injury (TBI) and cardiac arrest during 2 simulation sessions (S1 and S2), separated by a 6-month interval, by a single assessor using evaluation grids derived from standard care protocols.ResultsSeventeen senior emergency physicians with a mean experience of 9 ± 4 years participated in the study. The protocol for difficult intubation was correctly implemented by 6 physicians (35%) in S1 and 13 physicians (76%) in S2 (P = 0.02). The major difficulty in implementing the severe TBI management protocol was the prevention of secondary systemic insults to the brain. The number of physicians correctly implementing the TBI protocol increased from 5 (29%) in S1 to 12 (71%) in S2 (P = 0.03). The number of physicians performing cardiopulmonary resuscitation after cardiac arrest as per guidelines increased from 7 (41%) in S1 to 14 (82%) in S2 (P = 0.02).ConclusionAfter two simulator-based sessions with an interval of 6 months, the physicians performance and compliance with standard care protocols improved significantly, thus demonstrating that high-fidelity simulators can be used effectively in continuing medical education and professional development of experienced emergency physicians.

Management of Unanticipated Difficult Airway in the Prehospital Emergency Setting

We were greatly interested in the recent article of Combes et al. 1that prospectively validated a prehospital difficult-intubation algorithm. In this clinical study, the tracheal intubation with direct laryngoscope proved impossible in 160 patients. However, of these 160 patients, 15 had a laryngeal view of the Cormack and Lehane (C&amp;L) class I or II, which is generally regarded as an easy laryngoscopy.2The ease of direct laryngoscopy is not synonymous with ease of tracheal intubation, but the laryngeal view obtained by direct laryngoscopy usually is an important determinant of successful intubation. We would like to know the detailed cause of failed intubation in these patients with an easy laryngoscopy. Moreover, the authors did not clearly describe whether their algorithm required for use of an endotracheal tube with a malleable stylet at the initial intubation attempt. In managing difficult intubation, mounting the endotracheal tube onto a stylet and angling the distal tip upward help to guide the tube tip toward the glottis and improve the success rate of tracheal intubation.3This measure is especially useful when a poor laryngeal view is obtained during direct laryngoscopy or when using a flexible endotracheal tube without a natural anterior curve. In general, when speed of tracheal intubation is important (as in a patient with a full stomach or chest compression), an endotracheal tube should always be equipped with a stylet.4In this difficult-intubation management algorithm, the authors recommended that if the tracheal intubation failed after either two attempts with a C&amp;L class less than IV or a single attempt with a C&amp;L class IV, along with optimal upper airway and head manipulations, the participants were requested to move to the next step of the algorithm, the gum elastic bougie (GEB). GEB-guided intubation was used as first choice and the intubating laryngeal mask airway (ILMA) as a backup. However, what usually determines the successful intubation with the GEB is part or complete visualization of the epiglottis with or without laryngeal structure. For an intubator who has no extensive experience in the GEB-guided intubation, if direct laryngoscopy can not expose any epiglottic structure as an objective mark (e.g. , C&amp;L class IV), blindly inserting the GEB into the trachea will be very difficult. In clinical practice, the GEB-guided intubation is really most suitable for patients with a C&amp;L class less than IV.5Thus, we consider that in their difficult-intubation management algorithm, the rescue step to use the GEB-guided intubation as first choice may be suitable only for the patients with a C&amp;L class less than IV. After a single intubation attempt failed in patients with a C&amp;L class IV, the rescue airway algorithm should move directly to the step that uses the ILMA to ventilate the patients and then to intubate the trachea, but not to the step that attempts reintubation with the GEB because it has high risks of failed intubation and increased airway trauma. For this situation, we completely agree with the editorial view of Drs. Isono and Ishikawa that maintenance of oxygenation is the final goal of airway management.6The authors did not clearly state the type of the ILMA used for this difficult-intubation management algorithm. When an ILMA is used as a rescue airway device in the prehospital setting, we recommend use of the ILMA CTrach™ (Laryngeal Mask Company Limited, San Diego, CA) with the integrated fiberoptic channels and a detachable liquid crystal display viewer, rather than the ILMA Fastrach™ (Laryngeal Mask Company Limited). It has been shown that compared with the ILMA Fastrach™, the ILMA CTrach™ can enable a higher first-attempt success rate of tracheal intubation because of the view of the glottis it provides, the way it optimizes placement of the device, and the ability to observe the process of tracheal intubation through the device.7In addition, data from the study of Nickel et al. 8suggest that the ILMA CTrach™ is a suitable device for emergency airway management in the prehospital setting because it provides ventilation and facilitates intubation with a very high success rate.*Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China. fruitxue@yahoo.com.cn

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Performance of a Difficult Airway Algorithm in the Prehospital Setting

In a prospective observational study, researchers evaluated adherence to a difficult intubation management algorithm by a prehospital emergency medical