Endotracheal Intubation Attempts Research Articles

Longitudinal Changes in Emergency Medical Services Advanced Airway Management

Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care. To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort. This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024. Advanced airway management attempts, including ETI, SGA, and surgical airways. The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics). Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent. In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.

Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review.

Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system. This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated. A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt. Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

Assessment of Different Indices as Predictors of Difficult Airway in Obese Patients.

Introduction Difficulties with tracheal intubation contribute to the morbidity and mortality associated with anesthesia. Suggested predictors for difficult airwayinclude, history of obstructive sleep apnea, high Mallampati score, elderly, male, short neck, and high Wilson score.However, none of these has high diagnostic accuracy particularly in obese population. Parameters used to quantify obesity such as Body Mass Index(BMI), mid arm circumference, skin fold thickness,etc. have not been used as independent predictors of difficult airway. This study has been designed to evaluate the accuracy of commonly used tools to assess difficult airway and to test other obesity markers as scale for assessing difficult airway i.e. Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3. Aim To assess BMI, Mallampati grading, Neck circumference and Thyromental distance as predictors of difficult airway in obese patients and to validate neck circumference to thyromental distance ratio and skin fold thickness as a tool for assessment of difficult airway (Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3.) in obese patients. Methods This prospective observational study was carried out on 51 obese patients (as per BMI) of ASA gradeII, either sex, aged 23 to 57 years posted for elective surgery under general anesthesia with endotracheal intubation. After subjective assessment of difficult airway following data sets and variables were obtained - sex, weight, height, body mass index (BMI),Modified Mallampati class (MPG), Cormack-Lehane (CL) grade, adequacy of bag mask ventilation (BMV), number of endotracheal intubation attempts, patient's neck circumference (NC), thyromental distance (TMD), waist-hip ratio (WHR) and Skin fold thickness. The observations made during the study were statistically analyzed and correlated as predictors for difficult airway. Result Correlation of MPG to CL-grade (r-0.41, p-0.003), BMV (r-0.31, p-0.028) & No. of intubationattempts (r-0.37, p-0.007) was mild & statistically significant. Correlation of Neck Circumference with CL-grade (r-0.57, p-0.000), & No. of intubation attempts (r-0.62, p-0.000), found moderate & statistically significant, & with BMV was mild and statistically significant (r-0.48, p-0.000). Correlation of Thyromental Distance to CL-grade (r-0.65, p-0.000), BMV (r-0.70, p-0.000) & No. of intubationattempts (r-0.61, p-0.000) was moderate & statistically significant. Correlation of BMI to CL-grade (r-0.11, p-0.428), BMV (r-0.04, p-0.757) & No. of intubation attempts (r-0.16, p-0.257) was weak & not significant. Skin Fold Thickness showed no significant association with Difficult airway i.e., CL Grade (p-0.478), BMV (p-0.101), and No. of intubation attempts (p-0.143). Correlation of NC/TMD ratio with BMV (r-0.74, p-0.000), CL-grade (r-0.76, p-0.000), & No. of intubation attempts (r-0.77, p-0.000) wasmoderate & statistically significant. Conclusion NC, TMDand NC/TMD Ratio depicted a close association with airway difficulty in obese patients. Obesity grade is a risk factor for difficult airway but predictors of obesity including Skin Fold Thickness, individually did not showassociation with difficult airway (small sample size may be a limiting factor). None of the commonly performed tests alone has proven to be adequate in predicting difficult intubation in the obese population.

Association Between Emergency Medical Service Agency Intubation Rate and Intubation Success

Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database. We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders. We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes. Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success.

Effect of Blade Size on the First-Pass Success Rate of Endotracheal Intubation Using the C-MAC Video Laryngoscope.

