Intubation Attempts Research Articles

Integrated Assessment of Discrepancy Between Tracheal Tube and Tube Exchanger as Advancement: A Manikin Simulation Study.

Advancing a tracheal tube over a tracheal tube exchanger into the trachea frequently causes difficulties because of the tube impingement on laryngeal structures. In the present study, we measured the resistance of tube advancement both objectively and subjectively with a variety of combinations of tube exchanger sizes and tracheal tubes using a manikin simulator. Lubricated 7.5 mm ID standard and Parker Flex-Tip (PFT) tracheal tubes were railroaded over the tube exchangers (OD 1-6 mm) into the trachea through the oral route in a manikin. Consequently, 12 combinations of tracheal tube-exchanger tube assemblies were evaluated. Tube advancing resistance at the laryngeal inlet was subjectively evaluated. The objective tube advancing resistance (force) at the laryngeal inlet was evaluated using a digital force gauge. The execution of each tracheal tube-exchanger trial was conducted 10 times. With a 1-mm tube exchanger, all intubation attempts with both standard and PFT tubes failed. Esophageal intubation or severe impingement at the right arytenoid accompanied with a bent tracheal tube was observed. With a 2-mm tube exchanger, during intubation with a standard tracheal tube, rotation of the tube was sometimes required; however, all other intubations were done without problems. When PFT tubes were used, all intubation attempts were performed without problems. The rest of the trials were successfully performed regardless of the combinations of tube exchangers and tracheal tubes; however, one attempt of intubation with a combination of a 5 mm tube exchanger and a standard tracheal tube required withdrawal and rotation of the tube because of impingement at the epiglottis. In cases where there was no gap resistance, which means tube advancing resistance generated by a gap between an introducer and a tracheal tube, the pressing force was approximately less than 10 N. However, in the cases requiring some interventions to overcome the gap, the pressing force reached around 15 N. When intubation failed, for example when the tube bent, or esophageal intubation, the pressing force reached around 30 N. Impingement due to the gap between the tube exchanger and the tracheal tube is thought to occur in the PFT tube less frequently. Once an impingement occurs, we can feel approximately twice the amount of resistance as usual, which may be a chance to consider taking some interventions. When the impingement is not released, regardless of interventions, excessive force may result in esophageal intubation or tracheal injury.

Comparison of intubating conditions in supine (sniffing) and 25° back-up position using channelled and non-channelled video laryngoscopes - A randomised controlled study.

The 25°back-up position is proposed to increase the efficacy of preoxygenation and provide better tracheal intubating conditions when using a direct laryngoscope. This study aimed to compare the ease of tracheal intubation between supine and 25° back-up positions when using two video laryngoscopes (VLS). One hundred adults with normal airways and belonging to the American Society of Anesthesiologists physical status classes I and II, requiring general anaesthesia, were randomised in groups K and M. The trachea was intubated using King Vision and McGrath VLS in either supine (groups K1 and M1) or 25° back-up (groups K2 and M2) positions. The 25° backup position was given by raising the operating table from the horizontal position by flexing the torso at the hips so that an imaginary line connected the patient's external auditory meatus to the sternal notch. Modified Intubation Difficulty Scale (mIDS) was the primary outcome, and intubation time, the number of intubation attempts, vital parameters, and complications were compared secondarily. Statistical analysis was done using MedCalc software by applying an independent t-test for parametric data and a Chi-square test for categorical data and finding the risk ratio. Mean (Standard deviation) mIDS was significantly reduced using both VLS in the 25° back-up position [0.92 (0.75) versus 0.48 (0.58), P = 0.025, degree of freedom (DF): 48, mean difference (95% confidence interval [CI]):-0.44 (-0.821 to - 0.059) in group K1 versus group K2 and 0.76 (0.59) versus 0.36 (0.48), P = 0.012, DF: 48, mean difference (95% CI): -0.40(-0.706 to - 0.094) in group M1 versus group M2, respectively]. The risk ratio comparing both the positions for the total number of patients requiring manoeuvres during intubation using both the VLS was 0.48 with P = 0.0004 and 95% CI = 0.305 - 0.765. Intubation time was shorter in the 25° backup position by using King Vision (P = 0.005) and McGrath (P = 0.042) VLS. The 25° backup position helps provide ease of intubation using both the channelled (King Vision) and non-channelled (McGrath) VLS.

