Intubation Research Articles

Successful endotracheal intubation for difficult airway using a protruding malleable stylet

Successful endotracheal intubation for difficult airway using a protruding malleable stylet

Tracheostomy Cuff Herniation following Cardiac and Pulmonary Arrest

Tracheostomy is a common procedure performed on patients who require long-term airway maintenance and ventilation support. It is preferred over endotracheal intubation due to its reduced airway resistance, lower risk of displacement compared with the endotracheal tube, increased patient comfort, improved weaning from mechanical ventilation, and enhanced suction capabilities. According to the literature, patients needing airway support for fewer than 12 days can undergo translaryngeal intubation, while tracheostomy is indicated for patients requiring ventilatory support for more than 20 days. Although tracheostomy is frequently performed in ICUs and operating rooms, several complications can arise following the procedure. These complications include leakage, obstruction of the tracheal tube, minor or major bleeding or oozing, barotrauma, infections, tracheoesophageal fistula, stenosis, and injury to surrounding peripheral tissues such as arteries, veins, and nerves.1 While herniation of the endotracheal cuff is a more common cause of airway obstruction and hypoxia, tracheostomy tube cuff herniation is a rare complication of this procedure.1-7 In this report, we present a rare case of cardiopulmonary arrest following the implantation of a tracheostomy tube cuff in a female patient and its management.

Evaluating the Impact of Elective Endotracheal Tube Replacement on Postoperative Outcomes in Esophageal Atresia: A STROBE-guided Study

ABSTRACT Background: Elective ventilation and paralysis have been shown to decrease the anastomosis-related complications following primary repair of esophageal atresia (EA). Repeated endotracheal tube (ETT) block and replacement can increase these complications. We evaluated the results of our strategy of electively changing the ETT just before shifting the patient to the postoperative ward for elective ventilation. Materials and Methods: A retrospective study was conducted using the case records of patients from July 2015 to February 2024 including all the patients of EA with tracheoesophageal fistula who underwent primary repair with end-to-end esophageal anastomosis. The patients were divided into two groups Group A: ETT was changed and Group B: ETT was not changed immediately before shifting. The groups were compared for anastomotic leak and ETT tube block in the first 48 h. Results: Ninety-one patients were included in the study, 36 in Group A and 55 in Group B. Elective replacement of ETT decreased the tube block rates in the first 48 h following surgery (P = 0.032). Tension in the anastomosis was associated with a higher leak rate. The leak was present in 58.3% and 3.6% in cases with and without tension in the anastomosis (P = 0.001). Overall, the anastomotic leak was similar in both groups. In the subgroup of patients with anastomosis under tension, the rate of anastomotic leak was higher in patients with ETT block (P = 0.028). Conclusion: Elective replacement of EET decreases the tube block rates and anastomotic leak rates in cases with anastomosis under tension.

The Effects of Lavender and Rosemary Extracts on Sore Throat and Hoarseness After Endotracheal Intubation in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Clinical Trial

PurposeThis study aimed to compare the effects of lavender and rosemary extracts on sore throat and hoarseness after endotracheal intubation in patients undergoing percutaneous nephrolithotomy. DesignRandomized clinical trial. MethodsThis study was conducted on 90 patients undergoing percutaneous nephrolithotomy at Bahonar Hospital in Kerman in 2021. The patients were selected by convenience sampling method and randomly assigned to three groups: lavender, rosemary, and control. After general anesthesia with endotracheal intubation, an anesthesiologist put sterile gauzes impregnated with 3 cc of rosemary and lavender extracts into patients’ throats in the intervention groups, while the control group received 3 cc of distilled water. After the surgery, the gauzes and tracheal tubes were removed and the patients were transferred to the postanesthesia care unit (PACU), their sore throat and hoarseness were measured and recorded during and 2 to 6 to 24 hours after recovery. A significance level of < .05 was considered. FindingsThe study results showed a significant difference in the severity of sore throat between the 3 groups 2, 6, and 24 hours after surgery; sore throat in the rosemary group and then in the lavender group was lower than that in the control group (P < .05). The results also indicated a significant difference in hoarseness intensity between the three groups 2 and 6 hours after surgery; hoarseness intensity in the rosemary and lavender groups was lower than that in the control group, but it was not different between 3 groups 24 hours after surgery (P < .05). ConclusionsRosemary and lavender extracts had a positive effect on sore throat and hoarseness. As these herbs cause no complications in patients and are available and inexpensive, further studies are necessary to confirm the use of these herbs during intubation.

