Difficult Tracheal Intubation Research Articles

Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants.

The European Society of Anesthesiology and Intensive Care recommends the use of neuromuscular blocking agents (NMBA) in adults, to facilitate tracheal intubation and reduce its associated complications. Children who undergo tracheal intubation may suffer some of the same complications, however, no consensus exists regarding the use of NMBA for tracheal intubation in the pediatric population. We will explore the existing evidence assessing the effects of avoidance versus the use of NMBA for the facilitation of tracheal intubation in children and infants. This protocol follows the preferred reporting items for systematic reviews and meta-analyses protocols recommendations. We will include all randomized controlled clinical trials assessing the effects of avoidance versus the use of NMBA for facilitation of tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy in pediatric participants (<18 years). Our primary outcome is incidence of difficult tracheal intubation. Secondary outcomes include incidence of serious adverse events, failed intubation, events of upper airway discomfort or injury, and difficult laryngoscopy. We will conduct a thorough database search to identify relevant trials, including CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, CINAHL, and trial registries. Two review authors will independently handle the screening of literature and data extraction. Each trial will be evaluated for major sources of bias with the "classic risk of bias tool" used in the Cochrane Collaboration tool from 2011. We will use Review manager (RevMan) or R with the meta package to perform the meta-analysis. We will perform a trial sequential analysis on the meta-analysis of our primary outcome, providing an estimate of statistical reliability. Two review authors will independently assess the quality of the body of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We will use GRADEpro software to conduct the GRADE assessments and to create "Summary of the findings" tables.

Comparison of Modified Mallampati Classification in Supine and Sitting Positions to Predict Difficult Tracheal Intubation in Diabetic Patients.

Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons. Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation. A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value. Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001). Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.

Reliable prediction of difficult airway for tracheal intubation from patient preoperative photographs by machine learning methods

BackgroundEstimating the risk of a difficult tracheal intubation should help clinicians in better anaesthesia planning, to maximize patient safety. Routine bedside screenings suffer from low sensitivity. ObjectiveTo develop and evaluate machine learning (ML) and deep learning (DL) algorithms for the reliable prediction of intubation risk, using information about airway morphology. MethodsObservational, prospective cohort study enrolling n=623 patients who underwent tracheal intubation: 53/623 difficult cases (prevalence 8.51%).First, we used our previously validated deep convolutional neural network (DCNN) to extract 2D image coordinates for 27 + 13 relevant anatomical landmarks in two preoperative photos (frontal and lateral views). Here we propose a method to determine the 3D pose of the camera with respect to the patient and to obtain the 3D world coordinates of these landmarks. Then we compute a novel set of dM=59 morphological features (distances, areas, angles and ratios), engineered with our anaesthesiologists to characterize each individual's airway anatomy towards prediction.Subsequently, here we propose four ad hoc ML pipelines for difficult intubation prognosis, each with four stages: feature scaling, imputation, resampling for imbalanced learning, and binary classification (Logistic Regression, Support Vector Machines, Random Forests and eXtreme Gradient Boosting). These compound ML pipelines were fed with the dM=59 morphological features, alongside dD=7 demographic variables. Here we trained them with automatic hyperparameter tuning (Bayesian search) and probability calibration (Platt scaling). In addition, we developed an ad hoc multi-input DCNN to estimate the intubation risk directly from each pair of photographs, i.e. without any intermediate morphological description.Performance was evaluated using optimal Bayesian decision theory. It was compared against experts' judgement and against state-of-the-art methods (three clinical formulae, four ML, four DL models). ResultsOur four ad hoc ML pipelines with engineered morphological features achieved similar discrimination capabilities: median AUCs between 0.746 and 0.766. They significantly outperformed both expert judgement and all state-of-the-art methods (highest AUC at 0.716). Conversely, our multi-input DCNN yielded low performance due to overfitting. This same behaviour occurred for the state-of-the-art DL algorithms. Overall, the best method was our XGB pipeline, with the fewest false negatives at the optimal Bayesian decision threshold. ConclusionsWe proposed and validated ML models to assist clinicians in anaesthesia planning, providing a reliable calibrated estimate of airway intubation risk, which outperformed expert assessments and state-of-the-art methods. Our novel set of engineered features succeeded in providing informative descriptions for prognosis.

