Airway Intubation Research Articles

Landmark Detection using Transformer Toward Robot-assisted Nasal Airway Intubation

Robot-assisted airway intubation application needs high accuracy in locating targets and organs. Two vital landmarks, nostrils and glottis, can be detected during the intubation to accommodate the stages of nasal intubation. Automated landmark detection can provide accurate localization and quantitative evaluation. The Detection Transformer (DeTR) leads object detectors to a new paradigm with long-range dependence. However, current DeTR requires long iterations to converge, and does not perform well in detecting small objects. This paper proposes a transformer-based landmark detection solution with deformable DeTR and the semantic-aligned-matching module for detecting landmarks in robot-assisted intubation. The semantics aligner can effectively align the semantics of object queries and image features in the same embedding space using the most discriminative features. To evaluate the performance of our solution, we utilize a publicly accessible glottis dataset and automatically annotate a nostril detection dataset. The experimental results demonstrate our competitive performance in detection accuracy. Our code can be accessible at https://github.com/ConorLTH/airway-intubation_landmarks-detection.

Minimizing adverse effects of subjective measurement of endotracheal tube cuff pressure: Can the use of the loss of resistance technique help?

Background: Appropriate endotracheal tube cuff (ETTc) pressure estimation is essential to prevent airway complications. The pilot balloon palpation technique is the commonly used method of cuff inflation. It is however subjective thus prone to over or under estimation thus unreliable.
 Objective: To determine if the use of the passive release technique of cuff inflation would reduce commonly encountered airway complications following ETT intubation.
 Methodology: Patients scheduled for elective procedures under general anaesthesia with ETT were recruited into the study, 108 ASA I and II patients aged between 18-65 years were randomized into 2 groups with one group having their cuff inflated using the pilot balloon palpation (PBP) technique and the other by the use of a loss of resistance syringe (LOR). Airway complications were then assessed and compared between the 2 groups.
 Results: The incidences of sore throat, cough and hoarseness were significantly lower in the LOR group compared to the PBP group (35.2vs79.6%, 14.8 vs64.8% and 7.4 vs 79.6% respectively; p = 0.0001 in each case).
 Conclusion: Passive release technique using LOR was found to be less associated with post-endotracheal intubation airway complications than PBP technique

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Abstract Background A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case. Methods General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed. Results Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient. The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned. Conclusions We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling. Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

An Association of Predicted/Unpredicted Difficult Intubation with Fibreoptic Bronchoscopic Intubation

Aim: Inadequate preoperative airway assessment is one of the most common causes of failed airway management and intubation. Fibreoptic bronchoscopic intubation (FBI) is an effective technique for creating airway access in patients with expected and unexpected difficult airways. The aim of this study is to evaluate the incidence of predicted difficult airway (DA) in patients intubated due to DA with FBI.
 Materials and Methods: We retrospectively reviewed the medical records of one hundred and forty-three ASA I-V patients aged 0-80 years diagnosed with DA who underwent flexible FBI from January 2006 to December 2011. Age, weight, sex, concomitant syndromes, whether difficult intubation (DI) occurred after trauma, whether FBI was applied via nasal or oral ways, size of tube, whether FBI was successful or not and relationships of these parameters were analysed.
 Results: The study involved 143 patients, 38 (22.2%) in the pediatric group and 105 patients (77.8%) in the adult group. Of the patients, 64 (47.4%) were female and 71 (52.6%) were male. 42 patients underwent DI for syndromes with craniofacial abnormalities. As a result of preoperative anaesthetic assessment, DI could be predicted in 74 patients (51.7%) by history, physical examination and Mallampati scoring, while unexpected DI occurred in 69 (48.3%) of patients. The proportion of predicted DA was much higher in children compared to adults.
 Conclusion: It is not easy to check all predictors of DI in a pre-anaesthetic examination and the predictors are not accurate. Unexpected DI is not a rare occurrence in the operating room (OR). Despite a thorough pre-operative assessment, anaesthetists may not be able to predict what they will encounter during surgery and therefore should always be prepared for any challenge.
 Keywords: Preoperative assessment, predicted difficult intubation, fiberoptik bronchoscopic intubation, syndromes with craniofacial abnormalities

A manikin study comparing the performance of traditional Macintosh laryngoscope, GlideScope®, Airtraq®, and video-optical intubation stylet in endotracheal intubation used by emergency doctors in simulated difficult airway intubation: A pilot study