Use of an endotracheal tube for a thoracostomy in a child in cardiac arrest: A case report

Background: Traditionally when patients arrive at an Emergency Department in cardiac arrest with a concern for a pneumothorax, a thoracostomy tube is placed for decompression. In a literature review, there are no case reports of an endotracheal tube being used in lieu of a thoracostomy tube for a pneumothorax in a child in cardiac arrest.Case Presentation: We present a case of a 4-week-old female infant who presented to the Emergency Department in cardiac arrest with a pneumothorax.Why should an emergency physician be aware of this?: It is important for clinicians to be aware of alternative management strategies for the management of a pneumothorax. Our case suggests that an endotracheal tube being used as a thoracostomy tube in a child in cardiac arrest can help acutely treat a pneumothorax by providing immediate and continuous decompression. In a prehospital or low-resource setting, an endotracheal tube may offer similar benefits to a thoracostomy tube as an immediate treatment modality.

Development of a Novel Airway-Exchange Broncholaryngoscope.

The purpose of this project was to develop a novel airway-exchange broncholaryngoscope (AEBLScope) to improve the efficiency and accuracy of airway-exchange procedures. The AEBLScope was designed to combine a bronchoscope and airway-exchange catheter (AEC) into a single device and to reduce the blind placement of AECs. The prototype was constructed by modifying an existing distal-chip bronchoscope. A custom AEC was procured to fit concentrically over the flexible portion of the scope. The catheter was connected to the scope handpiece by a customized push-pull locking attachment. The AEBLScope was used to perform airway-exchange procedures with both tracheostomy and endotracheal tubes using two different airway models. Experimental procedures were recorded with still photography to evaluate the exchange of tubes and placement of AECs. In two airway models using the AEBLScope, both tracheostomy and endotracheal tubes were successfully exchanged on first-pass attempt, and AECs were accurately placed under visual guidance. The AEBLScope combines a bronchoscope and AEC into a single tool. Based on these first results, this novel scope has the potential to perform airway-exchange procedures more safely compared with standard procedures by increasing the accuracy of placement, decreasing procedural time, and reducing the morbidity and mortality that can occur from blind placement of AECs. NA Laryngoscope, 134:4488-4493, 2024.

Case Report of an Obstructive Endobronchial Mass from a Blood Clot: An Airway Nightmare

BackgroundCentral airway obstruction from a mass is a rare but deadly manifestation of advanced primary lung cancer that can cause significant challenges during endotracheal intubation, including airway debris or bleeding, ventilation difficulties, and prolonged post-intubation hypoxia. Case reportThis case report describes a patient presenting with the chief complaint of massive hemoptysis who was difficult to ventilate and oxygenate after an easy intubation. On bedside bronchoscopy, an obstructing mass was found at the carina that was later determined to be caused by a blood clot. Patient course was complicated by tension pneumothoraces, prolonged hypoxia and cardiopulmonary arrest. Why should an emergency physician be aware of thisEarly recognition of an obstructing airway mass can be achieved with bedside fiberoptic bronchoscopy and allow for prompt mobilization of specialty services with rigid bronchoscopy capabilities for mass removal.

Impacto del uso universal del videolaringoscopio McGrath como primera opción para todas las intubaciones en el quirófano: protocolo del estudio prospectivo, multicéntrico VIDEOLAR-SURGERY con metodología pre-post

IntroductionUsual tracheal intubation performed in the operating room is based on direct laryngoscopy, using a standard Macintosh laryngoscope. Several authors recommend the universal use of a videolaryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath videolaryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases complications associated to the intubation. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicenter, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9months [2600 intubations]), 35 anesthesiologists from 8hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2months), a McGrath Mac videolaryngoscope is provided to each anesthesiologist to train in its use. During the post-implementation period (interventional-phase, 6-9months [2600 intubations]), the 35 anesthesiologists perform all tracheal intubations using a McGrath Mac videolaryngoscope as the first intubation option. The main objective of present study is to evaluate whether the use of a McGrath Mac videolaryngoscope as the first intubation option, improves the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved May 2, 2023, by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered into the Clinicaltrials.gov clinical trials registry with No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If videolaryngoscope improves easy intubation compared with Macintosh direct laryngoscope when it is used for all intubations in operating room, its use may will become standard practice, thereby decreasing complications associated with the intubation procedure.