The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest

Introduction Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT. Methods This was a retrospective cohort study of trauma patients presenting to two level-1 trauma centers, St. Michael’s Hospital and Sunnybrook Health Sciences Center, in Toronto, Canada (January 1, 2005-December 31, 2020). Our exposures of interest were any prehospital intubation attempt and OOHT. Primary and secondary outcome measures were ROSC post-RT and survival to hospital discharge, respectively, and data analysis was performed using univariate logistic regression. Results A total of 195 patients were included, of which 86% were male, and the mean age was 33 years. ROSC and survival to hospital discharge were achieved in 30% and 5% of patients, respectively. Of those who survived to discharge, 89% sustained penetrating trauma. There was no association between OOHT and ROSC (OR = 1.00, 95% CI 0.97–1.03) or survival (OR = 0.99, 95% CI 0.94–1.05). The odds of ROSC were lower in penetrating trauma in the presence of any prehospital intubation attempt (OR = 0.39, 95% CI 0.19–0.82, p = 0.01). ROSC was less likely among all patients with no prehospital signs of life (SOL) compared to those who had prehospital SOL (OR = 0.30, 95% CI 0.13–0.69, p < 0.01). Conclusions There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Serial Kasus Tatalaksana Sulit Jalan Napas pada Tumor Tiroid

This case report studies three patients with difficult airways managed according to the American Society of Anesthesiologists (ASA) algorithm. The first case is a 46-year-old woman with bilateral SNNT who underwent a subtotal thyroidectomy without prior hyperthyroid therapy. The patient, with an ASA physical status II, was intubated using a videolaryngoscope. Postoperatively, the patient was cared for in the ward. The second case is a 58-year-old woman with a retrosternal goiter and comorbid hyperthyroidism and hypertension, who underwent a total thyroidectomy. The patient, with an ASA physical status II, was intubated while conscious. Postoperatively, the patient was admitted to the ICU. The third case is a 60-year-old woman with bilateral SNNT planned for thyroidectomy and permanent tracheostomy. The patient, with an ASA physical status III and comorbid hyperthyroidism, had failed intubation attempts with a videolaryngoscope and fiber optics. The patient could not be intubated, and the family was educated about the condition. This study demonstrates the importance of individualized management in patients with difficult airways, following ASA guidelines for optimal results.

Success rates of endotracheal intubation using the standard method versus the modified-ramped position.

The sniffing position used in intubation has disadvantages, including suboptimal glottic view, respiratory problems, increased risk of aspiration, and pain. In this regard, we have proposed new conditions to facilitate intubation and tube placement in patients with a Mallampati score higher than 2, by introducing a new position called the modified rapid airway management positioner (RAMP) position. The authors compared various parameters to improve intubation conditions between these two positions. This intervention is a randomized clinical trial study, with a random sampling method that divides the patients into two groups: a control group placed in the standard position (S) and an intervention group placed in the modified (M) RAMP position. An anesthesiologist performed intubation. In group (S), patients were placed in the supine position as usual, and a pillow with a height of 10cm was placed under their heads. In group (M), the patients were placed in the supine position on a modified RAMP with a triangular shape, 15cm in height, and 80cm in length, at a 30° angle. The pillow had lengths of 20 and 80cm. In the present study, 112 patients were investigated, consisting of 58 women (51.8%) and 54 men (48.2%). The intubation time in the intervention group using the modified RAMP roll technique was significantly shorter (51.25s) compared to the control group using the standard method (88.39s) (P=0.019). The results of the study showed that the modified RAMP roll improved the general conditions of intubation and led to a better view of the glottis in direct laryngoscopy. This is a very important aspect of intubation, and with a better view of the pharynx and glottis, the intubation procedure can be performed with higher quality, reducing the number of intubation attempts and the duration of the procedure.