Background: The video-optical intubation stylet (VS) is a slim, rigid but flexible intubating device that aids physicians to intubate patients, particularly with difficult airways. Objectives: The objective of this study was to compare the performance of emergency department doctors in using different intubating devices for intubation in an airway manikin simulating different difficult airway scenarios. Methods: Thirty emergency department doctors were recruited in a pilot study. Their performance of using traditional Macintosh laryngoscope, GlideScope®, Airtraq® and C-MAC® Video Stylet were compared in three situations: normal, restricted cervical motion and limited oral aperture. The time for intubation, first attempt success rate, failure rate, dental injury and the subjective ease of different devices by the participants were compared. Result: The mean intubation time by VS in each scenario was significantly shorter compared with other devices (Normal: 19.77s vs 24.67–28.19s, p = 0.014; Cervical restriction: 20.85 vs 26.17–31.26s, p = 0.008; Limited oral aperture:19.03 vs 29.35, p = 0.001). However, there was no significant difference in failure rate or first attempt success rate. The incidence of dental injury was significantly lower with VS than other laryngoscopes (p = 0.001, p < 0.05 and p < 0.05 in normal, cervical restriction and limited oral aperture scenarios, respectively). Moreover, participants appreciated that VS was the easiest device to intubate in each scenario. (p < 0.05 in all scenarios) Conclusion: The performance of VS was comparable to or even better than the commonly used laryngoscopes in the emergency department in airway management. When adequate training is provided, VS can be a potentially good alternative for tracheal intubation in different situations.

Risk Factors for Postoperative Sore Throat After Nasotracheal Intubation.

Postoperative sore throat is relatively frequent complication after orotracheal intubation. However, there are few reports about postoperative sore throat in nasotracheal intubation. In this retrospective study, we investigated the risk factors of postoperative sore throat in nasotracheal intubation. Anesthesia records of patients 16 to 80 years of age who underwent nasotracheal intubation were included. Patients underwent oral and maxillofacial surgery from February 2015 until September 2018. Airway device (Macintosh laryngoscope, Pentax-AWS, or McGRATH video laryngoscope, or fiberoptic scope), sex, age, height, weight, American Society of Anesthesiologists classification, intubation attempts, duration of intubation, intubation time, tube size, and fentanyl and remifentanil dose were investigated. Fisher exact test, Wilcoxon rank sum test, Welch t test, and Steel-Dwass multiple test were used, and a multivariable analysis was performed using stepwise logistic regression to determine the risk factors of postoperative sore throat. A total of 169 cases were analyzed, and 126 patients (74.6%) had a postoperative sore throat. Based on the univariate analysis of the data, 12 factors were determined to be potentially related to the occurrence of a postoperative sore throat. However, after evaluation using stepwise logistic regression analysis, the 2 remaining variables that correlated with postoperative sore throat were airway device (P < .05) and intubation attempts (P = .04). In the model using logistic regression analysis, the fiberoptic scope had the strongest influence on the incidence of sore throat with reference to Pentax-AWS (odds ratio = 5.25; 95% CI = 1.54-17.92; P < .05). Use of a fiberoptic scope was identified as an independent risk factor for postoperative throat discomfort. Compared with direct laryngoscopy and other video laryngoscopes, the use of a fiberoptic scope had a significantly higher incidence of sore throat.

Predicting difficult airway intubation in thyroid surgery using multiple machine learning and deep learning algorithms.

BackgroundIn this paper, we examine whether machine learning and deep learning can be used to predict difficult airway intubation in patients undergoing thyroid surgery.MethodsWe used 10 machine learning and deep learning algorithms to establish a corresponding model through a training group, and then verify the results in a test group. We used R for the statistical analysis and constructed the machine learning prediction model in Python.ResultsThe top 5 weighting factors for difficult airways identified by the average algorithm in machine learning were age, sex, weight, height, and BMI. In the training group, the AUC values and accuracy and the Gradient Boosting precision were 0.932, 0.929, and 100%, respectively. As for the modeled effects of predicting difficult airways in test groups, among the models constructed by the 10 algorithms, the three algorithms with the highest AUC values were Gradient Boosting, CNN, and LGBM, with values of 0.848, 0.836, and 0.812, respectively; In addition, among the algorithms, Gradient Boosting had the highest accuracy with a value of 0.913; Additionally, among the algorithms, the Gradient Boosting algorithm had the highest precision with a value of 100%.ConclusionAccording to our results, Gradient Boosting performed best overall, with an AUC >0.8, an accuracy >90%, and a precision of 100%. Besides, the top 5 weighting factors identified by the average algorithm in machine learning for difficult airways were age, sex, weight, height, and BMI.