Impact of universal use of the McGrath videolaryngoscope as the first option for all intubations in the operating room: The multicentre prospective before-after VIDEOLAR-SURGERY study protocol

IntroductionStandard tracheal intubation performed in the operating room is based on direct laryngoscopy using a standard Macintosh laryngoscope. Several authors recommend the universal use of a video laryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath video laryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases intubation-related complications. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicentre, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9 months [2600 intubations]), 35 anaesthesiologists from 8 hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2 months), each anaesthesiologist is given a McGrath Mac video laryngoscope and trained in its use. During the post-implementation period (interventional-phase, 6-9 months [2600 intubations]), the 35 anaesthesiologists perform all tracheal intubations using a McGrath Mac video laryngoscope as the first intubation option. The main objective of this study is to evaluate whether the use of a McGrath Mac video laryngoscope as the first intubation option increases the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved on 2 May 2023 by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered on the Clinicaltrials.gov clinical trials registry under No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If video laryngoscopy improves easy intubation compared with Macintosh direct laryngoscopy in all operating room intubations, its use may well become standard practice, thereby decreasing the risks of intubation-related complications.

Hydrogen regulated pyroptosis through NLRP3-GSDMD pathway to improve airway mucosal oxidative stress injury induced by endotracheal tube cuff compression.

The cuff of endotracheal tube (ETT) is an indispensable device for establishing an artificial airway, yet cuff-induced compression often causes damage to the airway mucosa. The mechanism of this damage involves mucosal compression ischemia and the oxidative stress injury following reperfusion. Currently, there is a lack of effective strategies to protect the mucosa. Hydrogen, as a natural antioxidant, has demonstrated significant potential in the prevention and treatment of oxidative stress injuries. This study aimed to determine the protective effects of hydrogen on compressed airway mucosa. We found that the damage to the airway mucosa caused by ETT cuff compression was associated with oxidative stress-induced pyroptosis of airway epithelial cells. Inhalation of hydrogen effectively reduced the levels of reactive oxygen species, significantly ameliorating changes in epithelial cell pyroptosis, and this protective effect is linked to the inhibition of the NLRP3-GSDMD pathway. Further cellular studies, involving knockdown and overexpression of NLRP3, clarified that hydrogen exerts its protective effects on the airway mucosa by inhibiting epithelial cell pyroptosis. Additionally, we observed that using hydrogen-rich saline to inflate the ETT cuff in patients under general anesthesia significantly reduced postoperative sore throat. This study confirms that hydrogen effectively enhances tolerance of airway mucosa to oxidative stress injuries, offering a potential preventive and therapeutic strategy for protecting the airway mucosa in patients undergoing endotracheal intubation.

Polytrauma in a Jet Pilot After Low-Altitude Ejection Without Parachute Deployment

BACKGROUND: Ejection seats are designed to be a lifesaving device for aircrew in emergencies. Modern ejection seats are widely prevalent in fighter and bomber aircraft and are occasionally associated with acceleration injury from axial loading (Gz) during the catapult phase of ejection, limb flail injury due to windblast, or parachute landing fall, especially if the ejection is outside of the seat’s performance envelope. CASE REPORT: We present the first known case in the medical literature of a military pilot who survived a low-altitude, high-angulation (&gt;90° of bank angle) ejection where the pilot’s ejection seat parachute did not deploy due to contact with the ground before completion of the ejection sequence. The patient’s initial exam upon arrival at a trauma center was significant for a Glasgow Coma Scale of 3T, with evidence of cranial and extremity trauma. The patient presented with respiratory acidosis and required upsizing of his endotracheal tube placed in the field. The patient’s injury list included bilateral subdural and subarachnoid hemorrhages, a Hangman’s fracture, spinal burst fractures, and extensive extremity fractures. After a prolonged hospital stay, the patient was discharged to rehabilitation. The patient made a functional and neurological recovery, including return to independent completion of his activities of daily living. DISCUSSION: This case provides evidence of favorable outcome after a low-altitude, high-angulation ejection without parachute deployment. This case details the medical and traumatic pathology medical personnel should expect from an ejection that occurs outside of the seat’s performance envelope. Zivkovic MM, Inman BL, Figlewicz MR, Burchett JA, Nowadly CD. Polytrauma in a jet pilot after low-altitude ejection without parachute deployment. Aerosp Med Hum Perform. 2024; 95(11):862–866.

