Facemask Ventilation Research Articles

Endotracheal intubation rate is lower with additional face-mask noninvasive ventilation for critically-ill SARS-CoV-2 patients requiring high-flow nasal oxygen: a retrospective bicentric cohort with propensity score analysis.

SARS-CoV-2 pneumonia is responsible for unprecedented numbers of acute respiratory failure requiring invasive mechanical ventilation (IMV). This work aimed to assess whether adding face-mask noninvasive ventilation (NIV) to high-flow nasal oxygen (HFNO) was associated with a reduced need for endotracheal intubation. This retrospective cohort study was conducted from July 2020 to January 2021 in two tertiary care intensive care units (ICUs) in Paris, France. Patients admitted for laboratory confirmed SARS-CoV-2 infection with acute hypoxemic respiratory failure requiring HFNO with or without NIV were included. The primary outcome was the rate of endotracheal intubation. Secondary outcomes included day-28 mortality, day-28 respiratory support and IMV free days, ICU and hospital length-of-stay. Sensitivity analyses with both propensity score matching and overlap weighting were used. One hundred twenty-eight patients were included, 88 (69%) received HFNO alone and 40 (31%) received additional NIV. Additional NIV was associated with a reduced rate of endotracheal intubation in multivariate analysis (53 [60%] vs. 15 [38%], HR=0.46 [95% CI: 0.23-0.95], P=0.04). Sensitivity analyses by propensity score matching (HR=0.45 [95% CI: 0.24-0.84], P=0.01) and overlap weighting (HR=0.52 [95% CI: 0.28-0.94], P=0.03) were consistent. Day-28 mortality was 25 (28%) in the HFNO group and 8 (20%) in the NIV group (HR=0.75 [95% CI: 0.15-3.82], P=0.72). NIV was associated with higher IMV free days (20 [0-28] vs. 28 [14-28], P=0.015). All sensitivity analyses were consistent regarding secondary outcomes. Need for endotracheal intubation was lower in critically-ill SARS-CoV-2 patients receiving face-mask noninvasive mechanical ventilation in addition to high-flow oxygen therapy.

Effect of Head Rotation on Efficiency of Face Mask Ventilation among Apnoeic Patients: A Cross-sectional Study

Introduction: Respiratory function is crucial in the practice of anaesthesia. An in depth understanding of respiratory physiology is a must because it aids in the proper execution of daily general anaesthesia practice. Head and body postures have long been known to affect the patency of the upper airway. Head extension and a lateral recumbent position help to clear the upper airway. Head rotation is known to expand the upper airway’s cross-sectional area. Aim: To determine the effect of head rotation on efficiency of face mask ventilation among apnoeic patients, by measuring expiratory tidal volume. Materials and Methods: This cross-sectional study was conducted in the Department of Anaesthesiology at Jawaharlal Nehru Medical College, Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India, from May 2021 to November 2021. Total 40 patients belonging to the age group of 20 to 40 years, American Society of Anaesthesiologists’ (ASA) class I and II, undergoing surgeries requiring general anaesthesia with endotracheal intubation, were selected as study subjects. They were administered inj. fentanyl at a dose of 1 to 2 μg/kg, inj.propofol at a dose of 1 to 2 mg/kg, and inj.vecuronium bromide (0.08 to 0.1 mg/kg). Patients were mask ventilated with pressurecontrolled ventilation, for a total of 3 minutes, during which they were ventilated in a neutral head position for 90 seconds and then rotated for another 90 seconds. Following induction, the expiratory tidal volume was measured every 30 seconds in both postures Software used was Statistical Package for Social Sciences for windows (SPSS Inc., Chicago, IL, USA), version 17.0. A p-value <0.05 was considered statistically significant. Results: The mean age of patients was 48±8.3 years. The 45° head rotation was beneficial to all patients, the mean expiratory tidal volume was 423±62.5 mL in the rotated head position compared to 397±52.5 mL in the neutral head position (p-value=0.045). It was also observed that some individuals profited more than others. Patients with airway obstruction, for example, had a greater VTE at 45° head rotation than in a neutral head position. Conclusion: The most notable conclusion is that in apnoeic adult patients, a 45° head rotation showed a significant enhancement in VTE when compared to a neutral position ofthe head.

Quantitative evaluation of aerosol generation during manual facemask ventilation.