Association of transport time interval with neurologic outcome in out-of-hospital cardiac arrest patients without return of spontaneous circulation on scene and the interaction effect according to prehospital airway management.

ObjectiveThis study analyzed the association of transport time interval (TTI) with survival rate and neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients without return of spontaneous circulation (ROSC) and the interaction effect of TTI according to prehospital airway management.MethodsA retrospective observational study based on the nationwide OHCA database from January 2013 to December 2017 was designed. Emergency medical service (EMS)-treated OHCA patients aged ≥18 years were included. TTI was categorized into four groups of quartiles (≤4, 5–7, 8–11, ≥12 minutes). The primary outcome was favorable neurologic outcome at discharge. The secondary outcome was survival to discharge from the hospital. Multivariable logistic regression was used to analyze outcomes according to TTI. A different effect of TTI according to the administration of prehospital EMS advanced airway was evaluated.ResultsIn total, 83,470 patients were analyzed. Good neurologic recovery decreased as TTI increased (1.0% for TTI ≤4 minutes, 0.9% for TTI 5–7 minutes, 0.6% for TTI 8–11 minutes, and 0.5% for TTI ≥12 minutes; P for trend <0.05). The adjusted odds ratio of prolonged TTI (≥12 minutes) was 0.73 (95% confidence interval, 0.57–0.93; P<0.01) for good neurologic recovery. However, the negative effect of prolonged TTI on neurological outcome was insignificant when advanced airway or entotracheal intubation were performed by EMS providers (adjusted odds ratio, 1.17; 95% confidence interval, 0.42–3.29; P=0.76).ConclusionEMS TTI was negatively associated with the neurologic outcome of OHCA without ROSC on scene. When advanced airway was performed on scene, TTI was insignificantly associated with the outcome.

Video laryngoscope versus USB borescope-aided endotracheal intubation in adults with anticipated difficult airway: a prospective randomized controlled study.

BackgroundVideo laryngoscopes are approved equipment for difficult airway intubations. The borescope, which was introduced during the coronavirus disease 2019 (COVID-19) era, is placed over a direct laryngoscope blade to provide an economical video laryngoscope. In the current study, we investigated the use of an endotracheal tube mounted over a USB borescope versus a video laryngoscope in patients with suspected difficult airways.MethodsAfter obtaining informed consent, 120 adult patients with suspected difficult airways undergoing elective surgery were included in this study. Patients were randomized into the USB borescope and video laryngoscope groups. The primary outcome was time to successful intubation. The secondary outcomes included hemodynamic changes, anesthetist’s satisfaction, and the incidence of complications.ResultsIntubation time was comparable between the two groups (video laryngoscope: 30.63 s and borescope: 28.35 s; P = 0.166). However, the view was clearer (P = 0.026) and the incidence of fogging was lower (P = 0.015) with the video laryngoscope compared to the borescope. Conversely, anesthetist’s satisfaction frequency was higher with the borescope than with the video laryngoscope (P < 0.001).ConclusionsThe video laryngoscope provided a better view and less fogging with an intubation time that was comparable to that of the borescope; however, the higher cost of the video laryngoscope limits its availability. Therefore, the borescope is a low-cost, readily available device that can be used for intubating patients with potentially difficult airways.

Predicting Difficult Airway Intubation Based on Maxillofacial Trauma: A Retrospective Study.

PurposeThe purpose of this study was to determine which types of facial injuries in traumatic patients' wounds cause difficult intubation for anesthesiology team. By anticipating potential complications with airway management, the surgeons can be better prepared for emergent cricothyrotomy if needed. This could include prior to the planned procedure in the operating room (OR) as well as in emergent conditions in trauma bay.MethodsTrauma patients with facial injuries in a level II trauma center from January 2007 to September 2017 that required intubation were evaluated for types of facial injury. Anesthesiology intubation documents were reviewed to determine which types of facial injuries were associated with difficult intubation per anesthesiology documentation.ResultsA total of 232 subjects were selected and it was found that patients with LeFort II facial fracture, bilateral mandibular fracture, and facial fracture associated with basilar skull fracture were noted to have difficult intubation by the anesthesiology team.ConclusionOn the basis of CT imaging findings, our study demonstrates that certain types of facial fractures could pose difficult intubation. Surgeons should be aware of these injuries and be ready to intervene with emergent cricothyrotomy if necessary.