We sought to determine whether blade size influences the first-pass success (FPS) rate when performing endotracheal intubation (ETI) with a C-MAC video laryngoscope (VL) in emergency department (ED) patients. This single-center, retrospective, observational study was conducted between August 2016 and July 2022. A total of 1467 patients was divided into two categories based on the blade size used during the first ETI attempt: blade-3 (n = 365) and blade-4 groups (n = 1102). The primary outcome was the FPS rate. The secondary outcomes included the glottic view, multiple attempt rate, and ETI-related complications. We used propensity score matching to reduce the potential confounders between the two groups. Among these, 363 pairs of matched propensity scores were generated. The FPS rate did not differ between the blade-3 (84.8%) and blade-4 groups (87.3%) in the matched cohort (p = 0.335). The multiple attempt rate did not differ significantly between groups (p = 0.289) and was 3.9% and 2.5% in the blade-3 and blade-4 groups, respectively. The difficult glottic view (11.3 vs. 6.9%, p = 0.039) and complication rates (15.4% vs. 10.5%, p = 0.047) were significantly higher in the blade-3 group than in the blade-4 group. The FPS rates of ETI with the blade-3 and blade-4 groups in adult patients in the ED did not differ significantly.

Abstract 234: Longitudinal Trends in Prehospital Advanced Airway Management in the United States

Background: While endotracheal intubation (ETI) is the most common prehospital advanced airway management technique in the United States (US), observations from clinical trials and the COVID-19 pandemic have motivated the broader use of supraglottic airways (SGA). The current national patterns of prehospital airway practices are unknown. We sought to describe longitudinal trends in Emergency Medical Services (EMS) advanced airway management in the US. Methods: We analyzed 2011-2021 data from ESO, a data set of US prehospital electronic health records. We identified all 911 events with attempted advanced airway management, determining the annual percentage receiving ETI and/or SGA attempts. We determined temporal trends using mixed effects regression. We stratified the analyses by condition (cardiac arrest, trauma, medical non-arrest) and age (adult vs. children [<18y]). Results: During the study period 355,532 patients underwent prehospital advanced airway management (annual incidence 9.0-10.0 per 1,000 911 events). Annual patients with SGA attempts increased almost three-fold (20.8% to 53.2%; p-trend<0.001), while annual patients with ETI attempts decreased (90.0% to 60.7%, p-trend<0.001). (Figure) Trends for cardiac arrest (SGA increased from 25.1% to 60.6%; ETI decreased from 87.3% to 54.7%) and trauma (SGA increased from 17.2% to 40.7%; ETI decreased from 90.5% to 71.8%) were similar. Advanced airway management in medical non-arrest patients remained stable (SGA 15.7% to 20.0%, p-trend=0.26; ETI 93.3% to 87.5%, p-trend=0.85). In children SGA attempts increased five-fold (11.2% to 50.9%, p-trend<0.001) while ETI attempts decreased (89.7% to 60.6%, p-trend<0.001). Conclusion: US prehospital advanced airway management practices have shifted, with marked increases in SGA and decreases in ETI attempts. These observations have critical implications for EMS care, training and system planning.

Secular trends in airway management of out-of-hospital cardiac arrest in the National Emergency Medical Services Information System (NEMSIS) dataset

IntroductionPrehospital airway management is essential in resuscitation from out-of-hospital cardiac arrest (OHCA). No longitudinal national studies have described longitudinal trends in airway device choice. We sought to evaluate secular trends of OHCA endotracheal intubation (ETI) and supraglottic airway (SGA) in the United States (US). MethodsWe evaluated ETI and SGA use for 2013–2022 in adult OHCA in the US using the National EMS Information System (NEMSIS) database. We identified OHCA events (CPR performed or defibrillation) and evaluated the proportions of ETI and SGA used during OHCA. We repeated the results stratified by urbanicity. We used descriptive statistics to describe the prevalence of airway device use by urbanicity. ResultsDuring the study period, we observed 320,154,097 adult 9-1-1 events. Of 3,118,703 OHCA, there were 699,568 and 337,458 cases with reported ETI and SGA attempts. The dominant airway choice was ETI, though the trend of ETI choice decreased as SGA increased over time. From 2013 to 2022, SGA use increased in urban settings, while rural and suburban remained stable. ConclusionOver ten years, rates of advanced airway use have increased, with ETI remaining the predominant airway for adults in OHCA. Interestingly, ETI choice decreased as SGA increased over the study period. SGA use distinctly differed in urban settings, increasing concerns for disparities in care provision among communities. With the increased use of SGA over time, further evaluation of patient outcomes is required in datasets with robust linkage to Utstein variables.