Incidence and Risk Factors of Post-Thyroidectomy Stridor

Background: Thyroidectomy is a common procedure performed by the general surgeons. Stridor is an airway sign caused by a variety of post-thyroidectomy complications.&#x0D; Objective: To determine the incidence of post-thyroidectomy stridor and the risk factors associated with its occurrence.&#x0D; Patients and Methods: The study included 280 adult patients who had total or partial thyroidectomy performed by various surgeons. Patients were followed up for 6 months after they were discharged from the hospital. Data collected included demographic information, type of thyroid disease, duration of illness before surgery, type of surgery, number of intubation attempts, and the presence of hoarseness and hematoma post-operatively.&#x0D; Results: Only eighteen patients (6.43%) who underwent thyroidectomy developed stridor during the follow-up period. They were compared to 25 other patients who were chosen from the original sample based regular visit of patients during the follow up. Higher body mass index (BMI), bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and more than one attempt at intubation were all associated with an increased risk of post-thyroidectomy stridor.&#x0D; Conclusion: Stridor affects only a small percentage of patients undergoing thyroidectomy. Increased BMI, bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and frequent tracheal intubation are the most common risk factors for post-thyroidectomy stridor.

The sniffing position facilitated easier light wand guided endotracheal intubation compared with the neutral position with chin-lift.

Traditionally, the patient's head is placed in a neutral position with a chin-lift to facilitate light wand guided endotracheal intubation. However, our study found that the sniffing position was more effective. In this study, we aimed to compare the two positions of light wand guided endotracheal intubation. Sixty adult patients were included in the study, after obtaining informed consent, and were randomly assigned to one of two groups: a control group in a neutral position with a chin-lift (group C, n = 30) and a sniffing position group (group S, n = 30). In group C, the anesthesiologist inserted a light wand after lifting the patient's mandible using the thumb of their non-dominant hand inside the patient's mouth. In group S, a light wand was inserted after the patient's head was flexed with the neck extended. We assessed variables such as light-search time, number of intubation attempts, time to achieve intubation, and side effects including blood tinge on the endotracheal tube, hoarseness, sore throat, and anesthesiologist satisfaction. The light-search and intubation times were shorter in group S than in group C. The incidence of blood tinge on the endotracheal tube was higher in group C than in group S. Anesthesiologist satisfaction was higher in group S than in group C. The sniffing position was more effective in facilitating light wand guided endotracheal intubation than the neutral position with a chin-lift.

Oropharyngeal Hemorrhage and Difficult Airway Management: A Decision Not to Intubate

BackgroundBleeding in the upper airways is an important cause of airway-related death. A higher incidence of airway management failure and complications after intubation attempts in the emergency department (ED) had been suggested. Airway management of patients with active oropharyngeal hemorrhage may be challenging, leading the clinician to modify the approach. Case ReportA 57-year-old woman presented to the ED with oropharyngeal hemorrhage after an extensive invasive dental procedure. She was on long-term warfarin therapy due to aortic and mitral valve replacement, which she suspended 5 days prior and restarted the day after the procedure. Besides the active bleeding, swelling, and hematoma of the face, the patient had other signs of “difficult airway,” so there were serious questions on when and how to manage the airway. Several strategies to address the airway were considered, the main point being an early versus later intubation. As the patient remained clinically stable, she was conservatively managed with local hemostasis and coagulopathy reversal. The patient was transferred to the intensive care unit, where she remained stable and was successfully discharged after restart on warfarin. Why Should an Emergency Physician Be Aware of This?When faced with an oropharyngeal hemorrhage, emergency physicians may be compelled to secure and protect the airway. This could be achieved by planning several strategies. Nevertheless, in selected patients, and considering the circumstances, not addressing the airway is a reasonable and justifiable alternative.