Obesity and the Other Independent Predictors in Elective Endotracheal Tube Intubations: A Narrative Review.

Obesity is one of the challenging elements in health care. Studies have shown that as the body mass index (BMI) increases, the risk of chronic conditions tends to increase due to altered physiologic and metabolic demands. In addition to underlying physiological changes, anatomical changes can lead to common procedural challenges, such as difficult intravenous (IV) cannulation, difficult airway, and difficult intubation, which makes their preoperative and postoperative care challenging for the anesthesiologists. According to previous studies, there is no single best predictor for difficult airway or intubations and no designed protocol for choosing an intubation technique in obese patients. Some of the preoperative risk factors and techniques such as the modified Mallampati class, sternomental distance, thyromental distance, neck circumference, indirect mirror laryngoscopy, BMI, and intraoperative risk factors such as inappropriate positioning of the patient, suboptimal medication dosing, inappropriate laryngoscopy device acted as independent predictors for difficult airway and difficult intubation. Analyzing each element’s importance and making suitable decisions for the individual will reduce the complications and prepare for unplanned emergencies in the operating room. This review is convincing with previous studies that obesity itself is not an independent predictor. Instead, as a preoperative risk factor, and till date, sternomental distance and the number of intubation attempts were demonstrated as significant independent predictors for adverse events. All the other independent factors and considerations were discussed, which can help with further research.

Airway management procedures in Swedish emergency department patients - a national retrospective study

BackgroundWith the on-going debate about which specialty should be responsible for intubations in the emergency department in mind, the aim of this study was to describe the prevalence of endotracheal intubation and other airway management procedures in emergency department patients in Sweden.MethodsAll patients registered in the Swedish Intensive Care Registry with admission date from January 1 2013 until June 7 2018 and reported admission type “from the emergency department” or “emergency department” reported in the SAPS3 scoring were included. All patients missing codes for procedures were excluded.ResultsA total of 110,072 admissions from an emergency department to an ICU were registered during the study period. Of these, 41,619 admissions (37.8%) were excluded due to lack of codes for medical procedures. The remaining 68,453 admissions (62.2%) were included, and 31,888 emergency airway procedures (within 3 h from admission time to the intensive care unit) were registered. Invasive emergency airway procedures were the most common type of airway procedure (n = 23,446), followed by non-invasive airway procedures (n = 8377) and high-flow nasal cannula (n = 880). In 2017 a total of 4720 invasive emergency airway management procedures were registered.ConclusionsThe frequency of invasive airway management procedures in Swedish EDs is low. With approximately 1.9 million adult ED visits per year, this gives an estimated incidence of 2.4 invasive airway management procedures per thousand ED visits in 2017.Trial registrationNot applicable.

A Market Review of Available Airway Suction Technology.

Airway injuries are the second leading cause of potentially survivable battlefield death and often require airway management strategies. Airway suction, the act of using negative pressure in a patient's upper airway, removes debris that can prevent respiration, decreases possible aspiration risks, and allows clearer viewing of the airway for intubation. The most important characteristics for a portable airway suction device for prehospital combat care are portability, strong suction, and ease of use. This market review searched academic papers, military publications, Google searches, and Amazon to identify devices. The search included specific characteristics that would increase the likelihood that the devices would be suitable for battlefield use including weight, size, battery life, noise emission, canister size, tubing, and suction power. Sixty portable airway suction devices were resulted, 31 of which met inclusion criteria - 11 manually powered devices and 20 battery-operated devices. One type of manual suction pump was a bag-like design with a squeezable suction pump that was extremely lightweight but had limited suction capabilities (vacuum pressure of 100mmHg). Another type of manual suction pump had a trigger-like design which is pulled back to create suction with a firm collection canister that had increased suction capabilities (vacuum pressures of 188-600mmHg), though still less than the battery operated, and was slightly heavier (0.23-0.458kg). Battery-operated devices had increased suction capabilities and were easier to use, but they were larger and weighed more (1.18-11.0kg). Future research should work to lighten and debulk battery-operated suction devices with high suction performance.

Cohen’s Comprehensive Thoracic Anesthesia

Cohen’s Comprehensive Thoracic Anesthesia

Helium-oxygen in bronchiolitis-A systematic review and meta-analysis.