Design and Superior Performance of a New Endotracheal Tube to Avoid the Asphyxiation of Premature Infants.

Background Neonatal endotracheal intubation attempts often fail, with failures typically attributable to unintended esophageal intubation, with asphyxia, brief or prolonged, as the consequence. Standard-of-care neonatal endotracheal tubes have changed little over recent decades, even as the gestational age of neonates thought eligible for resuscitation and intensive care has decreased. Methods A new neonatal endotracheal tube waspatterned after the soft steering mechanism of a two-string fishing line trocar.The new tuberemains patent throughout the intubation for air movement and CO2 detection and allows for a finger on the intubator's hand to stiffen, curve, and elevate the tip of the tube over the epiglottis and into the trachea without occluding the vision through a laryngoscope. Thistube's engineering principles were studied prospectively in a controlled open-label pilot studyin premature infants. Infantswereobserved during 12 intubationsin a one-to-one comparison with standard practice. Results The new design in comparison to a conventional neonatal endotracheal tube(CNETT) was found to be superior. The average intubation time (mean 36.6 sec, median 30 sec) was shorter (mean 44.6 sec, median 45 sec) in the new design. Intubation attempts were fewer (0 vs. 3), and unintended esophageal intubations were also fewer (0 vs. 4). Conclusion Tracheal intubation of premature infants with the new soft-steering mechanism endotracheal tube was associated with less asphyxia, fewer intubation attempts, and fewer esophageal intubations.

72 Airway Management Practices Among Community Emergency Departments: A Multicenter Evaluation of Over 11,000 Endotracheal Intubation Attempts

72 Airway Management Practices Among Community Emergency Departments: A Multicenter Evaluation of Over 11,000 Endotracheal Intubation Attempts

Factors that determine first intubation attempt success in high-risk neonates.

Approximately 50% of all neonatal endotracheal intubation attempts are unsuccessful and associated with airway injury and cardiorespiratory instability. The aim of this study was to describe intubation practice at a high-risk Neonatal Intensive Care Unit (NICU) and identify factors associated with successful intubation at the first attempt. Retrospective cohort study of all infants requiring intubation within the Royal Children's Hospital NICU over three years. Data was collected from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Outcomes were number of attempts, level of operator training, equipment used, difficult airway grade, and clinical factors. Univariate and multivariate analysis were performed to determine factors independently associated with first attempt success. Three hundred and sixty intubation courses, with 538 attempts, were identified. Two hundred and twenty-five (62.5%) were successful on first attempt, with similar rates at subsequent attempts. On multivariate analysis, increasing operator seniority increased the chance of first attempt success. Higher glottic airway grades were associated with lower chance of first attempt success, but neither a known difficult airway nor use of a stylet were associated with first attempt success. In a NICU with a high rate of difficult airways, operator experience rather than equipment was the greatest determinant of intubation success. Neonatal intubation is a high-risk lifesaving procedure, and this is the first report of intubation practices at a quaternary surgical NICU that provides regional referral services for complex medical and surgical admissions. Our results showed that increasing operator seniority and lower glottic airway grades were associated with increased first attempt intubation success rates, while factors such as gestational age, weight, stylet use, and known history of difficult airway were not. Operator factors rather than equipment factors were the greatest determinants of first attempt success, highlighting the importance of team selection for neonatal intubations in a high-risk cohort of infants.

Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit

BackgroundPrehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival. MethodsA retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance. ResultsIn total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6–12] vs 6 minutes [interquartile range 5–9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3–17] vs 14 minutes [interquartile range 8–45], P = .008) and longer total transport time (23 minutes [interquartile range 19–31] vs 19 minutes [interquartile range 16–24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching. ConclusionPrehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.