Incidence and Risk Factors of Post-Thyroidectomy Stridor

Background: Thyroidectomy is a common procedure performed by the general surgeons. Stridor is an airway sign caused by a variety of post-thyroidectomy complications. Objective: To determine the incidence of post-thyroidectomy stridor and the risk factors associated with its occurrence. Patients and Methods: The study included 280 adult patients who had total or partial thyroidectomy performed by various surgeons. Patients were followed up for 6 months after they were discharged from the hospital. Data collected included demographic information, type of thyroid disease, duration of illness before surgery, type of surgery, number of intubation attempts, and the presence of hoarseness and hematoma post-operatively. Results: Only eighteen patients (6.43%) who underwent thyroidectomy developed stridor during the follow-up period. They were compared to 25 other patients who were chosen from the original sample based regular visit of patients during the follow up. Higher body mass index (BMI), bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and more than one attempt at intubation were all associated with an increased risk of post-thyroidectomy stridor. Conclusion: Stridor affects only a small percentage of patients undergoing thyroidectomy. Increased BMI, bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and frequent tracheal intubation are the most common risk factors for post-thyroidectomy stridor. Keywords: Thyroidectomy, stridor, hoarseness of voice. Background: Thyroidectomy is a common procedure performed by the general surgeons. Stridor is an airway sign caused by a variety of post-thyroidectomy complications. Objective: To determine the incidence of post-thyroidectomy stridor and the risk factors associated with its occurrence. Patients and Methods: The study included 280 adult patients who had total or partial thyroidectomy performed by various surgeons. Patients were followed up for 6 months after they were discharged from the hospital. Data collected included demographic information, type of thyroid disease, duration of illness before surgery, type of surgery, number of intubation attempts, and the presence of hoarseness and hematoma post-operatively. Results: Only eighteen patients (6.43%) who underwent thyroidectomy developed stridor during the follow-up period. They were compared to 25 other patients who were chosen from the original sample based regular visit of patients during the follow up. Higher body mass index (BMI), bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and more than one attempt at intubation were all associated with an increased risk of post-thyroidectomy stridor. Conclusion: Stridor affects only a small percentage of patients undergoing thyroidectomy. Increased BMI, bilateral thyroidectomy, presence of concomitant hoarseness and hematoma, and frequent tracheal intubation are the most common risk factors for post-thyroidectomy stridor. Keywords: Thyroidectomy, stridor, hoarseness of voice.

Conventional videolaryngoscope versus 3D printed videolaryngoscope

&lt;b&gt;Background and objectives:&lt;/b&gt; In patients with Covid-19, using a video laryngoscope as an alternative to direct laryngoscopy is recommended to protect the intubator from infection and reduce intubation failures due to personal protective equipment. The cost of video laryngoscopes limits their availability in all healthcare institutions. The present study aimed to compare the efficacy and safety of 3D printed video laryngoscope and conventional video laryngoscope on intubation.&lt;br /&gt; &lt;b&gt;Material and methods:&lt;/b&gt; 30 ASA I-II patients who were not considered to have a difficult airway were included in the study after obtaining the ethics committee approval from Adnan Menderes University Clinical Research Ethics Committee. Patients were randomly divided into two groups, group 1 and group 2. After the induction of anesthesia under standard monitoring, the Cormack Lehane score was recorded by direct laryngoscopy in all patients. Patients in group 1 were intubated with a 3D-printed video laryngoscope. In contrast, patients in group 2 were intubated with a conventional video laryngoscope (STORZ C-mac videolaryngoscope). Intubation time, number of attempts, and hemodynamic values of patients with early postoperative complications were recorded. The data were recorded and statistically evaluated.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; There were no significant differences between the groups regarding demographic data, BMI, and hemodynamic data. The Cormack Lehane score was calculated as 1.6±0.51 in group 1 and 1.4±0.51 in group 2 (p=0.38). Intubation times of the groups were 32.6±18 s and 27.06±11.37 s, respectively (p=0.4). The number of intubation attempts was 1.2±0.63 in group 1 and 1±0.01 in group 2 (p=0.31). The image quality of the camera by the intubator, intubation conditions, and intubation satisfaction was similar in the two groups.&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt;&lt;b&gt; &lt;/b&gt;Comparing a 3D-printed videolaryngoscope with a conventional videolaryngoscope, no differences were observed in intubation times, number of intubation attempts, hemodynamic changes, and early postoperative complications. Intubation satisfaction values by the practitioner were found to be similar. It was concluded that the 3D-printed videolaryngoscope, which is cost-effective and easy to access, can be used instead of conventional videolaryngoscope in patients with a normal airway.