SummaryManual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol‐generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS‐CoV‐1 outbreak in 2003. There is no direct evidence to indicate whether facemask ventilation is a high‐risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation and facemask ventilation with an intentionally generated leak in anaesthetised patients. Recordings were made in ultraclean operating theatres and compared against the aerosol generated by tidal breathing and cough manoeuvres. Respiratory aerosol from tidal breathing in 11 patients was reliably detected above the very low background particle concentrations with median [IQR (range)] particle counts of 191 (77–486 [4–1313]) and 2 (1–5 [0–13]) particles.l‐1, respectively, p = 0.002. The median (IQR [range]) aerosol concentration detected during facemask ventilation without a leak (3 (0–9 [0–43]) particles.l‐1) and with an intentional leak (11 (7–26 [1–62]) particles.l‐1) was 64‐fold (p = 0.001) and 17‐fold (p = 0.002) lower than that of tidal breathing, respectively. Median (IQR [range]) peak particle concentration during facemask ventilation both without a leak (60 (0–60 [0–120]) particles.l‐1) and with a leak (120 (60–180 [60–480]) particles.l‐1) were 20‐fold (p = 0.002) and 10‐fold (0.001) lower than a cough (1260 (800–3242 [100–3682]) particles.l‐1), respectively. This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, we argue facemask ventilation should not be considered an aerosol‐generating procedure.

Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial

BackgroundApproximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting. MethodsA single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation. ResultsSuccess of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96–1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference −11 seconds, 95% confidence interval −39 to 18). ConclusionsIn newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers. Clinical trials registrationclinicalTrial.gov: NCT04056091.

High flow nasal cannula oxygen preventing deoxygenation during induction of general anaesthesia in caesarean section: A randomized controlled trial

BackgroundRecently high flow nasal oxygenation was used to prolong the safe apnoea period during induction of general anaesthesia. This randomized study was designed to compare between using transnasal humidified rapid insufflation ventilator exchange technique (THRIVE) and traditional face mask for preoxygenation in caesarean section. The primary aim was to measure the safe apnoea time. MethodsThe study was performed on 100 ASA II pregnant women scheduled for elective caesarean section under general anaesthesia. Patients were randomly assigned to either face mask ventilation or THRIVE. ResultsThe safe apnoea time was significantly longer under THRIVE with median of 7 min compared to facemask ventilation with 4 min. PaO2 with the facemask was 101 mmHg (74–215, median and range) after 3 min of apnoea vs. 355 mmHg (120–498) with THRIVE (P < 0.01). No statistically significant difference was found for PaCO2 between the two groups. ConclusionHigh humidified nasal flow oxygenation is more effective and practicable than face mask ventilation in improving oxygenation during induction of anaesthesia during caesarean section and might improve patients’ safety by avoiding desaturation.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PurposeSince the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.SourceCanadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.Findings and key recommendationsMost studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider “exit strategy” options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a “cannot ventilate, cannot oxygenate” emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as “airway lead” to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

PurposeSince the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated.SourceCanadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus.Findings and key recommendationsPrior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

The Prevalence of Difficult Airway in Children With Beckwith-Wiedemann Syndrome: A Retrospective Cohort Study.

Beckwith-Wiedemann syndrome (BWS) is the most common congenital overgrowth disorder with an incidence of approximately 1 in 10,000 live births. The condition is characterized by lateralized overgrowth, abdominal wall defects, macroglossia, and predisposition to malignancy. Historically, children with BWS have been presumed to have difficult airways; however, most of the evidence to support this has been anecdotal and derived from case reports. Our study aimed to determine the prevalence of difficult airway in patients with BWS. We hypothesized that most patients with BWS would not have difficult airways. We retrospectively reviewed the electronic medical records of patients enrolled in our institution's BWS registry. Patients with a molecular diagnosis of BWS who were anesthetized between January 2012 and July 2019 were included for analysis. The primary outcome was the presence of difficult airway, defined as difficult facemask ventilation, difficult intubation, or both. We defined difficult intubation as the need for 3 or more tracheal intubation attempts and the need for advanced airway techniques (nondirect laryngoscopy) to perform tracheal intubation or a Cormack and Lehane grade ≥3 during direct laryngoscopy. Secondary objectives were to define predictors of difficult intubation and difficult facemask ventilation, and the prevalence of adverse airway events. Generalized linear mixed-effect models were used to account for multiple anesthesia events per patient. Of 201 BWS patients enrolled in the registry, 60% (n = 122) had one or more documented anesthetics, for a total of 310 anesthetics. A preexisting airway was present in 22 anesthetics. The prevalence of difficult airway was 5.3% (95% confidence interval [CI], 3.0-9.3; 18 of 288) of the cases. The prevalence of difficult intubation was 5.2% (95% CI, 2.9-9.4; 12 of 226). The prevalence of difficult facemask ventilation was 2.9% (95% CI, 1.4-6.2; 12 of 277), and facemask ventilation was not attempted in 42 anesthetics. Age <1 year, macroglossia, lower weight, endocrine comorbidities, plastics/craniofacial surgery, tongue reduction surgery, and obstructive sleep apnea were associated with difficult airways in cases without a preexisting airway. About 83.8% (95% CI, 77.6-88.5) of the cases were intubated with a single attempt. Hypoxemia was the most common adverse event. The prevalence of difficult tracheal intubation and difficult facemask ventilation in children with BWS was 5.2% and 2.9%, respectively. We identified factors associated with difficult airway, which included age <1 year, macroglossia, endocrine abnormalities, plastics/craniofacial surgery, tongue reduction surgery, and obstructive sleep apnea. Clinicians should anticipate difficult airways in patients with these factors.

