Failed Intubation Research Articles

Epidemiology, presentation, management and outcomes of patients with acute epiglottitis - A 10-year retrospective study based on a tertiary hospital in northern China.

This study aimed to explore the new clinical characteristics and trends of acute epiglottitis (AE) in northern China. A retrospective, observational study was conducted on patients diagnosed with AE between January 2014 and December 2023 at a single-center medical institution in northern China. The clinical profiles of patients with AE were investigated. This study encompassed 366 AE patients (M: F = 1.79:1). The average age of the patients was 47.31 ± 13.18 years, and 33.4% patients had comorbidities. Common initial symptoms: sore throat (93.17%), dysphagia (48.09%), fever (10.65%). Dyspnea reported in 14.48%. AE incidence rose annually over a decade, with mild seasonal variations.Laryngoscopy remains the primary means of confirming AE. Almost all patients received intravenous antibiotic therapy, and 98% of them were also treated with corticosteroids. Emergency airway intervention needed in 2.73% (cricothyroidotomy: 0.54%; tracheotomy: 2.19%). Among all patients, 353 (96.44%) had a good prognosis, 1 death (0.27%) from cardiopulmonary arrest during tracheotomy, 1 anoxic encephalopathy (0.27%) after tracheotomy in the emergency room due to intubation failure. The incidence rate of AE is on the rise. Even if airway intervention is rarely required, clinicians must maintain a high degree of vigilance and conduct early identification of risk factors and emergencies that could progress severe cases into life-threatening. Furthermore, the development of safe and efficacious management strategies is crucial to prevent catastrophic complications and safeguard patient lives.

Predictors of nasolacrimal duct intubation failure for primary acquired nasolacrimal duct obstruction: a computed tomography-dacryocystography (CT-DCG) study.

Making a choice between nasolacrimal duct intubation and dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO) is an important issue in clinical practice. This study aimed to determine the potential lacrimal sac characteristics that could be used as predictors of unsuccessful intubation for PANDO based on computed tomography-dacryocystography (CT-DCG). In this retrospective comparative observational study, we included PANDO patients with a history of failed intubation for nasolacrimal duct obstruction as the intubation failure group and PANDO patients without a history of intubation as the control group. We analyzed the lacrimal sac height, lacrimal sac width, and obstruction site based on CT-DCG, all measured based on several reference levels on axial sections (upper, intermediate, lower level, common canaliculus level, and lowermost contrast level), which were defined according to the contrast and the bony structure. A total of 114 sides of the PANDO were studied, including 36 in the intubation failure group and 78 in the control group. The intubation failure group showed a smaller lacrimal sac height (11.69±4.59 mm) and width (2.28±1.97 mm, intermediate level) than the control group (14.13±2.92, 3.32±2.02 mm, P=0.005 and 0.012, respectively). The intubation failure group had a higher obstruction site than the control group (P=0.009). A small lacrimal sac and high obstruction site are predictors of nasolacrimal duct intubation failure in PANDO. For PANDO patients with a small lacrimal sac or a high obstruction position, DCR is recommended as opposed to intubation.

Difficult intubation in critical patient: how can we manage it? a case report

Difficult airway management represents a challenge. Guidelines recommend choosing the airway technique based on physicians’ skills, equipment, available devices and context. A man with acute respiratory failure needed an emergent intubation. He was obese with Mallampati score 4, Cormack-Lehane grading 4, macroglossia, reduced mouth opening, stocky and wide neck, and deviated laryngo-tracheal axis due to expanding neck hematoma. After endotracheal intubation failure, the anesthetist placed a second-generation laryngeal mask airway and started ventilation. In the next step, definite airway was provided by an endotracheal tube placed through the mask under flexible fiberscope vision. Supraglottic airway devices are recommended in cases of unanticipated difficult intubation after endotracheal intubation failure. They are used to ensure satisfactory oxygenation and occasionally to guide the endotracheal tube. Fiberscope is useful to ensure vision of larynx and trachea in these scenarios. This is a unique case of emergency and difficult airway management using this combined approach.

Preoperative bedside test indicators as predictors of difficult video laryngoscopy in obese patients: a prospective observational study.