A pilot, prospective trial of IntuBrite® versus Macintosh direct laryngoscopy for paramedic endotracheal intubation in out of hospital cardiac arrest

BackgroundIntubation in the case of out-of-hospital cardiac arrest (OHCA) is one of the most difficult procedures for Emergency Medical Services (EMS). The use of a laryngoscope with a dual light source is an interesting alternative to classic laryngoscopes. However, there are as yet no prospective data concerning the use of double light direct laryngoscopy (DL) by paramedics in traditional ground ambulance agencies in OHCA.MethodsWe performed a non-blinded trial in a single EMS in Poland within ambulances crews, comparing time and first pass success (FPS) for endotracheal intubation (ETI) in DL using the IntuBrite® (INT) and Macintosh laryngoscope (MCL) during cardiopulmonary resuscitation (CPR). We collected both patient and provider demographic information along with intubation details. The time and success rates were compared using an intention-to-treat analysis.ResultsOver a period of 40 months, a total of 86 intubations were performed using 42 INT and 44 MCL based on an intention-to-treat analysis. The FPS time of the ETI attempt (13.49 vs. 15.55 s) using an INT which was shorter than MCL was used (p < 0.05). First attempt success (34/42, 80.9% vs. 29/44, 64.4%) was comparable for INT and MCL with no statistical significance.ConclusionsWe found a statistically significant difference in intubation attempt time when the INT laryngoscope was used. Intubation first attempt success rates with INT and MCL were comparable with no statistical significance during CPR performed by paramedics.Trial RegistrationTrial was registered in Clinical Trials: NCT05607836 (10/28/2022)

Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial

To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI). A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests. Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P=.71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P=.035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P=.048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P=.02). There were more mucosal trauma events in the simulation-based JITT group (P=.02). Residents in both groups reported similar confidence level in performing ETI. Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents. ClinicalTrials.gov: NCT02809924.

Incidence of Postoperative Sore Throat and Associated Factors Among Pediatric Patients Undergoing Surgery Under General Anesthesia at Hawassa University Comprehensive Specialized Hospital, a Prospective Cohort Study.

Postoperative sore throat is one of the common postoperative complications following general anesthesia. Postoperative sore throat causes decreased patient satisfaction, and it affects patients' well-being after surgery, thus identifying its incidence and predictors helps to distinguish the preventable causes of postoperative sore throat. This study aimed to assess the incidence and associated factors of postoperative sore throat among pediatric patients undergoing surgery under general anesthesia at Hawassa university comprehensive specialized hospital. A prospective cohort study was conducted among children in the age range 6-16 years old who underwent emergency and elective surgical procedures under general anesthesia. Data were entered and analyzed using SPSS version 26 software packages. Univariate and multivariate analyses were performed to investigate the independent predictors. The presence and severity of postoperative sore throat were assessed by using a four-point categorical pain scale at the 2nd, 6th, 12th, and 24th-hour postoperative time. A total of 102 children were recruited in this study, from which 27 children (26.5%) complained of sore throat postoperatively. This study found that endotracheal intubation (P value: 0.030; AOR: 3.155; 95% CI [1.114-8.933]) and several attempts greater than one (P value: 0.027 and AOR: 4.890; 95% CI: [1.203-19.883]) had statistically significant association with a postoperative sore throat. The overall incidence of postoperative sore throat was 26.5%. Endotracheal intubation and the number of attempts greater than one were independent factors that were significantly associated with the occurrence of postoperative sore throat in this study.

Effect of intravenous fentanyl on cough reflex and quality of endotracheal intubation in cats

ObjectiveTo assess the effects of intravenous (IV) fentanyl on cough reflex and quality of endotracheal intubation (ETI) in cats. Study designRandomized, blinded, negative controlled clinical trial. AnimalsA total of 30 client-owned cats undergoing general anaesthesia for diagnostic or surgical procedures. MethodsCats were sedated with dexmedetomidine (2 μg kg–1 IV), and 5 minutes later either fentanyl (3 μg kg–1, group F) or saline (group C) was administered IV. After alfaxalone (1.5 mg kg–1 IV) administration and 2% lidocaine application to the larynx, ETI was attempted. If unsuccessful, alfaxalone (1 mg kg–1 IV) was administered and ETI re-attempted. This process was repeated until successful ETI. Sedation scores, total number of ETI attempts, cough reflex, laryngeal response and quality of ETI were scored. Postinduction apnoea was recorded. Heart rate (HR) was continuously recorded and oscillometric arterial blood pressure (ABP) was measured every minute. Changes (Δ) in HR and ABP between pre-intubation and intubation were calculated. Groups were compared using univariate analysis. Statistical significance was set as p < 0.05. ResultsThe median and 95% confidence interval of alfaxalone dose was 1.5 (1.5–1.5) and 2.5 (1.5–2.5) mg kg–1 in groups F and C, respectively (p = 0.001). The cough reflex was 2.10 (1.10–4.41) times more likely to occur in group C. The overall quality of ETI was superior in group F (p = 0.001), with lower laryngeal response to ETI (p < 0.0001) and ETI attempts (p = 0.045). No differences in HR, ABP and postinduction apnoea were found. Conclusions and clinical relevanceIn cats sedated with dexmedetomidine, fentanyl could be considered to reduce the alfaxalone induction dose, cough reflex and laryngeal response to ETI and to improve the overall quality of ETI.