A randomised trial of laryngeal mask airway in neonatal resuscitation.

Birth asphyxia is the leading cause of neonatal mortality in low-income countries.1 Improving resuscitation and outcomes from neonatal resuscitation at birth are crucial.2 Asphyxiated newborns often require bag-mask ventilation (BMV) as part of their initial resuscitation. When this fails, intubation is necessary. However, intubation is a difficult skill to practice especially for non-doctor staff present at delivery in low-income countries.2 Thus, improving the effectiveness of initial efforts to provide ventilation in asphyxiated newborn may decrease the need for extensive resuscitation and improve neonatal outcomes. Previous studies have shown an LMA is effective in providing positive pressure ventilation (PPV) ventilation at delivery,3 while other benefits of an LMA include ease of placement, minimal trauma, less air leak and improved seal.4 In this study, Pejovic et al. tested whether PPV provided in low-income countries by midwives using an LMA was superior to BMV. This large, RCT demonstrated that using an LMA to provide PPV at birth by midwives in neonates with asphyxia did not decrease mortality and morbidity when compared with facemask ventilation at birth. Although the current study did not show a benefit of using an LMA for initial resuscitative efforts when compared with facemask ventilation, it still may have a role in providing PPV at birth in low-income countries. The current phase three trial was done at a high volume delivery hospital in Uganda. Whether conducting the study in a hospital with low volume where midwives are less familiar with traditional BMV would have a different result is unknown. Furthermore, access to foetal monitoring would have increased the pre-test probability of birth asphyxia and potentially increased the ability of the study to detect a therapeutic effect. Previous studies have shown an LMA can be used in place of intubation for advanced airway management; it would be interesting to know if the transition from initial resuscitation to advanced resuscitation was improved with use of an LMA. Additional studies are needed to determine effectiveness of an LMA ventilation in infants with asphyxia with different study design, including foetal monitoring, patient selection, resuscitative steps and selection of hospital. This study shows an LMA can be used safely by midwives for providing ventilation at birth as measured by these short-term in-hospital experience. Along with these short-term morbidity and mortality data, assessment of long-term outcomes is needed. Furthermore, it would be interesting to know whether additional studies of an LMA vs facemask ventilation at birth would demonstrate a beneficial role for an LMA in neonatal resuscitation. Finally, although an LMA ventilation provided by midwives at birth in neonates with asphyxia while not superior to facemask ventilation with regard to in-hospital morbidity and mortality in low-income countries, it was shown to be safe, which opens the door to future study of an LMA in neonatal resuscitation in low-income countries. https://ebneo.org/laryngeal-mask-airway None.

Effect on Chest Compression Fraction of Continuous Manual Compressions with Asynchronous Ventilations Using an i-gel® versus 30:2 Approach during Simulated Out-of-Hospital Cardiac Arrest: Protocol for a Manikin Multicenter Randomized Controlled Trial.