The aim of this study was to identify factors associated with difficult video laryngoscopy in obese patients. A total of 579 obese patients undergoing elective laparoscopic weight loss surgery were intubated with a single-lumen endotracheal tube using a video laryngoscopy under general anesthesia, and the patients were divided into two groups based on the Cormack-Lehane classification (difficult video laryngoscopy defined as ≥ 3): the easy video laryngoscopy group and the difficult video laryngoscopy group. Record the general condition of the patient, bedside testing indicators related to the airway, Cormack-Lehane classification during intubation, and intubation failure rate. The findings of this study show that the incidence of difficult video laryngoscopy in obese patients is 4.8%. Multivariate logistic regression analysis indicated that body mass index was significantly associated with difficult video laryngoscopy (OR = 1.082, 95% CI [1.033-1.132], P<0.001). For Chinese obese patients without known difficult airways, the incidence of difficult video laryngoscopy is 4.8%. Body mass index is associated factors for the occurrence of difficult video laryngoscopy, with an increased risk observed as body mass index rise.

The i-view® Video Laryngoscope Compared With the Macintosh Laryngoscope Does Not Enhance the Endotracheal Intubation Skills of Dental Students.

Background A disposable i-view® video laryngoscope (Intersurgical Limited, Berkshire, United Kingdom) is yet to be used to educate medical and dental students, who must learn endotracheal intubation skills. Additionally, the advantage of the i-view® use for the purpose, compared with the Macintosh laryngoscope, is unknown. We aimed to first determine whether the i-view® video laryngoscope enhances endotracheal intubation skills among dental students compared with the Macintosh laryngoscope. Methodology A prospective, observational, simulation study was conducted among 67 dental students in their sixth clinical year of education. Intubation skills were evaluated on a computer-assisted simulator with a standardized manikin. Each student was asked to intubate using the conventional Macintosh laryngoscope and the i-view® video laryngoscope in the trachea of the simulator's manikin. We collected objective data, including the retroflection angle of the manikin, the maxillary incisor contact pressure, time from picking up the laryngoscope to ventilation, intubation success, and intubation delay. Each student was further asked to grade their subjective evaluation concerning the visual field, Cormack and Lehane classification, operability, stability, needed force for intubation, and easiness during intubation. Results Enrolled dental students quoted that the i-view® video laryngoscope demonstrated better visual field, Cormackand Lehane classification, operability, and stability than the Macintosh laryngoscope. However, they felt intubation easiness could have been better using Macintosh than i-view®. Intubation time, failure rate, and delay rate did not differ between the two laryngoscopes. Nevertheless, the maxillary incisor contact pressure (medianinterquartile range (IQR)) during the intubation increased in the i-view® intubation compared with Macintosh (32 (24 to 41) vs. 25 (18 to 35) N, p = 0.010). Conclusions We first demonstrated that the i-view® video laryngoscope compared with the Macintosh laryngoscope does not enhance the endotracheal intubation skills of dental students. However, the possible repeated use as an educational simulator training tool may add some advantages to the experience of video laryngoscope in both medical and dental students.

A Comparative Study Between Video Laryngoscope and Video Stylet for Tracheal Intubation in Patients With Simulated Cervical Fracture Injury: A Prospective Randomised Controlled Study.