IntroductionBronchiolitis is common reason for infant hospitalization. The aim of our systematic review and meta‐analysis was to evaluate helium–oxygen (heliox) in bronchiolitis.MethodsWe screened 463 studies, assessed 22 of them, and included six randomized controlled trials. Primary outcomes were the need for continuous positive airway pressure (CPAP) or intubation, hospitalization duration, and change in the modified Woods Clinical Asthma Scale (M‐WCAS). We calculated mean differences with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes.ResultsSix studies (five double‐ and one single‐blinded) with 560 infants were included. The risk of bias was high in one, moderate in four, and low in one. The RR for the need for CPAP (three studies) was 0.87 (CI: 0.56–1.35), and for intubation (four studies) was 1.39 (CI: 0.53–3.63), heliox compared to air–oxygen. The hospital stay (four studies) was 0.25 days longer (CI: −0.22 to 0.71) in the heliox group. The mean decrease in M‐WCAS from the baseline (three studies) was 1.90 points (CI: 1.46–2.34) greater in the heliox group.ConclusionWe found low‐quality evidence that heliox does not reduce the need for CPAP, intubation, or length of hospitalization for bronchiolitis. Based on the M‐WCAS scores, heliox seems to relieve respiratory distress symptoms rapidly after its initiation. The included studies had high heterogeneity in their methods and included relatively mild cases of bronchiolitis. A larger randomized controlled trial with more severe cases of bronchiolitis with enough power to analyze the need for intubation is needed in the future.

Association Between Systemic Corticosteroid Use and Mortality in Patients with Epiglottitis.

To clarify whether treatment with systemic corticosteroids at a certain dose was associated with better outcomes in patients with epiglottitis requiring airway management (tracheotomy or airway intubation). This was a retrospective cohort study on patients hospitalized for epiglottitis requiring airway management from a nationwide inpatient database (between July 2010 and March 2019). Patients treated with systemic corticosteroids equivalent to methylprednisolone ≥40 mg/d within 2 days of admission and patients who were not treated with corticosteroids within 2 days of admission were compared after inverse probability of treatment weighting using covariate balancing propensity score. The primary outcome was all-cause 30-day in-hospital mortality, and secondary outcomes included all-cause 7-day in-hospital mortality, length of hospital stay, and total medical cost. There were 1986 and 1771 patients in the corticosteroid and control groups, respectively. A total of 72 of 3757 (1.9%) patients died within 30 days of admission, including 17 of 1986 (0.9%) patients in the corticosteroid group and 55 of 1771 (3.1%) in the control group (weighted odds ratio, 0.28 [95% confidence interval, 0.11-0.70]; weighted risk difference, -2.2% [-3.2% to -1.3%]). Treatment with corticosteroids was associated with lower total medical costs (weighted median, $6,187 vs. $6,587; weighted difference, $-1,123 [-2,238 to -8]) but not all-cause 7-day in-hospital mortality (weighted odds ratio, 0.63 [0.22-1.82]; weighted risk difference, -0.3% [-0.9 to 0.2]) and length of hospital stay (weighted median, 13 vs. 13 days; weighted difference, -0.2 days [-2.1 to 1.8]). Systemic corticosteroids may be beneficial to patients with epiglottitis requiring airway management. 3 Laryngoscope, 133:344-349, 2023.

Five-year audit of adherence to an anaesthesia pre-induction checklist.

SummaryAlthough patient safety related to airway management has improved substantially over the last few decades, life‐threatening events still occur. Technical skills, clinical expertise and human factors contribute to successful airway management. Checklists aim to improve safety by providing a structured approach to equipment, personnel and decision‐making. This audit investigates adherence to our institution's airway checklist from 1 June 2016 to 31 May 2021. Inclusion criteria were procedures requiring airway management and we excluded all procedures performed solely under regional anaesthesia, sedation without airway management or paediatric and cardiovascular surgery. The primary outcome was the proportion of wholly performed pre‐induction checklists. Secondary outcomes were the pattern of adherence over the 5 years well as details of airway management, including: airway management difficulties; time and location of induction; anaesthesia teams in operating theatres (including teams for different surgical specialities); non‐operating theatre and emergency procedures; type of anaesthesia (general or combined); and urgency of the procedure. In total, 95,946 procedures were included. In 57.3%, anaesthesia pre‐induction checklists were completed. Over the 5 years after implementation, adherence improved from 48.3% to 66.7% (p < 0.001). Anticipated and unanticipated airway management difficulties (e.g. facemask ventilation, supraglottic airway device or intubation) defined by the handling anaesthetist were encountered in 4.2% of all procedures. Completion of the checklist differed depending on the time of day (61.3% during the day vs. 35.0% during the night, p < 0.001). Completion also differed depending on location (66.8% in operating theatres vs. 41.0% for non‐operating theatre anaesthesia, p < 0.001) and urgency of procedure (65.4% in non‐emergencies vs. 35.4% in emergencies, p < 0.001). A mixed‐effect model indicated that urgency of procedure is a strong predictor for adherence, with emergency cases having lower adherence (OR 0.58, 95%CI 0.49–0.68, p < 0.001). In conclusion, over 5 years, a significant increase in adherence to an anaesthesia pre‐induction checklist was found, and areas for further improvement (e.g. emergencies, non‐operating room procedures, night‐time procedures) were identified.