The optimal airway management strategy during cardiopulmonary resuscitation is uncertain. In the case of out-of-hospital cardiac arrest, a high chest compression fraction is paramount to obtain the return of spontaneous circulation and improve survival and neurological outcomes. To improve this fraction, providing continuous chest compressions should be more effective than using the conventional 30:2 ratio. Airway management should, however, be adapted, since face-mask ventilation can hardly be carried out while continuous compressions are administered. The early insertion of a supraglottic device could therefore improve the chest compression fraction by allowing ventilation while maintaining compressions. This is a protocol for a multicenter, parallel, randomized simulation study. Depending on randomization, each team made up of paramedics and emergency medical technicians will manage the 10-min scenario according either to the standard approach (30 compressions with two face-mask ventilations) or to the experimental approach (continuous manual compressions with early insertion of an i-gel® supraglottic device to deliver asynchronous ventilations). The primary outcome will be the chest compression fraction during the first two minutes of cardiopulmonary resuscitation. Secondary outcomes will be chest compression fraction (per cycle and overall), compressions and ventilations quality, time to first shock and to first ventilation, user satisfaction, and providers’ self-assessed cognitive load.

Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children

BackgroundThe objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). MethodsIn this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients’ age (older or younger than 1 year). ResultsComplete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). ConclusionsResults of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.

A comparison of gastric gas volumes measured by computed tomography after high‐flow nasal oxygen therapy or conventional facemask ventilation*

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm3 in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm3 in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U=1136, p=0.432, n1 =n2 =50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

Ultrasound assessment of gastric insufflation in obese patients receiving transnasal humidified rapid-insufflation ventilatory exchange during general anesthesia induction

To assess the effect of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) on gastric insufflation during general anesthesia induction in obese patients. Ninety obese patients (BMI 30-39.9 kg/m2) undergoing laparoscopic cholecystectomy under general anesthesia were randomized into 3 groups (n=30) to receive facemask pre- oxygenation followed by face mask ventilation (FMV) after administration of anesthetics (Group M), oxygenation with THRIVE (Group T), or pre-oxygenation with facemask combined with THRIVE followed continuous oxygenation with both FMV and THRIVE after administration of anesthetics (Group M+T). The patients in the latter two groups received continuous oxygen via THRIVE during tracheal intubation. All the patients received real-time ultrasound monitoring of the gastric antrum, and positive gastric insufflation (GI+) was defined by the presence of comet-tail artifacts. The cross-sectional area of the gastic antrum (CSA-GA) was measured by ultrasound before and after pre-oxygenation and after intubation. The patients' SpO2, PaO2, and PaCO2 at admission (T1), 5 min after pre-oxygenation (T2), 5 min after medication (T3), and immediately after intubation (T4) were recorded, and the incidence of postoperative adverse events was assessed. The incidence of gastric insufflation was significantly higher in Group M and Group M+T than in Group T (P < 0.05). The CSA-GA was significantly greater at T4 than at T1 in Group M and Group M+T and in their GI+s ubgroups. The GI+ subgroups in Group M and Group M+ T had significantly larger CSA-GA at T4 than the GI- subgroups (P < 0.05). CSA-GA did not vary significantly during anesthesia induction in Group T (P>0.05). The incidence of grade Ⅰ gastric distension was lower but grade Ⅱ gastric distention was higher in Group M and Group M+T than in Group T (P < 0.05). Group M showed significantly greater variations of PaO2 at T3 and T4 than Group T and Group M+T (P < 0.05). Ultrasound monitoring of the comet tail sign and the changes of CSA-GA in the gastric antrum is feasible and reliable for detecting gastrointestinal airflow, and in obese patients, the application of THRIVE for induction of anesthesia can ensure the oxygenation level without further increasing gastric insufflation.

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation

BackgroundFace-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown.MethodsIn this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization.ResultsComplete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P=0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic–ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups.ConclusionsIn neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic–ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra ClinicalTrials.gov number, NCT03133572.)

Aerosolisation during tracheal intubation and extubation in an operating theatre setting.

SummaryAerosol‐generating procedures such as tracheal intubation and extubation pose a potential risk to healthcare workers because of the possibility of airborne transmission of infection. Detailed characterisation of aerosol quantities, particle size and generating activities has been undertaken in a number of simulations but not in actual clinical practice. The aim of this study was to determine whether the processes of facemask ventilation, tracheal intubation and extubation generate aerosols in clinical practice, and to characterise any aerosols produced. In this observational study, patients scheduled to undergo elective endonasal pituitary surgery without symptoms of COVID‐19 were recruited. Airway management including tracheal intubation and extubation was performed in a standard positive pressure operating room with aerosols detected using laser‐based particle image velocimetry to detect larger particles, and spectrometry with continuous air sampling to detect smaller particles. A total of 482,960 data points were assessed for complete procedures in three patients. Facemask ventilation, tracheal tube insertion and cuff inflation generated small particles 30–300 times above background noise that remained suspended in airflows and spread from the patient’s facial region throughout the confines of the operating theatre. Safe clinical practice of these procedures should reflect these particle profiles. This adds to data that inform decisions regarding the appropriate precautions to take in a real‐world setting.