Comparison of the success rate of tracheal intubation between stylet and bougie with a hyperangulated videolaryngoscope: a randomised controlled trial.

Hyperangulated videolaryngoscopes are known to increase the success rate of tracheal intubation in the setting of difficult airway management when used with a stylet or bougie. However, there is controversy over which adjunct is more useful. This randomised study aimed to compare first attempt tracheal intubation success rate between a stylet and bougie when using a hyperangulated videolaryngoscope. We recruited patients aged > 20 years who were scheduled for elective surgery under general anaesthesia and required tracheal intubation. We only included patients with factors predicting difficult tracheal intubation based on pre-anaesthesia airway evaluation. Tracheal intubation was attempted using a Glidescope® with either a stylet or bougie as an adjunct according to group assignment. Primary outcome was the success rate of the first tracheal intubation attempt, and secondary outcomes were success of second and third attempts; tracheal intubation time; and occurrence of sore throat, dysphagia or hoarseness. A total of 166 patients were included. The success rate of the first tracheal intubation attempt was significantly higher in patients allocated to the bougie group compared with those allocated to the stylet group (81/83 (98%) vs. 73/83 (88%), respectively; p = 0.032). The number of patients who needed two attempts was significantly lower in those allocated to the bougie group compared with those allocated to the stylet group (1/83 (1%) vs. 9/83 (11%), respectively; p = 0.018). Each group had one patient (1%) where tracheal intubation was achieved after a third attempt. There was no significant difference in the occurrence of sore throat, dysphagia and hoarseness between the two groups. When difficult tracheal intubation is anticipated and a hyperangulated videolaryngoscope is used, the success rate of the first attempt is higher when a bougie is used compared with a stylet.

Observation of the validity of the upper lip bite test in predicting difficult intubation

The upper lip bite test (ULBT) is considered an effective method for predicting difficult airways, but data on the ULBT for predicting difficult tracheal intubation are lacking. This study aimed to examine the clinical utility of the ULBT in predicting difficult endotracheal intubation. We conducted an observational case-cohort study of adult patients undergoing elective surgery and requiring endotracheal intubation for general anesthesia. Difficult airway assessment was performed on the recruited patients before the operation, including the ULBT, mouth opening, thyromental distance, modified Mallampati test, and body mass index. The primary outcome was the incidence of difficult tracheal intubation. The receiver operating characteristic curve analysis was used to compare the performance of variables in predicting difficult tracheal intubation. We successfully recruited 2522 patients for analysis and observed 64 patients with difficult tracheal intubation. When predicting difficult tracheal intubation, grade 2 ULBT had a sensitivity of 0.75 and a specificity of 0.54, and grade 3 had a sensitivity of 0.28 and a specificity of 0.75. Compared with mouth opening, the area under the receiver operating characteristic curve of the ULBT was lower in predicting difficult tracheal intubation (0.69 [95% confidence interval: 0.67–0.71] vs. 0.84 [95% confidence interval: 0.82–0.87], P < 0.05).Clinical Trials Registry: ChiCTR-ROC-16009050, principal investigator: Weidong Yao.