Purpose Video laryngoscopes were being used more often in cases of potentially difficult airways. The Karl Storz video stylet offered clear advantages over conventional laryngoscopes for patients with cervical spine fractures. This study aimed to compare the performance of the C-MAC video laryngoscope with the new Karl Storz video stylet in patients with simulated cervical fracture injuries. Material and methods The study, approved by the Board of Studies and the Ethical Committee of Jawaharlal Nehru Medical College and Hospital in Aligarh, involved 50 patients undergoing operative procedures under general anaesthesia. It was a prospective randomised controlled study on patients aged 20-60, weighing 30-80 kg, and classified as American Society of Anesthesiologists (ASA) Grades I and II, admitted for elective operative procedures. Patients were randomly assigned to two groups for intubation using different devices: the control group (N = 25) was intubated with the C-MAC (Mac blade) video laryngoscope (CM), and the study group (N = 25) was intubated with the Karl Storz video stylet (VS). The anaesthetic procedure involved a detailed pre-anesthetic check-up for all patients, including a medical history review, physical examination, and necessary tests based on age. Standard monitoring and pre-medication were administered uniformly. Anesthesia was induced and intubation was attempted using appropriate devices, following manual stabilisation of the neck. Parameters such as intubation attempts, time taken, failures, hemodynamic changes, and complications were recorded throughout the procedure. If intubation was unsuccessful, alternative measures were taken, and the operative procedure proceeded. Results The intubation success rates were compared between the two groups, CM and VS. In the CM group, all 25 patients (100%) were successfully intubated on the first attempt, while in the VS group, 23 patients (92%) were successfully intubated on the first attempt, and two patients (8%) required two attempts. The difference in the distribution of the number of attempts between the two groups was not statistically significant (p = 0.4915). The mean intubation time in the CM group was 27.24 ± 2.16 seconds, while in the VS group, the mean intubation time was significantly longer at 30.84 ± 6.81 seconds, with a statistically significant difference (p = 0.0105). Adjustment manoeuvres were required in only 4% of patients in the CM group compared to 0% in the VS group, although this difference was not statistically significant. The occurrence of blood on the device during intubation was recorded, and the distribution of patients with blood on the device among the two groups did not show a statistically significant difference (p = 0.617). Conclusion This study compared the effectiveness of two intubation devices. The C-MAC video laryngoscope showed a significantly higher rate of first-attempt successful intubations and required fewer attempts compared to the Karl Storz video stylet. The C-MAC also had shorter intubation times compared to the Karl Storz device. However, the Karl Storz video stylet demonstrated comparable performance to the C-MAC video laryngoscope in clinical settings, with both devices having similar safety profiles and minimal complications.

Development of the obstetric unanticipated difficult video-laryngoscopy algorithm through a quality improvement randomized open-label in situ simulation study

BackgroundVideo-laryngoscopy is increasingly used during general anesthesia for emergency cesarean deliveries. Given the heightened risk of difficult tracheal intubation in obstetrics, addressing challenges in airway management is crucial. In this simulation study, we hypothesized that using a flexible bronchoscope would lead to securing the airway faster than the Eschmann introducer when either device is used in addition to video-laryngoscopy. MethodsTwenty-eight anesthesia trainees (n=14/group) were randomized to use either one of the rescue devices and video-recorded in a simulated scenario of emergency cesarean delivery. The primary outcome was the time difference in establishing intubation; secondary outcomes were the differences in incidence of hypoxemia, need for bag and mask ventilation, and failed intubation between the two rescue devices. ResultsMean (±SD) time to intubation using flexible bronchoscopy was shorter compared to using an Eschmann introducer (24 ± 10 vs 86 ± 35 s; P<0.0001; difference in mean 62 seconds, 95% CI 42 to 82 seconds). In the fiberoptic bronchoscopy group, there were no episodes of hypoxemia or need for bag and mask ventilation; in contrast both such events occurred frequently in the Eschmann introducer group (71%, 10/14); P=0.0002). All flexible bronchoscopy-aided intubations were established on the first attempt. The incidence of failed intubation was similar in both groups. ConclusionsOur data from simulated emergency tracheal intubation suggest that flexible bronchoscopy combined with video-laryngoscopy results in faster intubation time than using an Eschmann introducer combined with video-laryngoscopy.

Probing and nasolacrimal intubation outcomes in children over 18 Months of age with congenital nasolacrimal duct obstruction

PurposeTo evaluate how risk factors impact success rates of initial probing and nasolacrimal duct (NLD) tube intubation in children over 18 months of age with congenital nasolacrimal duct obstruction (CNLDO). MethodsThis cohort study included 98 CNLDO patients aged 18 months to 10 years who underwent NLD probing with stent insertion. We employed the multivariate frailty model as our final model to conceptually elaborate on our correlated eye data, with the primary outcome measure evaluating the success rates of probing and tube intubation. Factors such as age, probing complexity, tube type, prior surgeries, and passive smoking were considered in the evaluation. ResultsThe study involved 98 patients (54 males, 44 females) with a mean age of 41.46 months and an average follow-up of 98.37 days (95 % CI 87.65–109.1). Out of the 110 eyes that underwent surgery, 13 (11.8 %) experienced failure while 97 (88.2 %) were censored. Kaplan-Meier analysis indicated significant differences in age category and probing (P-value = 0.03 and 0.006 respectively), but not tube type (P-value = 0.8). Multivariable analysis confirmed that older age and complex probing were associated with higher failure rates in CNLDO cases, with each monthly increase correlating to a two percent higher likelihood of intubation failure. ConclusionsPatient age and probing complexity influence CNLDO treatment, impacting surgical techniques and outcomes. Tube type, prior surgery, and passive smoking have no significant impact on treatment success.