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

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

First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department.

The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED. We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods. Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events. The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.

Does Increasing the Bend Angle of a Stylet to 90° Increase the Nasotracheal Intubation Success Rate?

BackgroundVideo-stylet-guided nasotracheal intubation is an effective technique for airway management. However, the impact of the bend angle on the success rate of intubation remains unclear. PurposeDoes increasing the bend angle of a stylet to 90 degrees increase nasotracheal intubation success rate? Study design, setting, sampleThis prospective randomized controlled trial was conducted in the operating room of a population-based hospital. Adult patients requiring nasotracheal intubation were recruited. Predictor/exposure/independent variableThe primary predictor variable is the choice of stylet bend angle (90° versus 70° bend) in nasotracheal intubation. Main outcome variable(s)The primary outcome variables were success rates of nasotracheal intubation, defined as the proportion of successful intubation cases to total cases. CovariatesDemographics, intubation time, the distance from the thyroid prominence to the nostril, additional maneuvers applied during intubation, and cases of epistaxis were recorded. AnalysesThe student’s t-test was used to compare continuous variables between groups. Ordinal data (intubation attempts, head extension, and epistaxis) were analyzed using the Wilcoxon rank-sum test. As appropriate, frequency (external pharyngeal pressure) was analyzed using the chi-square test or Fisher’s exact test. A p-value of <0.05 was considered statistically significant. ResultsOf the 103 subjects assessed for eligibility, 98 were enrolled in the study. The mean age (27.0±6.9 years vs. 27.0±4.1 years, p=0.972) and sex differences (male/female: 9/40 vs. 7/42, p=0.136) were comparable between groups. The overall success rate in the 70° group was significantly lower than that in the 90° group (91.8% vs. 100%, p<0.001). The intubation time in the 70° group was significantly longer than that in the 90° group (43.2±15.8 s vs. 33.7±7.3 s, p<0.001). Conclusions and RelevanceA 90° bend angle of the stylet significantly improves the likelihood of successful nasotracheal intubation.

Effect of operation table height on ease of mask ventilation, laryngeal view, and endotracheal intubation success.

Optimal patient positioning and operating table height are essential for an ergonomic posture of an anesthesiologist in which there is minimal or no strain on thewrist during mask ventilation. It also avoids flexion of the neck, lower back, and knee bending at the time of laryngoscopy and intubation. One hundred eighty patients were randomly allocated to three groups based on different table heights. The height of the table is kept at the mid-sternum level of an anesthesiologist in group 1, at the xiphoid process in group 2, and at the level of umbilicus in group 3. Laryngoscopic view with or without postural changes (exertion at wrist joint, flexion of the neck, lower back, or knee bending) was graded as per Cormack Lehane's (CL) grading. The degree of discomfort experienced by the anesthesiologist during mask ventilation or tracheal intubation was graded subjectively (1 = no discomfort, 2 = mild discomfort, 3 = moderate discomfort, and 4 = severe discomfort) at different table heights. Postural changes required to obtain the best glottic view and quality of endotracheal (ET) intubation (intubation time and attempts required) were also noted. For analysis, quantitative variables were expressed as mean ± SD and compared using unpaired t or analysis of variance test. Qualitative variables were expressed as frequencies/percentages and compared using the Chi-square test. Results with P value <0.05 were considered significant statistically. Moderate discomfort (strain at wrist joint) during bag-mask ventilation was experienced by the anesthesiologist in a maximum number of patients in group 1 (81.7%). Significant improvement was seen in CL grade after the use of postural modifications in groups 1 and 2 (P value ≤0.05). Greater postural modifications were required during ET intubation at lower table heights (group 3). It is advisable to adopt higher table positioning in relation to anesthesiologist performing the laryngoscopy for smooth and single-attempt ET intubation since the best laryngoscopic view and intubation with minimal postural modifications was seen at higher table heights (at the mid-sternum level of an anesthesiologist).

