Difficult Orotracheal Intubation Research Articles

Validation of a Natural Language Processing Algorithm using National Reporting Data to Improve Identification of Anesthesia-related ADVerse evENTs: The “ADVENTURE” Study

BackgroundReporting and analysis of adverse events (AE) is associated with improved healthcare learning, quality outcomes, and patient safety. Manual text analysis is time-consuming, costly, and prone to human errors. We aimed to demonstrate the feasibility of machine learning and natural language processing (NLP) approaches for early predictions of adverse events and provide input to direct quality improvement and patient safety initiatives. MethodsWe used machine learning to analyze 9,559 continuously reported AE by clinicians and healthcare systems to the French National Health accreditor (HAS) between January 1, 2009, and December 31, 2020, for a total of 135,000 unique de-identified AE reports. We validated the labeling and determined the associations between different root causes and patient consequences. The model was validated by independent expert anesthesiologists. ResultsThe machine learning and Artificial Intelligence (AI) model trained on 9,559 AE datasets accurately categorized 8800 (88%) of reported AE. The three most frequent AE types were “difficult orotracheal intubation” (16.9% of AE reports), “medication error” (10.5%), and “post-induction hypotension” (6.9%). The accuracy of the AI model reached 70.9% sensitivity, 96.6% specificity for “difficult intubation”, 43.2% sensitivity, and 98.9% specificity for “medication error.” ConclusionsThis unsupervised method provides an accurate, automated, AI-supported search algorithm that ranks and helps to understand complex patterns of risky patient situations and has greater speed, precision, and clarity when compared to manual human data extraction. Machine learning (ML) and natural language processing models can effectively be used to process natural language AE reports and augment expert clinician input. This model can support clinical applications and methodological standards of implementations and be used to better inform and enhance decision-making for improved risk management and patient safety. Trial RegistrationThe study was approved by the ethics committee of the French Society of Anesthesiology (IRB 00010254-2020-20) and the CNIL (CNIL: 118 58 95) and the study was registered with ClinicalTrials.gov (NCT: NCT05185479).

Factors associated with anaesthetic complications in bariatric surgery at the Delafontaine Saint-Dénis Hospital

Background and objective. Anaesthesia during bariatric surgery is a high-risk procedure. This study investigated factors associated with anaesthetic complications in patients undergoing this type of surgery at Delafontaine hospital. Methods. This cross-sectional study was conducted at the Delafontaine Hospital from 01/01/2021 to 01/06/2022 in patients who underwent anaesthesia for bariatric surgery for all indications. Sociodemographic, clinical, anaesthetic and evolutionary data were collected and analysed with SPSS 25.0 using Student's t test, Pearson's Chi-square test or Fischer's exact test and logistic regression for p<0.05. Results. One hundred and thirty-five patients were enrolled. Females predominated (sex ratio M/F: 0.35). The mean age was 39.41 (range: 20 to 57 years). The median BMI was 43.25kg/m². All patients underwent surgery under general anaesthesia with tracheal intubation. Complications were present in 44% of patients: arterial hypotension (28.8%), difficult orotracheal intubation (28.1%), desaturation (22.9%), postoperative nausea and vomiting (16.2%), bronchospasm (7.4%), arterial hypertension (6.6%) and anaphylactic shock (3.3%). No deaths were recorded. Older age, the presence of comorbidities and Mallampati, Cormack and ASA scores ≥ 3 were associated with the occurrence of complications. Conclusion. The incidence of peri-anaesthetic complications in bariatric surgery is high in this series. Advanced age (> 40 years), the presence of comorbidities and Mallampati, Cormack and ASA scores ≥ 3 were associated with the occurrence of complications.

Cross-cultural adaptation and validation of the STOP-bang Questionnaire from English to Spanish as a tool for the early detection of sleep apnea syndrome in the surgical patient and in the general population.