Integrating the Airway Lead structure into a large healthcare system to appraise the landscape of airway management resources

Airway Leads are clinicians who guide safe airway management institutionally and act as liaisons between the evolving airway management landscape and bedside clinicians. Internationally, resources produced by Airway Leads Networks aid clinicians in establishing emergency airway management protocols and making difficult airway equipment decisions. The creation of an Airway Leads Network within the United States' multi-payer healthcare system is ongoing, spearheaded nationally by groups such as the Society for Airway Management. We aimed to build a committee of airway leaders across the Yale New Haven Health system and to leverage this committee to appraise the airway equipment and personnel resources throughout the system. We identified key stakeholders in airway management across the healthcare system and administered a quality improvement survey to members of the assembled committee querying their knowledge of the availability of airway management devices. The dataset was gathered from 14 airway management leaders identified across 4 surgical facilities, 6 emergency departments and 5 medical intensive care units at 8 hospitals and hospital campuses within the Yale New Haven Health system. Equipment available in greater than 75 % of locations included hyperangulated and standard geometry videolaryngoscopes, rigid tracheal tube stylets, tracheal tube introducers, flexible intubation scopes, scalpels and waveform capnography. Equipment available in 25 % to <75 % of locations included emergency invasive airway kits, wheeled airway towers or airway boxes, intubating oral airways, airway exchange and Aintree catheters, intubation-capable supraglottic airways, and awake intubation supplies. Glidescope (Verathon) was the most common videolaryngoscope and flexible intubation scope, and Aura (Teleflex) was the most common intubation-capable supraglottic airway available. The initiative illustrated the feasibility and utility of developing a committee of airway leaders in a large health system. While all locations had access to a requisite array of airway management devices, there was variation in the availability and brand of individual airway equipment.

Comparison of hemodynamic responses to orotracheal intubation with Tuoren video laryngoscope and Macintosh direct laryngoscope in adult hypertensive patients

Comparison of hemodynamic responses to orotracheal intubation with Tuoren video laryngoscope and Macintosh direct laryngoscope in adult hypertensive patients

Multidisciplinary Approach in Rare, Fulminant-Progressing, and Life-Threatening Facial Necrotizing Fasciitis

(1) Background: Necrotizing fasciitis is known as a severe condition with a high risk of mortality, placing it among the most feared infections. In most cases, it has a polymicrobial etiology (type 1), requiring complex treatment that is continuously adapted to the evolving microbiological status. The facial localization of the disease is rare, fulminant progressing, and is often life-threatening. (2) Methods: We present the case of a patient with multiple comorbidities who, following trauma to the nasal dorsum, developed a wound with a rapid and severe progression to extensive bilateral periorbital necrosis. This was accompanied by a dramatic deterioration in their general condition, a polymicrobial biological status, and fluctuating progression despite instituted treatment (both medical and surgical). (3) Results: The patient required multiple surgical interventions by multidisciplinary teams (plastic surgery; ear, nose, and throat specialist (ENT); maxillofacial surgery; and ophthalmology), experiencing periods of a severe, life-threatening general condition, necessitating prolonged orotracheal intubation. Wounds with fluctuating progression, extensive skin necrosis, and significant post-excisional soft tissue defects required skin graft coverage. The result meant a saved life and functional and aesthetic sequelae at the level of the face. (4) Conclusions: Necrotizing fasciitis of the face is a rare and severe disease that must be recognized early and treated appropriately by a multidisciplinary team to save the patient’s life and minimize the resulting functional and aesthetic sequelae.

Comparative study of intubating condition between rocuronium and vecuronium for endotracheal intubation in general anesthesia

Comparative study of intubating condition between rocuronium and vecuronium for endotracheal intubation in general anesthesia

Prehospital endotracheal intubation for traumatic out-of-hospital cardiac arrest and improved neurological outcomes.

Patients with traumatic out-of-hospital cardiac arrest (t-OHCA) require on-scene airway management to maintain tissue oxygenation. However, the benefits of prehospital endotracheal intubation remain unclear, particularly regarding neurological outcomes. Therefore, this study aimed to evaluate the association between prehospital intubation and favourable neurological outcomes in patients with t-OHCA. This retrospective cohort study used a Japanese nationwide trauma registry from 2019 to 2021. It included adult patients diagnosed with traumatic cardiac arrest on emergency medical service arrival. Glasgow Outcome Scale (GOS) scores, survival at discharge and presence of signs of life on hospital arrival were compared between patients with prehospital intubation and those with supraglottic airway or manual airway management. Inverse probability weighting with propensity scores was used to adjust for patient, injury, treatment and institutional characteristics, and the effects of intubation on outcomes averaged over baseline covariates were shown as marginal ORs. A total of 1524 patients were included in this study, with 370 undergoing intubation before hospital arrival. Prehospital intubation was associated with favourable neurological outcomes at discharge (GOS≥4 in 5/362 (1.4%) vs 10/1129 (0.9%); marginal OR 1.99; 95% CI 1.12 to 3.53; p=0.021) and higher survival to discharge (25/370 (6.8%) vs 63/1154 (5.5%); marginal OR 1.43; 95% CI 1.08 to 1.90; p=0.012). However, no association with signs of life on hospital arrival was observed (65/341 (19.1%) vs 147/1026 (14.3%); marginal OR 1.09; 95% CI 0.89 to 1.34). Favourable outcomes were observed only in patients who underwent intubation with a severe chest injury (Abbreviated Injury Score ≥3) and with transportation time to hospital >15 min (OR 14.44 and 2.00; 95% CI 1.89 to 110.02 and 1.09 to 3.65, respectively). Prehospital intubation was associated with favourable neurological outcomes among adult patients with t-OHCA who had severe chest injury or transportation time >15 min.