C-MAC VL as Saviour Following Failed Intubation Attempts in an Infant with Huge Hydrocephalous

Airway management in infants can become more challenging in the presence of congenital anomalies such as hydrocephalus. In this case, we present the extreme airway challenges faced during the intubation of a 7-month-old child with massive hydrocephalus presenting for ventriculoperitoneal (VP) shunt surgery. The C-MAC video laryngoscope (VL) turned out to be the ultimate saviour after the failure of direct laryngoscopy and Airtraq. Paediatric airway management can sometimes be a nightmare for the anaesthesiologist in such scenarios. Early use of rescue devices such as the C-MAC VL can help tide over the crisis.

GlideScope versus C-MAC D-blade videolaryngoscope for double-lumen tube intubation in patients with anticipated difficult airways: A multi-center, prospective, randomized, controlled trial

Study objectiveVideolaryngoscopes are widely used to visualize difficult airways. Our aim was to compare the GlideScope and C-MAC D-blade videolaryngoscopes for double-lumen tube (DLT) intubation in patients with difficult airways. DesignA multi-center, prospective, randomized controlled trial. SettingThree comprehensive tertiary, high-volume hospitals from 5 December 2020 to 4 November 2021. PatientsWe included 348 adult patients with anticipated difficult airways who underwent elective thoracic surgery. InterventionsPatients were randomized into two groups: GlideScope and C-MAC D-blade. Following anesthesia induction, DLT intubation was performed using different videolaryngoscopes. MeasurementsThe primary outcome was the first-pass success rate of DLT intubation. All other results were recorded as secondary outcomes. Main resultsNo significant differences were observed in the first-pass success rate of DLT intubation between the GlideScope and C-MAC D-blade (86.21% and 89.66%, respectively; P = 0.323). However, compared with the GlideScope, the C-MAC D-blade provided a lower Cormack–Lehane grade (P < 0.001), lower rates of external laryngeal pressure (48 vs. 15, P < 0.001), and postprocedure sore throat (26 vs. 8, P < 0.001). The numerical rating score for difficulty of videolaryngoscope insertion into the oral cavity, delivery to the glottis, and intubation into the main bronchus were significantly lower when using the C-MAC D-blade (P < 0.001). Moreover, the duration of DLT intubation was shorter in the C-MAC D-blade group (81 s [70–97 s] vs. 95 s [78–115 s], P < 0.001). In each group, two patients underwent fiberoptic intubation after three attempts with a videolaryngoscope failed. ConclusionsIn patients with difficult airways, the GlideScope and C-MAC D-blade provided a similar success rate on the first DLT intubation attempt; however, the C-MAC D-blade offers a better glottic view, easier and faster intubation, and lower incidence of sore throat.

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

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

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

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

Factors associated with immediate postoperative pulmonary complications after Appendectomies under general anesthesia: A retrospective analysis

Background: Postoperative pulmonary complications (PPC) include any complication that affects the respiratory system after anesthesia and surgery and are a significant cause of postoperative mortality and morbidity. Objectives: To describe the risk factors for immediate postoperative pulmonary complications after appendectomy under general anesthesia and to determine if rapid sequence induction decreases the risk. Design and Setting: A retrospective analysis of perioperative medical records of patients who underwent appendectomy under general anesthesia over a year, from January 1st, 2014, to December 31st, 2014, at Hamad General Hospital, Doha, Qatar, was done. Results: Of the 1005 patients who met the inclusion criteria, 27 (3.7%) had PPC. The incidence of PPC had a significant positive association with diabetes mellitus (DM), bronchial asthma (BA), number of intubation attempts, laparoscopic approach, and longer surgeries (&gt;2 h). Hypertension, recent or ongoing upper respiratory tract infections, and smoking were not associated with an increased risk of PPC. Non-rapid sequence intubation (RSI) was not associated with an increased risk of PPC compared with RSI. Conclusions: The incidence of immediate PPC in ASA 1 and 2 appendectomy patients aged between 15 and 50 is significant. There is an increased risk among asthmatics, diabetics, and those with difficult airways. The RSI technique does not offer protection.