Obstructive Sleep Apnea Syndrome (OSAS) or Apnea-Hypoapnea Syndrome (SAHS) is one of the most prevalent sleep disorders in the general population. It is associated with an increase in the prevalence of difficult orotracheal intubation and postoperative complications. The application of validated early detection tests, such the STOPbang test in English (STBC), is recommended; a test of high methodological quality, sensitivity and specificity in the early detection of SAHS in both surgical and general populations. The validation, translation, cross-cultural adaptation of the STBC to the Spanish population. The transcultural adaptation of the STBC to Spanish was carried out and a subsequent validation study with 77 consecutive patients was carried out. The statistical analysis evaluated the reliability, validity and feasibility of the translated and culturally adapted version. 44% of women and 56% of men were included, with a mean age of 53.58 ± 12.88 years. The reliability results were: a Cronbach's Alpha Coefficient of 0.767, a Pearson correlation r = 0.777 (P < .001) and a Sperman correlation rho = 0.455 (P = .044). The feasibility of the study was 100%. Criterion validity was evaluated using the Kappa coefficient, which was 0.444. For a score >3 of the questionnaire adapted to Spanish, the results of sensitivity, specificity according to the different cut-off levels of the apnea hypopnea index (AHI) >5, >15, >30) were: Sensitivity 87%, 91% and 100% respectively and Specificity of 50%, 31% and 22%. The STBC questionnaire translated, adapted and validated into Spanish, evaluated in the present study, is reliable and valid with respect to the original design of the questionnaire. It is a useful tool that is easy to understand and implement, which can be used rigorously to stratify surgical risk and carry out adequate perioperative planning of those patients at risk of SAHS.

Cervical spine immobilization does not interfere with nasotracheal intubation performed using GlideScope videolaryngoscopy: a randomized equivalence trial

GlideScope-assisted nasotracheal intubation (NTI) has been proposed as an alternative to difficult orotracheal intubation for critical patients or those under cervical immobilization. We evaluated the difficulty of performing NTI using GlideScope under cervical orthosis. A total of 170 patients scheduled for elective cervical spinal surgery that required NTI were randomized to receive cervical immobilization using a cervical collar (collar group) or no cervical immobilization at all (control group) before anesthetic induction (group assignment at 1:1 ratio). All NTI during anesthetic induction were performed using the GlideScope. The primary outcome was time to intubation. The secondary outcomes were ease of intubation, including the necessity of auxiliary manipulations to assist intubation, and the nasotracheal intubation difficulty scale (nasoIDS). An exploratory analysis identified morphometric parameters as predictors of time to intubation, the necessity of auxiliary manipulations, and a nasoIDS score ≥ 4. For time to intubation, the mean difference (collar group—control) was − 4.19 s, with a 95% confidence interval (CI) of − 13.9 to 5.52 that lay within our defined equivalence margin of 16 s. Multivariate regressions precluded the association of cervical immobilization with a necessity for auxiliary manipulations (adjusted odds ratio [aOR] 0.53, 95% CI [0.26–1.09], P = 0.083) and a nasoIDS ≥ 4 (aOR 0.94 [0.84–1.05], P = 0.280). Among all morphometric parameters, the upper lip bite test class was predictive of a longer time to intubation (all analyses relative to class 1, 14 s longer for class 2, P = 0.032; 24 s longer for class 3, P = 0.070), increased necessity for auxiliary manipulation (aOR 2.29 [1.06–4.94], P = 0.036 for class 2; aOR 6.12 [1.04–39.94], P = 0.045 for class 3), and nasoIDS ≥ 4 (aOR 1.46 [1.14–1.89], P = 0.003 for class 3).The present study demonstrated that GlideScope achieved NTI in patients with or without cervical immobilization equivalently with respect to intubation time and ease.

Analysis of Airway Management for Cesarean Delivery: Use of Risk and Proportion Differences.

Securing the parturient airway is essential during general anesthesia for cesarean delivery. The purpose of this study was to compare inferior airway views provided by the use of three commonly available laryngoscopy blades-Macintosh, Miller, or Glidescope Mac-Style-to the incidence of difficult orotracheal intubation. Following institutional review board approval, data from 449 electronic medical records in parturients undergoing general anesthesia for cesarean delivery were extracted during a 6-year period. The association of these blades with difficult orotracheal intubation was analyzed with risk and proportion differences measures of effect size. The overall incidence of difficult orotracheal intubation was 4.2% (95% confidence interval 2.7 - 6.5%), with 6 failed orotracheal intubations (5 laryngeal mask airways rescues and 1 mask rescue). Clinically important increases in risk differences for difficult orotracheal intubation were observed in parturients with restricted mouth openings, modified Mallampati III and IV views, and reduced thyromental distances. When modified Cormack-Lehane views were grouped into III and IV versus I and II cohorts; proportion differences for difficult orotracheal intubation were dependent upon the type of blade used, with the Miller blade providing the lowest proportion difference. Miller blade laryngoscopy provided the lowest proportion difference for difficult orotracheal intubation during general anesthesia for cesarean delivery. Miller blade laryngoscopy provides effective procurement of the parturient airway.