Comparison of the Characteristics of Intubation Airway Barrier Devices Using a Simulated Airway Task Trainer.

Background: With the advent of variant strains such as Delta and Omicron, there have been renewed concerns regarding transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease 2019 (COVID-19)) disease to healthcare professionals, particularly during intubation procedures. Several forms of barrier protection aimed at decreasing the spread of aerosolized droplets were developed during the early onset of the pandemic.Objectives: Using a simulated airway model, we examined the impact that three separate barrier devices had on intubation time and success using both direct and video laryngoscopy. We hypothesized that the functionally simplistic devices would be preferred and would allow for faster intubations.Methods: Just-in-time training sessions focusing on COVID-19 intubations were set up between March and June of 2020. Sixty-seven emergency physicians and anesthesiologists participated. For a subset of physicians, exact times to barrier device setup and both direct and indirect intubations using three different barrier devices were recorded. Subsequently, physicians were asked to fill out a survey regarding their experiences.Results: The survey response rate was 60%. In general, this cohort preferred a plain clear plastic drape or clear plastic drape with polyvinyl chloride (PVC) cube for direct laryngoscopy and video laryngoscopy setups. The use of these two devices resulted in significantly faster times to completed intubation when compared with the fiberglass box while using a simulated task trainer.Conclusion: In general, a simple, plastic sheet was the preferred barrier device using video laryngoscopy. Although setup times were faster using the fiberglass box, intubation times were significantly faster using the plastic drape or PVC frame.

Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU.

Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU.

Evidence-based practice of self-made tracheal catheter fixation band in prevention of unplanned extubation

With the development of medical technology, the fixation method of the oral duct is constantly updated, and the selection of a relatively safe, effective, simple and fast fixation method of the oral duct has been widely concerned. However, the use of traditional 3M I-shaped tape fixation needs to be cut, which wastes time and easily leads to the outward displacement of the tracheal tube, and is easy to be soaked by oral secretions, resulting in facial skin damage. Therefore, the medical staffs of the department of critical care medicine of Hengshui People's Hospital designed a self-made tracheal catheter fixing band (composed of the main structure, the fixed band, the internal adjusting structure and the internal structure of the fixed block), and obtained the national utility model patent (ZL 2018 2 0508681.6). The inner side of the fixing band is fixed with a spongy body, which can absorb the secretions around the mouth to avoid the moist condition around the mouth and cheek skin. Meanwhile, the endotracheal catheter is fixed with the help of the card slot, hinge and other structures, which can fully ensure the fixation effect. A total of 80 patients undergoing airway intubation were admitted to the department of critical care medicine of our hospital from October 2020 to September 2021. They were divided into observation group and control group according to intubation time (single number and double number), with 40 patients in each group. The observation group was fixed with self-made tracheal catheter fixation band. Through evidence-based practice path, relevant literatures at home and abroad were searched for clinical practice basis, and the practice plan was formulated and implemented. The control group was fixed with 3M tape + inch tape according to the traditional method. The fixation of tracheal tube and the degree of facial skin injury were compared between the two groups. All patients were included in the final analysis without shedding cases. Severe catheter displacement occurred in 3 patients (7.5%) in the control group, and no severe catheter displacement occurred in the observation group. The incidence of facial skin injury in the observation group was significantly lower than that in the control group [25.0% (10/40) vs. 55.0% (22/40), P < 0.05]. Moreover, the fixation time of the observation group was significantly shorter than that of the control group (minute: 12.11±1.69 vs 17.59±1.27, P < 0.05). The application of self-made tracheal catheter fixation band can shorten the fixation time of tracheal catheter and reduce the incidence of unplanned endotracheal extubation (UEE) and facial skin injury, which is worthy of clinical promotion and application.