Comparison of propofol versus dexmedetomidine sedation for awake C-MAC® D-Blade video laryngoscopic nasotracheal intubation in patients with difficult airway: A randomised clinical study.

Awake intubation is the preferred method for securing difficult airways. We compared intravenous (IV) propofol and dexmedetomidine for C-MAC® D-blade-guided anticipated difficult nasotracheal intubation under conscious sedation. This randomised study included 60 patients with difficult airway (El-Ganzouri Score 4-9). After adequate airway preparation with IV midazolam 0.03 mg/kg and IV fentanyl 1 µg/kg, in Group P, propofol was infused at 250 µg/kg/min and in Group D, dexmedetomidine was infused at 1 μg/kg over 10 min, then at 0.5 μg/kg/h till a bispectral index (BIS) value 65-70 was achieved. Patients underwent C-MAC® D-blade video laryngoscope-guided nasotracheal intubation. The intubation score was the primary outcome measure. Secondary outcome measures included haemodynamic parameters, intubation time, number of attempts, the incidence of failed awake intubation, glottic view, time to achieve desired BIS, complications, study drug consumption and patient-reported satisfaction with the awake intubation technique. Quantitative variables were compared between groups using unpaired t-test/Welsch test/Mann-Whitney Test. Qualitative variables were correlated using the Chi-square test/Fisher's exact test. A P value of <0.05 was considered statistically significant. The intubation score was significantly higher in Group D versus Group P (P = 0.007). Patient reaction to intubation, haemodynamic parameters and percentage of glottis opening score were more favourable in Group P. Coughing and vocal cord movement were comparable between the groups (P > 0.05). The time to target BIS was four times longer, and the time to intubate was 6 seconds longer in Group D. Successful awake C-MAC® D-blade video laryngoscopic intubation can be performed under dexmedetomidine/propofol conscious sedation, with propofol giving a better intubation score.

Difficult airway management in patients with laryngeal tumor: Case series and systematic review

Airway management in patients with laryngeal tumor presents significant challenges and risks. SEEKflex (Safe Easy Endotracheal Kit-flexible) is a modified introducer developed by our team for the intubation in severe COVID-19 patients. Here, we present 4 cases where SEEKflex facilitated tracheal intubation in patients with laryngeal tumors underwent surgeries and achieved a definitive airway. A systematic review of MEDLINE, EMBASE, CINAHL, and Web of Science databases was also performed using the keywords such as “laryngeal tumor”, “airway management” and “anesthesia” to identify the reports on airway management techniques for patients with laryngeal tumors. 14 papers involving 17 patients were retrieved. All the cases reported positive patient outcomes, though there were instances of intubation failure after general anesthesia. Despite increased availability of basic airway management techniques and various types of intubation tools, challenges persist, especially in patients with pre-existing severe airway obstruction. SEEKflex provides a simple and rapid solution for intubating patients with laryngeal tumors, which ensures a clear airway for patient safety.

Long-Term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study

IntroductionEmergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. MethodsData on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. ResultsOf the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. ConclusionsThis retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

Macintosh-style videolaryngoscope use for tracheal intubation in elective surgical patients revisited: a sub-analysis of the 2022 Cochrane review data

The Cochrane systematic review and meta-analysis published in 2022 that compared videolaryngoscopy (VL) with direct laryngoscopy (DL) for facilitating tracheal intubation in adults found that all three types of VL device (Macintosh-style, hyper-angulated and channeled) reduced the risk of failed intubation and increased the likelihood of first-pass success. We report the findings of a subgroup re-analysis of the 2022 Cochrane meta-analysis data focusing on the Macintosh-style VL group. This was undertaken to establish whether sufficient evidence exists to guide airway managers in making purchasing decisions for their local institutions based upon individual device-specific performance. This re-analysis confirmed the superiority of Macintosh-style VL over Macintosh DL in elective surgical patients, with similar efficacy demonstrated between the Macintosh-style VL devices examined. Thus, when selecting which VL device(s) to purchase for their hospital, airway managers decisions are likely to remain focused upon issues such as financial costs, portability, cleaning schedules and previous device experience.