Adaptación transcultural y validación del cuestionario STOP-bang del inglés al español como herramienta de detección precoz del síndrome de apnea del sueño en el paciente quirúrgico y en la población general

IntroductionObstructive sleep apnea syndrome (OSAS) or apnea-hypoapnea syndrome (SAHS) is one of the most prevalent sleep disorders in the general population. It is associated with an increase in the prevalence of difficult orotracheal intubation and postoperative complications. The application of validated early detection tests,such the STOP-Bang test in English (STBC), is recommended; a test of high methodological quality, sensitivity and specificity in the early detection of SAHS in both surgical and general populations. ObjectiveThe validation, translation, cross-cultural adaptation of the STBC to the Spanish population. Material and methodsThe transcultural adaptation of the STBC to Spanish was carried out and a subsequent validation study with 77 consecutive patients was carried out. The statistical analysis evaluated the reliability, validity and feasibility of the translated and culturally adapted version. Results44% of women and 56% of men were included,with a mean age of 53.58±12.88 years. The reliability results were: a Cronbach's Alpha Coefficient of 0.767, a Pearson correlation r=.777 (P<.001) and a Sperman correlation rho=.455 (P=.044). The feasibility of the study was 100%. Criterion validity was evaluated using the Kappa coefficient, which was 0.444. For a score >3 of the questionnaire adapted to Spanish, the results of sensitivity, specificity according to the different cut-off levels of the apnea hypopnea index (AHI)>5, >15, >30) were: Sensitivity 87%, 91% and 100% respectively and Specificity of 50%, 31% and 22%. ConclusionsThe STBC questionnaire translated, adapted and validated into Spanish, evaluated in the present study, is reliable and valid with respect to the original design of the questionnaire. It is a useful tool that is easy to understand and implement, which can be used rigorously to stratify surgical risk and carry out adequate perioperative planning of those patients at risk of SAHS.

Evaluation of the Wilson risk-sum and the modified Mallampati Test as predictors of difficult orotracheal intubation: Cross-sectional study

Evaluation of the Wilson risk-sum and the modified Mallampati Test as predictors of difficult orotracheal intubation: Cross-sectional study

Difficult orotracheal intubation in dogs and cats

In veterinary practice, difficult orotracheal intubation is an uncommon occurrence but it can be a life-threatening situation. Arduous tracheal intubation can occur for a number of reasons, sometimes unknown to...

The prevalence of perioperative complications in patients with and without obstructive sleep apnoea: a prospective cohort study.

Patients with obstructive sleep apnoea (OSA) have a high risk of postoperative complications. The purpose of the study was to record the spectrum and frequency of postoperative complications in patients with OSA versus (vs.) without OSA depending on the type of surgery and type of anaesthesia in a large cohort of patients. We conducted a prospective, descriptive study (n = 400). Ethics Committee approval was obtained and written informed consent was signed. The Berlin screening questionnaire was used for OSA screening (77.2% - OSA [+]). Adverse events and complications were recorded postoperatively (AOS [+] vs. AOS [-]). Statistics: Chi square test. The highest rate of complications was found in patients who had underwent surgery in the abdominal cavity under general anaesthesia, AOS [+] vs. AOS [-]: cardiovascular [56.4%] vs. [7.5%], respiratory [17.6%] vs. [3.5%], stroke [0.7%] vs. [0.0% ], prolonged awakening from anaesthesia [2.5%] vs. [0.0%], postoperative fever [1.4%] vs. [0.3%], difficult orotracheal intubation [3.5%] vs. [0.3% ], unscheduled transfer to the intensive care unit [5.7%] vs. [0.0%]. OSA [+] patients who underwent abdominal surgery under general anaesthesia had a higher rate of complications compared to OSA [-] patients, and also compared to patients who had undergone peripheral limb surgery. Surgery on the musculoskeletal system is much better tolerated by patients with OSA, suffering a lower number and range of events and postoperative complications. Loco-regional anaesthesia should be considered a priority in patients with OSA.

Difficult orotracheal intubation in a rabbit resulting from the presence of faecal pellets in the oropharynx

Rabbits have a high rate of anaesthesia-related death compared with other companion animal species. This is influenced by a variety of factors, one of which is difficulty in obtaining a...

Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis

Single studies of video laryngoscopy (VL) use for airway management in intensive care unit (ICU) patients have produced controversial findings. The aim of this study was to critically review the literature to investigate whether VL reduces difficult orotracheal intubation (OTI) rate, first-attempt success, and complications related to intubation in ICU patients, compared to standard therapy, defined as direct laryngoscopy (DL). We performed a systematic review and meta-analysis of randomized controlled trials, as well as prospective and retrospective observational studies, by searching PubMed, EMBASE, and bibliographies of articles retrieved. We screened for relevant studies that enrolled adults in whom the trachea was intubated in the ICU and compared VL to DL. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. We generated pooled odd ratios (OR) across studies. The primary outcome measure was difficult OTI. The secondary outcomes were first-attempt success, Cormack 3/4 grades, and complications related to intubation (severe hypoxemia, severe cardiovascular collapse, airway injury, esophageal intubation). Nine trials with a total of 2,133 participants (1,067 in DL and 1,066 in VL) were included in the current analysis. Compared to DL, VL reduced the risk of difficult OTI [OR 0.29 (95% confidence interval (CI) 0.20-0.44, p < 0.001)], Cormack 3/4 grades [OR 0.26 (95% CI 0.17-0.41, p < 0.001)], and esophageal intubation [0.14 (95% CI 0.02-0.81, p = 0.03)] and increased the first-attempt success [OR 2.07 (95% CI 1.35-3.16, p < 0.001)]. No statistically significant difference was found for severe hypoxemia, severe cardiovascular collapse or airway injury. These results suggest that VL could be useful in airway management of ICU patients.

Evaluation of intubating conditions using stylet by conventional through-tube technique and through Murphy's eye in patients with high Mallampati scores.

Background:Difficult intubation is always a nightmare for an Anaesthetist. This study was planned to study the alternative method of stylet use during difficult oro-tracheal intubation. Outcome measures assessed were ease of intubation, hemodynamic stability and reducing complications.Materials and Methods:A cohort of 60 patients of Mallampati class III patients was formed and patients were divided into two groups. In group 1 patients, conventional through tube method was used for inserting stylet, whereas, in group 2 patients, Murphy's eye was used for inserting malleable flexi tip stylet.Results:Hemodynamic stability in terms of mean arterial blood pressure and heart rate was observed in group 2. Intubating time, number of attempts of successful intubation and post operative pharyngo-laryngeal complications was also low in group 2 patients.Conclusion:The use of Murphy's eye to pass stylet during difficult airway manoeuvre is a safe alternative over conventional rail-road technique.

Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial

Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial

Difficult tracheal intubation in randomized controlled studies: ethical considerations

To the Editor, We read with great interest the article by Thiboutot et al. published recently in the Journal. The authors evaluated the effects of manual in-line stabilization (MILS) of the cervical spine on the rate of difficult orotracheal intubation without cervical trauma in adult patients under general anesthesia. The study hypothesis was that the rate of failed tracheal intubation would be significantly greater with MILS than without. Although the results are convincing and the methodology seems correct, we believe this study raises an important ethical problem. While MILS is a maneuver frequently used while securing the airway of patients with a known or a potentially unstable cervical spine, its effect is known to impair visualization of the larynx with a reduction in the incidence of Cormack and Lehane’s grade 1 laryngeal visualization and an increased incidence of grades 2, 3, and 4. In Thiboutot et al.’s study, 50% of patients in the MILS group had an unsuccessful intubation and a significantly longer time for successful tracheal intubation than the control group. Manual in-line stabilization was also associated with a negative impact on glottic exposure during laryngoscopy. In our opinion, the patients included in the MILS group had an exposure to an unacceptable iatrogenic morbidity because the predictable risk they might have incurred was not in proportion with the expected benefit. More frequent tracheal intubation attempts increase intubation difficulty, and it is known that difficult intubation is associated with a higher rate of complications. Unfortunately, the incidence of side effects was not reported in this study. In our view, the prerequisites for ethical approval to conduct a randomized controlled trial should include confirmation that the intervention will not expose the test group to potential complications without complete disclosure to the patient of the associated risks and benefits.

Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial

Although manual in-line stabilization (MILS) is commonly used during endotracheal intubation in patients with either known or suspected cervical spine instability, the effect of MILS on orotracheal intubation is poorly documented. This study evaluated the rate of failed tracheal intubation in a fixed time interval with MILS. Two hundred elective surgical patients were randomized into two groups. In the MILS group, the patient's head was stabilized in a neutral position by grasping the patient's mastoid processes to minimize any head movement during tracheal intubation. In the control group, the patient's head rested in an optimal position for tracheal intubation. A 30-sec period was allowed to complete tracheal intubation with a #3 Macintosh laryngoscope blade. The primary endpoint was the rate of failed tracheal intubation at 30 sec. Secondary endpoints included tracheal intubation time and the Cormack & Lehane grade of laryngoscopy. Patient characteristics were similar with respect to demographic data and risk factors for difficult tracheal intubation. The rate of failed tracheal intubation at 30 sec was 50% (47/94) in the MILS group compared to 5.7% (6/105) in the control group (P < 0.0001). Laryngoscopic grades 3 and 4 were more frequently observed in the MILS group. Mean times for successful tracheal intubation were 15.8 +/- 8.5 sec and 8.7 +/- 4.6 sec for the MILS and control groups, respectively (mean difference 7.1, CI(95%) 5.0-9.3, P < 0.0001). All patients who failed tracheal intubation in the MILS group were successfully intubated when MILS was removed. In patients with otherwise normal airways, MILS increases the tracheal intubation failure rate at 30 sec and worsens laryngeal visualization during direct laryngoscopy.