Awake Prone Positioning in COVID-19 Patients

BackgroundThe World Health Organization (WHO) has declared SARS-CoV-2 as pandemic. Patients with COVID-19 present mainly with respiratory symptoms. Prone position has been traditionally used in acute respiratory distress syndrome (ARDS) to improve oxygenation and prevent barotrauma in ventilated patients. Awake proning is being used as an investigational therapy in COVID to defer invasive ventilation, improve oxygenation, and outcomes. Hence, we conducted a retrospective case study to look for benefits of awake proning with oxygen therapy in non-intubated COVID patients.Materials and methodsA retrospective case study of 15 COVID patients admitted from June 15 to July 1, 2020 to HDU in our hospital was conducted. Cooperative patients who were hemodynamically stable and SpO2 < 90% on presentation were included. Oxygen was administered through facemask, non-rebreathing mask and noninvasive ventilation to patients as per requirement. Patients were encouraged to maintain prone position and target time was 10–12 hours/day. SpO2 and P/f ratio in supine and prone position was observed till discharge. Primary target was SpO2 > 95% and P/f > 200 mm Hg. Other COVID therapies were used according to institutional protocol.ResultsThe mean SpO2 on room air on admission was 80%. In day 1 to 3, the mean P/f ratio in supine position was 98.8 ± 29.7 mm Hg which improved to 136.6 ± 38.8 mm Hg after proning (p = 0.005). The difference was significant from day 1 to 10. Two patients were intubated. The mean duration of stay was 11 days.ConclusionAwake prone positioning showed marked improvement in P/f ratio and SpO2 in COVID-19 patients with improvement in clinical symptoms with reduced rate of intubation.HighlightsProne position ventilation improves oxygenation by reducing V/Q mismatch.Awake prone positioning has been used along with high-flow oxygen therapy in recent pandemic of SARS-CoV-2 virus for management of mild to moderate cases.How to cite this articleSingh P, Jain P, Deewan H. Awake Prone Positioning in COVID-19 Patients. Indian J Crit Care Med 2020;24(10):914–918.

A quantitative evaluation of aerosol generation during tracheal intubation and extubation.

SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l−1) allowing resolution of transient increases in airborne particles associated with airway management. As a positive reference control, we quantitated the aerosol produced in the same setting by a volitional cough (average concentration, 732 (418) particles.l−1, n = 38). Tracheal intubation including facemask ventilation produced very low quantities of aerosolised particles (average concentration, 1.4 (1.4) particles.l−1, n = 14, p < 0.0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 (18) l−1, n = 10) which was 15‐fold greater than intubation (p = 0.0004) but 35‐fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol‐generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high‐risk aerosol‐generating procedure. These novel findings from real‐time aerosol detection in a routine healthcare setting provide a quantitative methodology for risk assessment that can be extended to other airway management techniques and clinical settings. They also indicate the need for reappraisal of what constitutes an aerosol‐generating procedure and the associated precautions for routine anaesthetic airway management.

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.

IntroductionBecause of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients.Material and methodsThis single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10–15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation.ResultsCPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54–71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30–40) and median SpO2 was 92% (90–95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1–5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated.ConclusionsCPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.