Development and validation of a screening method for difficult tracheal intubation based on geometric simulation and computer technology

BackgroundThe anatomical characteristics of difficult airways can be analysed geometrically. This study aims to develop and validate a geometry-assisted difficult airway screening method (GADAS method) for difficult tracheal intubation.MethodsIn the GADAS method, a geometric simulated model was established based on computer graphics. According to the law of deformation of the upper airway on laryngoscopy, the expected visibility of the glottis was calculated to simulate the real visibility on laryngoscopy. Validation of the new method: Approved by the Ethics Committee of Yijishan Hospital of Wannan Medical College. Adult patients who needed tracheal intubation under general anaesthesia for elective surgery were enrolled. The data of patients were input into the computer software to calculate the expected visibility of the glottis. The results of tracheal intubation were recorded by anaesthesiologists. The primary observation outcome was the screening performance of the expected visibility of the glottis for difficult tracheal intubation.ResultsThe geometric model and software of the GADAS method were successfully developed and are available for use. We successfully observed 2068 patients, of whom 56 patients had difficult intubation. The area under the receiver operating characteristic curve of low expected glottis visibility for predicting difficult laryngoscopy was 0.96 (95% confidence interval [CI]: 0.95–0.96). The sensitivity and specificity were 89.3% (95% CI: 78.1-96.0%) and 94.3% (95% CI: 93.2%-95.3), respectively.ConclusionsIt is feasible to screen difficult-airway patients by applying computer techniques to simulate geometric changes in the upper airway.

Left Head Rotation as Alternative to Difficult Tracheal Intubation: Randomized Open Label Clinical Trial.

Tracheal intubation is a life-saving intervention not only for physicians but also for allied health workers. Optimizing the patient's head and neck position for the best glottic view is a crucial step that accelerates tracheal intubation. The left head rotation maneuver has been recently described as an innovative approach to tracheal intubation with marked improvement in glottic visualization and can be an alternative before proceeding to a surgical airway. This study compared the glottic view and intubating conditions in the sniffing position versus left head rotation during direct laryngoscopy. This randomized, open-label clinical trial enrolled fifty-two adult patients admitted to the Baguio General Hospital & Medical Center from September 2020 to January 2021 for an elective surgical procedure requiring tracheal intubation under general anesthesia. Intubation was done using a 45-degree left head rotation in the experimental group (n=26), while the control group (n=26) was intubated using the conventional sniffing position. Glottic visualization and intubation difficulty with left head rotation and sniffing position were assessed using Cormack-Lehane Grade and Intubation Difficulty Scale, respectively. Successful intubation is measured by observing a capnographic waveform in the end-tidal CO2 monitor after placement of the endotracheal tube. There was no significant statistical difference in the clinicodemographic characteristics between the left head rotation and sniffing position groups. There was no statistically significant difference in the Cormack-Lehane Grade, with 85% of patients classified under Grades 1 and 2 in both groups. Also, there were no statistically significant differences in the Intubation Difficulty Scale scores of patients intubated with left head rotation or sniffing position; 30.7% of patients in both groups were easily intubated, while 53.8% in left head rotation and 57.6% in sniffing position groups were intubated with slight difficulty. Similarly, there were no significant differences between the two techniques in any of the seven parameters of the Intubation Difficulty Scale, although numerically fewer patients required the application of additional lifting force [7 (26.9%) vs. 11 (42.3%)] or laryngeal pressure [3 (11.5%) vs. 7 (26.9%)] when intubated with left head rotation. The intubation success rate with left head rotation was 92.3% vs. 100% in the sniffing position, but this difference was not statistically significant. Left head rotation produces comparable laryngeal exposure and intubation ease to the conventional sniffing position. Therefore, left head rotation may be an alternative for patients who cannot be intubated in the sniffing position, especially in hospitals where advanced techniques such as video laryngoscopes and flexible bronchoscopes are unavailable, as is the case in this study. However, since our sample size was small, studies with a larger study population are warranted to establish the generalizability of our findings. In addition, we observed inadequate familiarity among anesthesiologists with the left head rotation technique, and the intubation success rate may improve as practitioners attain greater technical familiarization. This trial was registered in the International Traditional Medicine Clinical Trial Registry (ISRCTN23442026).