Use of combined laryngo-bronchoscopy intubation approach in a simulated difficult airway scenario with cervical stabilization

The occurrence of unexpected difficult airway management (DAM) during endotracheal intubation (ETI) attempts represents a life-threatening scenario. The management of such challenges may improve with training in simulated DAM scenarios. Moreover, simulation allows investigation at the potential value of new devices and techniques for DAM. The combined use of laryngoscopy with fiberoptic bronchoscope (CLBI) has been proposed in this regard, but its performance by novices facing DAM remain unexplored. We performed a randomized crossover simulation study evaluating the performance of ninety-six anesthesiology residents during ETI with four approaches: direct laryngoscopy (DL), Glidescope®, McGrath® and CLBI. Increased difficulty was produced by placement of a cervical collar. Residents had maximum of 3 attempts per device/technique (up to 60 seconds per attempt). The main outcomes were success rate (SR) and corrected time-to-intubation (cTTI, with 60 seconds added for each failed attempt). Subgroup analyses were performed separating residents according to their experience (junior, n = 60; senior, n = 36).The CLBI had significantly lower SR at both 1st and 3rd attempt (31% and 64%, respectively) as compared to DL (93% and 98%), Glidescope® (70% and 86%) and McGrath® (58% and 84%), with all p &lt; 0.001. Moreover, CLBI had significantly longer cTTI (158.5 seconds; (54.3; 180)) than other devices: Glidescope® (37.6 seconds; (24.7; 88.2)), McGrath® (39.3 seconds; (20.6; 105.1)), and DL (19 seconds; (15.4; 27.2)), all p &lt; 0.002. CLBI and McGrath® were the only approaches performing better in senior as compared to junior residents. In a DAM simulated setting, anesthesiology residents had lower SR and longer cTTI with the CLBI as compared to direct and video-laryngoscopy.

Comparison of AirTraq® laryngoscope with smartphone camera adapter vs Macintosh laryngoscope for endotracheal intubation performed by operators without clinical experience – a randomised, control manikin study

Aim: Difficult or failed tracheal intubation is a well-known cause of morbidity and mortality associated with anesthesia and emergency medicine. The aim of the presented study was to evaluate the laryngoscopes AirTraq, AirTraq with phone camera adapter and Macintosh in simulated conditions when used by people without clinical experience. Material and methods: A total of 32 students of medical direction were qualified for the study. The tested laryngoscopes were evaluated in terms of the effectiveness and time of endotracheal intubation procedure. In each scenario, participants had up to three attempts to intubate with each laryngoscope. The AirTraq was previously unknown to the study participants. In total, 288 endotracheal intubation attempts were evaluated. Results: The overall number of successful intubations with the AirTraq was 96 (100%), for the AirTraq with smartphone adapter 96 (100%) and with the Macintosh classic laryngoscope 88 (91%). The median time of endotracheal intubation was 28,3 seconds for the Macintosh laryngoscope, 16,4 seconds for AirTraq and 17,6 second for the AirTraq with smartphone adapter. Intubation performed with the AirTraq was shorter by 11.9 seconds in comparison with Macintosh laryngoscope and intubation performed with the use of camera-guided AirTraq was shorter by 10,7 seconds in comparison with Macintosh. Conclusions: The study shows that AirTraq and AirTraq with smartphone adapter are the most useful devices, combining high efficiency with a statistically significant reduction in time between successive attempts compared with Macintosh classic laryngoscope.

Choice of the correct size of endotracheal tube in pediatric patients.