Tracheal rupture following double lumen tracheal intubation: A case report

Tracheal rupture following double lumen tracheal intubation: A case report

Development of postoperative laryngeal edema in patients undergoing craniotomy for elective intracranial tumor excision: a prospective, observational, preliminary study

BackgroundIntracranial tumor surgeries require different head and surgical positions as well as large fluid administration, which can cause laryngeal edema (LE) and increased morbidity. But there are no studies regarding its incidence in this patient population. As these patients often receive steroids for reducing peri-tumoral edema, which can also reduce LE, we hypothesized that incidence of LE in patients undergoing intracranial tumor resection in various positions might not be high. Thus, this prospective, observational study aimed to find LE incidence, as assessed by cuff leak test in these patients. MethodsASA I/ II, patients (18- 60 yrs) undergoing elective intracranial tumor resection were included after atraumatic tracheal intubation under standard general anesthetic technique. Cuff leak volume (CLV) was measured in supine position before start of surgery (CLVb) and completion (CLVc) of surgery. CLV ˂110 ml was considered to indicate LE. Important parameters were noted and patients were followed till discharge from the hospital. ResultsSeventy-three patients with male preponderance (58.9%) participated in study. Number of patients operated in supine, lateral, prone and sitting positions were 34, 16, 14 and 09, respectively. CLV decreased significantly in lateral and supine positions (p = 0.009 and 0.0002 respectively). Only, 02(2.74%) patients had CLVc <110 ml; both were male patients operated in supine position with head rotation. Anesthetic duration and intraoperative fluid administration were comparable across surgical positions. No PES was seen in any patient. ConclusionWe found that optimal intraoperative care of patients undergoing excision of intracranial tumors resulted in a low PLE incidence (2.74%) as detected by CLT at completion of surgery. However larger studies are required to further elaborate this issue.

Generation of preoperative anaesthetic plans by ChatGPT-4.0: a mixed-method study.

Recent advances in artificial intelligence (AI) have enabled development of natural language algorithms capable of generating coherent texts. We evaluated the quality, validity, and safety of this generative AI in preoperative anaesthetic planning. In this exploratory, single-centre, convergent mixed-method study, 10 clinical vignettes were randomly selected, and ChatGPT (OpenAI, 4.0) was prompted to create anaesthetic plans, including cardiopulmonary risk assessment, intraoperative anaesthesia technique, and postoperative management. A quantitative assessment compared these plans with those made by eight senior anaesthesia consultants. A qualitative assessment was performed by an adjudication committee through focus group discussion and thematic analysis. Agreement on cardiopulmonary risk assessment was calculated using weighted Kappa, with descriptive data representation for other outcomes. ChatGPT anaesthetic plans showed variable agreement with consultants' plans. ChatGPT, the survey panel, and adjudication committee frequently disagreed on cardiopulmonary risk estimation. The ChatGPT answers were repetitive and lacked variety, evidenced by the strong preference for general anaesthesia and absence of locoregional techniques. It also showed inconsistent choices regarding airway management, postoperative analgesia, and medication use. While some differences were not deemed clinically significant, subpar postoperative pain management advice and failure to recommend tracheal intubation for patients at high risk for pulmonary aspiration were considered inappropriate recommendations. Preoperative anaesthetic plans generated by ChatGPT did not consistently meet minimum clinical standards and were unlikely the result of clinical reasoning. Therefore, ChatGPT is currently not recommended for preoperative planning. Future large language models trained on anaesthesia-specific datasets might improve performance but should undergo vigorous evaluation before use in clinical practice.

Lubrication of endotracheal tube cuffs reduces gas leakage during positive pressure ventilation

Lubrication of endotracheal tube cuffs reduces gas leakage during positive pressure ventilation