Evaluation of Ultrasound Guided Measurement of Tongue Thickness in Predicting Difficult Tracheal Intubation in Patients Undergoing Elective Surgery: A Cross Sectional Study

Background: Preoperative airway assessment is necessary to identify airway difficulties to the earliest, ensure adequate preparation to airway management before induction and to avoid airway related complications. Various Imaging techniques have been studied for prediction of the difficult airway. the ultrasound is a quick and simple technique. Aim of the study was to evaluate ultrasound guided measurement of tongue thickness in predicting difficult tracheal intubation in patients undergoing elective surgery.&#x0D; Methods: Sixty-one patients American Society of Anesthesiologist class I and II,18-65 years of age, either sex, were included. Tongue thickness was measured by ultrasound as the distance from the surface of tongue to the submental skin. Modified mallampatti score was also recorded.&#x0D; Results: Receiver operating characteristic (ROC) curve of tongue thickness showed an AUC of 0.879 for a cut off value of &gt;6 cm. This shows it has an excellent predictive value. Tongue thickness (&gt;6cm) was found to have 90.16% combined diagnostic accuracy with 75% sensitivity and 94.74% specificity for prediction of difficult intubation. No correlation between tongue thickness and modified mallampatti score. (Correlation coefficient was 0.013, p value 0.920).&#x0D; Conclusion: We conclude that ultrasound guided measurement of tongue thickness&gt; 6 cm can reliably predict difficult tracheal intubation in patients undergoing elective surgery.

Value of the Hyomental Distance Measured With Ultrasound in Forecasting Difficult Laryngoscopy in Newborns

PurposePreoperative evaluations of difficult airways are imperative, especially in newborns. The hyomental distance is a reliable index for predicting difficult airways in adults. However, few studies have evaluated the value of the hyomental distance for predicting difficult airways in newborns. It is unclear whether the hyomental distance forecasts a restricted or difficult view when using direct laryngoscopy. We intended to develop an effective system for predicting difficult tracheal intubation in newborns. DesignA prospective observational clinical study. MethodsNewborns aged 0 to 28 days undergoing oral endotracheal intubation with direct laryngoscopy for elective surgery under general anesthesia were enrolled. The hyomental distance and hyoid level tissue thickness were assessed by ultrasound. Other parameters, such as the mandibular length and sternomental distance, were also evaluated before anesthesia. The glottic structure view under laryngoscopy was graded according to the Cormack-Lehane classification. The patients with Grade 1 and 2 laryngeal views were assigned to Group E. Those with Grade 3 and 4 views were assigned to Group D. FindingsA total of 123 newborns were recruited for our study. The incidence of poor visualization of the larynx during laryngoscopy in our study was 10.6%. The multifactor logistic regression results showed that the hyomental distance was a powerful predictor of difficult laryngoscopy (OR = 0.16, 95% CI 0.03-0.74, P = .019). The curve with the highest sensitivity and specificity and the maximum area under the curve (AUC) was the hyomental distance. The receiver operating characteristic (ROC) curve for the hyomental distance suggested that the best cut-off value was less than equal to 2.74 cm, with an AUC of 0.80 (95% CI 0.64-0.95). ConclusionsIt is noninvasive and feasible to accurately measure the hyomental distance with ultrasound in newborns, and the results are reliable. We believe that the hyomental distance measured with ultrasound could be used as a marker for predicting difficult laryngoscopy in newborns.

Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry.