Utilisation d’un mandrin d’Eschmann dans l’intubation orotrachéale difficile, évaluation d’une pratique professionnelle sur huit ans

The objective was to check on the effectiveness of difficult orotracheal intubation by Eschmann's gum elastic bougie in our institution. Retrospective observation study led for eight years. All the orotracheal intubations during the inductions in the surgical unit of the hospital of Laon were listed from 1998 to 2005, whether they were achieved in a classical way, with a fibrobronchoscope or with Eschmann's gum elastic bougie. Out of 15,657 intubations, 301 of them were difficult. Eschmann's gum elastic bougie was used 276 times with a rate of success of 99%. Our study confirms the figures of publications, particularly the anglo-saxon ones and proves the interest of the Eschmann's gum elastic bougie in orotracheal intubations and this in first intention.

Lateral neck radiography for prediction of difficult orotracheal intubation

Failed endotracheal intubation is a principal cause of morbidity and mortality in anesthetized patients. The aim of this study was to investigate the efficiency of lateral neck radiography in predicting difficult intubation. In a prospective triple-blind study, 100 patients (aged 18-89 yr), scheduled for elective surgery were randomly selected. Lateral neck X-ray was obtained from each of the patients before operation. Several angles and parameters on the X-ray were proposed to illustrate a relationship with easy or difficult intubation. A radiologist recorded these angles before the operation. An anaesthesiologist also determined the Mallampati score preoperation. At the time of intubation, two other anesthesiologists performed a laryngoscopy and, according to established criteria, identified the patients as easy or difficult intubation. The results were then compared with each other. Fifteen patients were identified as having difficult intubation (laryngoscopy Grades III and IV). Sensitivity and specificity of the Mallampati Class test were 26% and 100%, respectively. The sensitivity and specificity of the lateral neck X-ray for three measured angles were 100%. The positive and negative predictive values (NPVs) for those angles were 100% and for Mallampati classification were 100% and 80%, respectively. Compared to the Mallampati Class test, our method of analyzing the lateral X-ray, although not as easy and universally applicable as Mallampati Class test, proved to be a suitable method for predicting difficult intubation.

Predicting difficult orotracheal intubation in pharyngo-laryngeal disease: preliminary results of a composite index.

Prediction of difficulty in orotracheal intubation (DI) in patients undergoing laryngeal microsurgery should help reduce the morbidity-mortality associated with this clinical situation. To establish a simple score to predict this difficulty, we studied 11 variables and their association with DI in these patients. The study included 181 patients. The variables evaluated were: Mallampati grade, thyromental distance, mouth opening, temporomandibular joint movement, tooth morphology, maxillary deficiency, head and neck movement, receding mandible, body mass index, and clinical symptoms of laryngeal and supraglottic disease. To establish the score, regression coefficients of the statistically significant variables were used on adjusted logistic regression analysis. DI was present in 50 patients (28%) and orotracheal intubation was impossible in four (2%). Except for obesity, all the variables evaluated were predictive of DI. A simple predictive test was established based on logistic regression analysis including all the variables except temporomandibular joint movement. To determine the optimum cut-off for the new test, a receiver operating characteristic curve analysis was applied. A score > or = 5 in the proposed test provided a sensitivity of 94% and a specificity of 76%. The index we describe is aimed at predicting DI in a very specific population with a high risk of this complication. This index uses a series of variables which may be measured easily during the preoperative period and provides an excellent predictive capacity with a high sensitivity and specificity when the index is > or = 5.

Minitracheostomy in elective surgery of the larynx: an alternative to formal tracheostomy

A patient scheduled for surgical removal of a giant polyp of the larynx, and in whom difficult orotracheal intubation was anticipated in the preoperative visit, was managed successfully with a minitracheostomy performed with a Mini-Trach II kit. The ventilation achieved was adequate throughout the procedure. Thus, conventional tracheostomy was avoided.

" TOTI " Method for Difficult Orotracheal Intubation in Adult Patients

" TOTI " Method for Difficult Orotracheal Intubation in Adult Patients