Nasopharyngeal airway assistance improves esophageal intubation rates of high-resolution esophageal manometry catheters.

High-resolution esophageal manometry (HREM) is the gold standard test for esophageal motility disorders. Nasopharyngeal airway-assisted insertion of the HREM catheter is a suggested salvage technique for failure from the inability to pass the catheter through the upper esophageal sphincter (UES). It has not been demonstrated that the nasopharyngeal airway improves procedural success rate. Patients undergoing HREM between March 2019 and March 2023 were evaluated. Chart review was conducted for patient factors and procedural success rates before and after use of nasopharyngeal airway. Patients from March 2019 to May 2021 did not have nasopharyngeal airway available and were compared to patients from May 2021 to March 2023 who had the nasopharyngeal airway available. In total, 523 HREM studies were conducted; 234 occurred prior to nasopharyngeal airway availability, and 289 occurred with nasopharyngeal airway availability. There was no difference in HREM catheter UES intubation rates between periods when a nasopharyngeal airway attempt was considered procedural failure (85% vs. 85%, p = 0.9). Nasopharyngeal airway use after UES intubation failure lead to improved UES intubation rates (94% vs. 85%, p < 0.01). Thirty-six patients that failed HREM catheter UES intubation had the procedure reattempted with a nasopharyngeal airway, 30 (83%) of which were successful. The nasopharyngeal airway assisted catheter UES intubation for failures attributed to nasal pain and hypersensitivity, gagging, coughing, and pharyngeal coiling. Utilization of the nasopharyngeal airway increased rates of UES intubation. When HREM catheter placement through the UES fails, placement of a nasopharyngeal airway can be trialed to overcome patient procedural intolerance.

Efficacy and safety of video double-lumen tube intubation in lateral position in patients undergoing thoracic surgery: a randomized controlled trial

BackgroundVideo double-lumen tube (VDLT) intubation in lateral position is a potential alternative to intubation in supine position in patients undergoing thoracic surgery. This non-inferiority trial assessed the efficacy and safety of VDLT intubation in lateral position.MethodsPatients (18–70 yr) undergoing right thoracoscopic lung surgery were randomized to either the left lateral position group (group L) or the supine position group (group S). The VDLT was placed under video larygoscopy. The primary endpoint was the intubation time. Secondary endpoints included VDLT displacement rate, intubation failure rate, the satisfaction of surgeon and nurse, and intubation-related adverse events.ResultsThe analysis covered 80 patients. The total intubation time was 52.0 [20.4]s in group L and 34.3 [13.2]s in group S, with a mean difference of 17.6 s [95% confidence interval (CI): 9.9 s to 25.3 s; P = 0.050], failing to demonstrate non-inferiority with a non-inferiority margin of 10 s. Group L, compared with group S, had significantly lower VDLT displacement rate (P = 0.017) and higher nurse satisfaction (P = 0.026). No intubation failure occurred in any group. Intubation complications (P = 0.802) and surgeon satisfaction (P = 0.415) were comparable between two groups.ConclusionsThe lateral VDLT intubation took longer time than in the supine position, and non-inferiority was not achieved. The incidence of displacement as the secondary endpoint was lower in the L group, possibly due to changing body positions beforehand. The indication of lateral VDLT intubation should be based on a balance between the safety of airway management and the lower incidence of displacement.Trial registrationThe study was registered at Chictr.org.cn with the number ChiCTR2200064831 on 19/10/2022.

Awake video laryngoscopy as a rescue airway maneuver after a failed awake flexible bronchoscope-guided intubation: A case report.

Awake video laryngoscopy as a rescue airway maneuver after a failed awake flexible bronchoscope-guided intubation: A case report.