Children with difficult tracheal intubation are at increased risk of severe complications, including hypoxaemia and cardiac arrest. Increasing experience with the simultaneous use of videolaryngoscopy and flexible bronchoscopy (hybrid) in adults led us to hypothesise that this hybrid technique could be used safely and effectively in children under general anaesthesia. We reviewed observational data from the international Pediatric Difficult Intubation Registry from 2017 to 2021 to assess the safety and efficacy of hybrid tracheal intubation approaches in paediatric patients. In total, 140 patients who underwent 180 attempts at tracheal intubation with the hybrid technique were propensity score-matched 4:1 with 560 patients who underwent 800 attempts with a flexible bronchoscope. In the hybrid group, first attempt success was 70% (98/140) compared with 63% (352/560) in the flexible bronchoscope group (odds ratio (95%CI) 1.4 (0.9-2.1), p = 0.1). Eventual success rates in the matched groups were 90% (126/140) for hybrid vs. 89% (499/560) for flexible bronchoscope (1.1 (0.6-2.1), p = 0.8). Complication rates were similar in both groups (15% (28 complications in 182 attempts) hybrid; 13% (102 complications in 800 attempts) flexible bronchoscope, p = 0.3). The hybrid technique was more likely than flexible bronchoscopy to be used as a rescue technique following the failure of another technique (39% (55/140) vs. 25% (138/560), 2.1 (1.4-3.2) p < 0.001). While technically challenging, the hybrid technique has success rates similar to other advanced airway techniques, few complications and may be considered an alternative technique when developing an airway plan for paediatric patients whose tracheas are difficult to intubate under general anaesthesia.

Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma.

The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT). The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group). One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%. NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor. 4 Laryngoscope, 134:120-126, 2024.

Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry

BackgroundDifficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. MethodsWe queried a multicentre registry for children who experienced “difficult” or “impossible” facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. ResultsThe incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with “difficult” mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. ConclusionsCertain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways.

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON method, which looks for and evaluates the Mallampati classification, signs of obstruction, and neck mobility. Clinical findings help predict a higher likelihood of difficult tracheal intubation, but no clinical result reliably excludes difficult intubation. Ultrasound as an adjunct to clinical examination can provide the clinician with a dynamic anatomical airway assessment, which is impossible with clinical examination alone. In the hands of anesthesiologists, ultrasound is becoming more popular in the perioperative period. This method is particularly applicable for identifying proper endotracheal tube positioning in specific patient populations, such as those who are morbidly obese and patients with head and neck cancer or trauma. The focus is on identifying the normal anatomy, correctly positioning the endotracheal tube, and refining the parameters that predict difficult intubation. Several ultrasound measurements are clinical indicators of difficult direct laryngoscopy in the literature. A meta-analysis revealed that the distance from the skin to the epiglottis (DSE) is most associated with a difficult laryngoscopy. An ultrasound of the airway could be applied in routine practice as an adjunct to the clinical examination. A full stomach, rapid sequence intubation, gross visual anatomical abnormalities, and restricted neck flexibility prevent using ultrasound to assess the airway. The airway evaluation is performed with a linear array transducer of 12-4 MHz, with the patient in the supine position, with no pillow, and with the head and neck in a neutral position. The central axis of the neck is where the ultrasound parameters are measured. These image acquisitions guide the standard ultrasound examination of the airway.

Objective structured assessment ultrasound skill scale for hyomental distance competence – psychometric study

BackgroundUltrasound assessment of the airway recently integrates the point-of-care approach to patient evaluation since ultrasound measurements can predict a difficult laryngoscopy and tracheal intubation. Because ultrasonography is performer-dependent, a proper training and assessment tool is needed to increase diagnostic accuracy. An objective, structured assessment ultrasound skill (OSAUS) scale was recently developed to guide training and assess competence. This work aims to study the psychometric properties of OSAUS Scale when used to evaluate competence in ultrasound hyomental distance (HMD) measurement. Methods: Prospective and experimental study. Volunteers were recruited and enrolled in groups with different expertise. Each participant performed three ultrasonographic HMD evaluation. The performance was videorecorded and anonymized. Five assessors blindly rated participants’ performance using OSAUS scale and a Global Rating Scale (GRS). A psychometric study of OSAUS scale as assessment tool for ultrasound HMD competence was done. Results: Fifteen voluntaries participated on the study. Psychometric analysis of OSAUS showed strong internal consistency (Cronbach’s alpha 0.916) and inter-rater reliability (ICC 0.720; p < 0.001). The novice group scored 15.4±0.18 (mean±SD), the intermediate 14.3±0.75 and expert 13.6±0.1.25, with a significant difference between novice and expert groups (p = 0.036). The time in seconds to complete the task was evaluated: novice (90±34) (mean±SD), intermediate (84±23) and experts (83±15), with no significant differences between groups. A strong correlation was observed between OSAUS and global rating scale (r = 0.970, p < 0.001).ConclusionThe study demonstrated evidence of validity and reliability. Further studies are needed to implement OSAUS scale in the clinical setting for training and assessment of airway ultrasound competence.