Selection and insertion of an endotracheal tube (ETT) of appropriate size for airway management during general anesthesia in pediatric patients is very important. A very small ETT increases the risk of inadequate ventilation, air leakage, and aspiration, whereas a very large ETT may cause serious complications including airway damage, post-intubation croup, and, in severe cases, subglottic stenosis. Although the pediatric larynx is conical, the narrowest part, the rima glottidis, is cylindrical in the anteroposterior dimension, regardless of development, and the cricoid ring is slightly elliptical. A cuffed ETT reduces the number of endotracheal intubation attempts, and if cuff pressure can be maintained within a safe range, the risk of airway damage may not be greater than that of an ETT without cuff. The age-based formula suggested by Cole (age/4 + 4) has long been used to select the appropriate ETT size in children. Because age-based formulas in children are not always accurate, various alternative methods for estimating the ETT size have been examined and suggested. Chest radiography, ultrasound, and a three-dimensional airway model can be used to determine the appropriate ETT size; however, there are several limitations.

Endotracheal Intubation Using C-MAC Video Laryngoscope vs. Direct Laryngoscope While Wearing Personal Protective Equipment.

This study sought to determine whether the C-MAC video laryngoscope (VL) performed better than a direct laryngoscope (DL) when attempting endotracheal intubation (ETI) in the emergency department (ED) while wearing personal protective equipment (PPE). This was a retrospective single-center observational study conducted in an academic ED between February 2020 and March 2022. All emergency medical personnel who participated in any ETI procedure were required to wear PPE. The patients were divided into the C-MAC VL group and the DL group based on the device used during the first ETI attempt. The primary outcome measure was the first-pass success (FPS) rate. A multiple logistic regression was used to determine the factors associated with FPS. Of the 756 eligible patients, 650 were assigned to the C-MAC group and 106 to the DL group. The overall FPS rate was 83.5% (n = 631/756). The C-MAC group had a significantly higher FPS rate than the DL group (85.7% vs. 69.8%, p < 0.001). In the multivariable logistic regression analysis, C-MAC use was significantly associated with an increased FPS rate (adjusted odds ratio, 2.86; 95% confidence interval, 1.69–4.08; p < 0.001). In this study, we found that the FPS rate of ETI was significantly higher when the C-MAC VL was used than when a DL was used by emergency physicians constrained by cumbersome PPE.

Intubation in Swine: What Recumbency to Choose?

Simple SummaryWhether a pig should be placed on its back or sternum to facilitate endotracheal intubation is currently not known and a subject of debate. Enrolling participants with different clinical anaesthesia backgrounds, we aimed at assessing which recumbency (dorsal versus sternal) is advantageous, and if operator experience can influence the results. Using objective and subjective outcomes, we found that sternal recumbency is advantageous if compared to dorsal, but that this is true only for operators lacking experience in anaesthetising animals. Experts’ confidence in intubating various animal species with different techniques probably minimized the influence of recumbency.Endotracheal intubation (ETI) is challenging in pigs. We compared the number of attempts and time to perform ETI, and the subjective perception of ease, while the animal was positioned in dorsal (DR) or sternal (SR) recumbency, as well as assessed whether operator experience influences the outcome. Participants were divided into three groups: undergraduates (ST; veterinary students), graduates (GR; veterinarians without specific anaesthesia training) and experts (EX; veterinary anaesthesia intern/resident and diplomate of the European College of Veterinary Anaesthesia and Analgesia). Each participant intubated one freshly euthanised pig in DR and ST. Number of attempts and time to correctly perform ETI, number of oesophageal intubations and answers to Likert-scale questions on larynx visualization and ease of endotracheal tube introduction and advancement were recorded. Thirty-three participants were enrolled (15 ST, 10 GR and 8 EX). Less attempts (p = 0.002) and time (p = 0.002) to correctly perform ETI were needed in SR for the ST group. In 21/119 and 5/48 ETI attempts, oesophageal intubation was performed in DR and SR, respectively. Larynx visualization (p < 0.001) and endotracheal tube introduction (p < 0.001) were perceived as easier in SR for the ST group. No difference between recumbencies was found in perceived ease to advance the endotracheal tube. For inexperienced operators, intubation in SR can be recommended.