Comparison of three supraglottic airway devices for blind tracheal intubation by novice practitioners: A randomized manikin study.

Supraglottic airway (SGA) devices are good alternatives for failed intubations or difficult airways. The aim of our study was to compare the success of intubation with SGA devices such as LMA Fastrach® (LMA Fastrach), Ambu Aura-i® (Aura-i), and Cookgas Air-Q® (Air-Q) in an airway manikin by novice practitioners. This study was conducted in a randomized crossover design using a manikin model. Following training on the equipment used, 36 6th-year medical students were randomized into six groups. Participants performed three stages of intubation as follows: the first stage (1S) as SGA insertion, the second stage (2S) as intubation through the SGA, and the third stage (3S) as the removal of the SGA over the intubation tube. The primary outcomes were intubation success and duration. The successful intubation rate (Stage 1S + 2S + 3S) was 100% for LMA Fastrach and Air-Q and 83.3% for Aura-i (P = 0.002). The median time to intubation was 54.4 s, 55.8 s, and 58.7 s for LMA Fastrach, Aura-i, and Air-Q, respectively (P = 0.794). Our study shows that novice practitioners can proficiently utilize LMA Fastrach, Air-Q, and Aura-i as SGAs in airway management. LMA Fastrach and Air-Q are more successful for endotracheal intubation than Aura-i. While the successful intubation time with SGA is similar for all three devices, the successful SGA insertion time is shorter with LMA Fastrach and Aura-i compared to Air-Q. Practitioners preferred LMA Fastrach and Air-Q more than Aura-i.

Comparison of the effects of paratracheal pressure and cricoid pressure on placement of the i-gel® supraglottic airway: a randomized clinical trial

PurposeAnesthesiologists can use supraglottic airway devices as a rescue technique for failed intubation even in patients with an increased risk of gastric regurgitation. In this randomized study, we aimed to evaluate the effects of cricoid pressure and paratracheal pressure on placement of the i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK).MethodsAfter induction of anesthesia in 76 adult patients, we inserted the i-gel under paratracheal or cricoid pressure, and assessed the success rate of i-gel insertion, resistance during insertion, time required for insertion, accuracy of the insertion location, tidal volumes, and peak inspiratory pressure with or without each maneuver after i-gel insertion.ResultsThe overall success rate of insertion was significantly higher under paratracheal pressure than under cricoid pressure (36/38 [95%] vs 27/38 [71%], respectively; difference, 24%; 95% confidence interval [CI], 8 to 40; P = 0.006]. Resistance during insertion was significantly lower under paratracheal pressure than under cricoid pressure (P < 0.001). The time required for insertion was significantly shorter under paratracheal pressure than under cricoid pressure (median [interquartile range], 18 [15–23] sec vs 28 [22–38] sec, respectively; difference in medians, −10; 95% CI, −18 to −4; P < 0.001). Fibreoptic examination of the anatomical alignment of the i-gel in the larynx revealed no significant difference in the accuracy of the insertion location between the two maneuvers (P = 0.31). The differences in tidal volume and peak inspiratory pressure with or without the maneuvers were significantly lower with paratracheal pressure than with cricoid pressure (P = 0.003, respectively).ConclusionsInsertion of the i-gel supraglottic airway was significantly more successful, easier, and faster while applying paratracheal pressure than cricoid pressure.Study registrationClinicalTrials.gov (NCT05377346); first submitted 11 May 2022.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room

Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. ClinicalTrials.gov Identifier: NCT04701762.

Difficult mask ventilation: An objective criterion

Effective mask ventilation plays a critical role in safe management of airway before intubation or after failed intubation. Mask ventilation (MV) is the primary technique of ventilation before tracheal intubation or insertion of any airway device. Its most unique role however, is as a rescue technique for ventilation should tracheal intubation fail or prove difficult. The ability to establish adequate MV has, therefore, become a major branch point in any difficult airway algorithm. Despite it being an important skill, MV has received little attention in the extensive body of literature and book chapters addressing airway management when compared to laryngoscopy and intubation. At present, there is no standard definition for Difficult Mask Ventilation (DMV) that is based on precise and objective criterion. The authors propose a simple objective criterion to categorize difficult mask ventilation based on the best monitoring parameters.

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage. This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required. The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.