CASE OF REFRACTORY INTERSTITIAL LUNG DISEASE IN ANTISYNTHETASE SYNDROME

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Along with corticosteroids, patients with anti-synthetase syndrome associated interstitial lung disease (ILD) require a corticosteroid-sparing agent, such as azathioprine, rituximab, or cyclophosphamide. However, there is no study that demonstrates the superiority of one agent, making it difficult to choose one over the other given their high side effect profile. CASE PRESENTATION: A 67 years old female who had symptoms of left shoulder, arms, and eye pain that started 5 months ago, and dyspnea with exertion that started 7 months prior to presenting with worsening dyspnea. Initial work up was significant for elevated CK and aldolase, and positive ANA, anti Jo-1 and anti SS-A. CT was significant for NSIP pattern; and workup for infection was negative. Her initial oxygen requirement was 6 L. She was started on prednisone 60 mg daily, but her dyspnea progressed, getting into respiratory failure that required intubation. She was switched from prednisone to methylprednisolone 1 g/day for 3 days. She also received 2 doses of IV cyclophosphamide 1000 mg, followed by a total of 3 doses of IV Rituximab 700 mg that was initiated 8 days later. She was extubated 6 days later to facemask ventilation. She had frequent episodes of worsening dyspnea that occurred after a corticosteroid tapering attempt, therefore, requiring increased corticosteroids. She was eventually weaned to 2 liters of oxygen and discharged with home oxygen and a tapered dose of prednisone. DISCUSSION: Anti-synthetase syndrome is part of the idiopathic inflammatory myopathies (IIM) in which antibodies develop against aminoacyl tRNA. The diagnostic criteria for antisynthetase syndrome is the presence of tRNA synthetase autoantibody in addition to clinical features, such as ILD and/or myositis. The most commonly identified antibody is anti-Jo-1; other less common antibodies include: anti-PL12 and anti-PL7. ILD Anti-synthetase syndrome is more severe, rapidly progressing and leads to a high mortality when compared to ILD in the other IIMs. Corticosteroid-monotherapy in these patients is known to cause frequent lung disease reoccurrence. Therefore, an additional agent needs to be added in refractory cases. Azathioprine is a commonly used agent in conjunction with prednisone, but not well studied. Multiple other case studies showed improvement in lung function and/or pulmonary symptoms in patients who received Rituximab as the adjunctive medication. The treatment options that can be used in antisynthetase ILD lies at the discretion of the physician. In our case, the use of corticosteroids, Rituximab, and cyclophosphamide appeared to have significant clinical outcome. CONCLUSIONS: To better treat patients with this condition, high clinical suspicion is needed, and patients may benefit from early rituximab therapy. Future studies that compare the effect of corticosteroid-sparing agents would help on deciding the best treatment agents. Reference #1: Witt L., Curran J., Strek M. The Diagnosis and Treatment of Antisynthetase Syndrome. Clin Pulm Med. 2016 Sep; 23(5): 218-226. DISCLOSURES: no disclosure on file for Subramanyam Chittivelu; No relevant relationships by Ronald Espinosa, source=Web Response No relevant relationships by Abdirahman Hussein, source=Admin input

Simulation-based training for early procedural skills acquisition in new anesthesia trainees: a prospective observational study

BackgroundIn a setting in which learning of basic procedural skills commences upon graduation from medical school, and as a first step towards integration of simulation-based learning into the anesthesiology training program, a preparatory course for new anesthesia trainees was designed. Three educational strategies were sequentially combined (e-learning, simulation-based hands on workshops, and on-site observational learning), and performance was assessed in a stepwise approach on five procedural skills considered essential for early anesthetic management (peripheral intravenous cannulation, sterile hand wash and gowning, anesthesia workstation preparation, face-mask ventilation, and orotracheal intubation). The primary aim of this study was to determine if this preparatory training course at the onset of anesthesiology residency is useful to achieve a competent trainee performance in the clinical setting.MethodsThis prospective study was carried out at a university-affiliated hospital in Buenos Aires, Argentina, from 2017 to 2019. The 24 participants, comprising three cohorts of 8 residents each, underwent a preparatory course at the onset of residency. Diverse, consecutive educational strategies, and assessments (three stages: 1, 2, 3) took place using task-specific tools (checklists) and global rating scales for five procedural skills. The primary outcome was achievement of competent scores (85%) in final assessments, and the secondary outcomes were performance improvement between assessment stages and compliance with predefined safety items.ResultsTwenty trainees (83.3%) were found to be globally competent (both assessment tools for all procedures) during final assessments (stage 3). Statistically significant improvement was found for all procedural skills between baseline and after workshop assessment scores (stages 1–2), except for orotracheal intubation in checklists, and for all procedural skills between stages 2 and 3 except for sterile hand wash and gowning in checklists.ConclusionsIn our single-center experience, the gap for competent trainee performance in essential early anesthetic management skills can be effectively covered by conducting an intensive, preparatory course using the combination of three educational strategies (e-learning, simulation-based hands on workshops, and observational learning) at the onset of residency. This course has allowed learning to be generated in a secure environment for both patients and trainees.