Methodical control of the difficult pediatric airway: two case reports

BackgroundManagement of children who present with a history of impossible mask ventilation or difficult tracheal intubation is fraught with challenges. Despite this, the “airway stress test” of an inhalational induction is frequently employed risking airway obstruction, breath holding, apnea, and laryngospasm.Case presentationsWe present two cases of children with anticipated difficult airway management. The first child (14-year-old African American boy) had severe mucopolysaccharidosis with a history of failed anesthetic induction and failed airway management. The second child (3-year-old African American girl) had progressive lymphatic infiltration of the tongue, resulting in severe macroglossia. We describe a technique that forgoes inhalational induction, incorporates recent pediatric airway guidelines, and provides a greater margin of safety. The technique encompasses the use of drugs that facilitate sedation for intravenous access, without respiratory depression or airway obstruction, titrated use of medications to achieve anesthetic depth while preserving ventilatory drive and airway tone, and the continuous provision of directed oxygen flow during airway manipulation. Propofol and volatile gases were avoided to preserve airway tone and respiratory drive.ConclusionsWe emphasize that an intravenous induction technique utilizing medications that preserve airway tone and ventilatory drive, and the use of continuous oxygen flow throughout airway manipulation, allows for successful management of children with a difficult airway. The common practice of volatile inhalational induction should be avoided in anticipated difficult pediatric airways.

Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis.

Normalization of metabolic alkalosis is an important pillar in the treatment of infantile hypertrophic pyloric stenosis (IHPS) because uncorrected metabolic alkalosis may lead to perioperative respiratory events. However, the evidence on the incidence of respiratory events is limited. We aimed to study the incidence of peroperative hypoxemia and postoperative respiratory events in infants undergoing pyloromyotomy and the potential role of metabolic alkalosis. We retrospectively reviewed all patients undergoing pyloromyotomy between 2007 and 2017. All infants received intravenous fluids preoperatively to correct metabolic abnormalities close to normal. We assessed the incidence of perioperative hypoxemia (defined as oxygen saturation [SpO2] < 90% for > 1min) and postoperative respiratory events. Additionally, the incidence of difficult intubations was evaluated. We performed a multivariate logistic regression analysis to evaluate the association between admission or preoperative serum pH values, bicarbonate or chloride, and peri- and postoperative hypoxemia or respiratory events. Of 406 included infants, 208 (51%) developed 1 or more episodes of hypoxemia during the perioperative period, of whom 130 (32%) experienced it during induction, 43 (11%) intraoperatively, and 112 (28%) during emergence. About 7.5% of the infants had a difficult intubation and 17 required more than 3 attempts by a pediatric anesthesiologist. Three patients developed respiratory insufficiency and 95 postoperative respiratory events were noticed. We did not find a clinically meaningful association between laboratory values reflecting metabolic alkalosis and respiratory events. IHPS frequently leads to peri- and postoperative hypoxemia or respiratory events and high incidence of difficult tracheal intubations. Preoperative pH, bicarbonate, and chloride were bad predictors of respiratory events.

Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study

IntroductionFor thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. Patients and methodsIn this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg−1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 μV. If not, sugammadex (2 mg.kg−1) was administered. The dissection began when the signal was positive. ResultsFrom January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/− 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DiscussionThis prospective study shows that the use of 0.5 mg.kg−1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.

Nove preporuke Američkog udruženja anesteziologa (2022) za zbrinjavanje otežanog disajnog puta

Difficulty establishing an airway and lung ventilation is one of the most urgent conditions in medicine, which can lead to severe complications, including permanent neurological damage and death. To facilitate handling this difficult clinical situation, various guides and recommendations were created to increase patient safety, help doctors, and protect them from criminal liability. The American Society of Anesthesiologists (ASA) issued new recommendations in 2022, which cover all segments of this problem, starting with the clear definition of different clinical situations (difficult laryngoscopy, difficult tracheal intubation, difficult face mask ventilation, difficult placement supra, and infraglottic means), through recommendations for the preparation of care for difficult airway, to algorithms and strategies for solving anticipated and unanticipated difficult airway. The paper presents the most important aspects of the mentioned segments of the new ASA recommendations, as well as their comparison with previous ASA recommendations and recommendations of other associations.

Implementation of video laryngoscopes and the development in airway management strategy and prevalence of difficult tracheal intubation: A national cohort study.

We aimed to determine the development in the use of video laryngoscopy over a 9-year period, and its possible impact on airway planning and management. We retrieved 822,259 records of tracheal intubations recorded from 2008 to 2016 in the Danish Anaesthesia Database. The circumstances regarding pre-operative airway assessment, the scheduled airway management plan and the actual airway management concerning video laryngoscopy were reported for each year of observation. Further, the association between year of observation and various airway management related outcomes was evaluated by multivariate logistic regression. There was a significant increase in airway management with 'advanced technique successfully used within two attempts' from 2.7% in 2008 to 15.5% in 2016 (p <.0001). This predominantly reflects use of video laryngoscopy. The prevalence of tracheal intubations 'scheduled for video laryngoscopy' increased from 3.5% in 2008 to 10.6% in 2016 (p <.0001). We found a significant increase in the prevalence of anticipated difficulties with intubations by direct laryngoscopy from 1.8% in 2008 to 5.2% in 2016 (p <.0001). The prevalence of failed tracheal intubations decreased from 0.14% in 2008 to 0.05% in 2016 (p <.0001). From 2008 to 2016, a period of massive implementation of video laryngoscopes, a significant change in airway management behaviour was recorded. Increasingly, video laryngoscopy is becoming a first-choice device for both acute and routine airway management. Most importantly, the data showed a noticeable reduction in failed intubation over the time of observation.

Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study

Study objectiveObesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/m2, is associated with adverse outcomes and challenges during surgery. Difficulties during endotracheal intubation, occur in 3–8% of procedures and are among the principal causes of anesthetic-related morbidity and mortality. Endotracheal intubation can be challenging in obese patients due to an array of anatomic and physiologic factors. Double lumen tubes (DLTs), the most commonly used airway technique to facilitate anatomic isolation of the lungs for one lung ventilation. However, DLTs can be difficult to properly position and are also more likely to cause airway injuries and bleeding when compared to conventional single lumen tubes. We investigated the association between BMI and difficult tracheal DLT intubation. DesignRetrospective cohort study. SettingOperating room. PatientsWe analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021. MeasurementsBMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression. Main resultsAmong 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/m2 increase in BMI was associated with a marginal increase of difficult intubation, odds ratio (OR) 1.06 (95% Confidence Interval [CI]: 1.002, 1.11; P = 0.040). Difficult intubation was not associated with airway abnormalities, estimated OR 0.85 (95% CI: 0.62, 1.17; P = 0.321). There was no interaction between known airway abnormalities and BMI (P = 0.894). ConclusionsDifficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m2 corresponds to an increase in average absolute risk for difficult intubation from 16 to 19%, which probably is not clinically meaningful.