Airway Intubation Research Articles

Factors for advancing emergency airway management practice

Compiling factors from scientific evidence of airway management in the emergency setting is a strategy for improving patient outcomes. Review and original articles in this special issue highlight the essential elements that deserve special attention in clinical practice, including airway assessments before artificial airway establishment, rapid sequence induction, continuous monitoring of vital signs after airway intubation, and management of artificial airway-associated discomfort.

Perioperative Anesthetic Management in Preterm 12 Days Infants with Giant Meningoencephalocele at Mid Occipital and Secondary Trigonocephaly

Introduction: A meningoencephalocele is herniation of neural element along with meninges through a congenital defect in cranium. The incidence of encephalocele is approximately 1/5000 live births; occipital encephalocele is more common in females than males. It is called as giant meningoencephalocele when the head is smaller than the meningoencephalocele. These giant meningoencephaloceles harbor a large amount of cerebrospinal fluid (CSF) and brain tissue, so there occur various surgical challenges and anesthetic challenges in positioning and intubation. Case: A 12 days neonate was consulted to the neurosurgery department with complaints of large swelling over the back of head and difficulty in feeding. She was diagnosed with ventriculomegaly and meningoencephalocele since 32-33 pregnancy. The swelling was small at the time of birth, but it gradually increased in size. The child was born by section caesarean because of fetal distress and meningoenchepalocele. The neonate current weight was 3.195 grams with Post Conceptional Age (PCA) 35-36 weeks. On examination, the patient large spherical swelling was present over occipital region and there was no head control. The patient was active, conscious with no impression of focal neurological deficit. Systemic examination was unremarkable. The head circumference was 30 cm and circumference of occipital swelling was 40 cm. Potential problems in this patient include preoperative preparation and optimization of general condition, difficulty in positioning the patient, difficult airway (intubation), periodic apnea and potential hemodynamic disturbances and a sudden decrease in intracranial pressure during cele resection. Conclusion: Perioperative management in this case started from preoperative to postoperative evaluation. Preoperative preparation in anticipation of airway difficulties and communication with the operator is very important. Appropriate anesthetic techniques should aim to maintain stable hemodynamics and oxygenation and prevent a sudden increase or decrease in intracranial pressure.

Airway Management: A Case of Desmoplastic Ameloblastoma of Right Mandibular Body

Background- Desmoplastic ameloblastoma (DA) is an uncommon variety of ameloblastoma that accounts for 4–13% of all cases, with notable differences in anatomical location, imaging, and histologic appearance. It is classified as a variety of ameloblastoma in the WHO classification of head and neck tumours (WHO-2005). Because it commonly occurs in the anterior region of the jaws as a mixed radio-opaque-radiolucent lesion, the tumour resembles a benign fibro-osseous lesion.
 Case report- We present a case of desmoplastic ameloblastoma in a 51-year-old female with a painless swelling in the lower right region of mandible. Fine needle aspiration revealed no fluid. Both panoramic radiographs and a computed tomography scan revealed a mixed lesion with a multilocular appearance. Desmoplastic ameloblastoma was confirmed after an incisional biopsy. From teeth 41 to the angle of the jaw, a composite resection of the lesion was performed with segmental mandibulectomy. With a peek implant, it was repaired. The possibility for a problematic airway is emphasised in this case, with great surgical results.
 Conclusion: Desmoplastic ameloblastoma is a kind of ameloblastoma with unique clinic radiographic and histologic characteristics. Despite its rarity, the tumour necessitates a thorough examination due to the challenges it poses with airway ventilation and intubation.

50 Continuing Essential Education During the COVID-19 Pandemic: Virtual Neonatal Skills Training

Practical procedures are integral to neonatal care. All first-year paediatric specialist trainees (ST1s) are expected to develop essential skills from their first neonatal placement. However, many trainees join the speciality with minimal prior exposure. With recent changes in junior doctors’ contracts, reduced working hours and evolving clinical practices, trainees may not get enough clinical exposure to acquire required skills. Simulation is recognized as essential to bridge this training gap The aim of the study was to adapt neonatal skills training to virtual delivery.In September 2020, we trialled a half-day virtual training course for new trainees on core topics. The first part included ‘Human Factors’ followed by ‘Stabilization of the premature infant’ using a pre-recorded simulation followed by a live debrief. The second part covered ‘intubation and difficult airway’ followed by ‘vascular access’. We used interactive lectures and pre-recorded demonstrations. A full-day course was then organized for new trainees in March 2021. We included additional sessions on ‘Newborn Infant Physical Examination’ (NIPE), ‘chest drain insertion’ and ‘journal club’, including sign posting to the Critical Appraisal Skills Programme (CASP). Interaction was encouraged to facilitate peer bonding. A Paediatric Trainee Committee representative also joined to outline the support available for trainees. We followed a similar structure to the first course but added live simulation demonstrations of equipment and techniques.Seventeen trainees attended the full-day course. A number of candidates rating the sessions as extremely useful were 16 for ‘Stabilization of the premature infant’ and ‘intubation and difficult airway’, 14 for ‘Human Factors’ and ‘NIPE’, 12 for ‘vascular access’ and ‘chest drain insertion’ and 11 for Journal club. Trainees commented positively on the videos, equipment demonstration, level of interactivity and overall usefulness of the course. Nine trainees commented on desire for additional face-to-face training.After balancing the safety and learning needs of trainees, we adapted an established face-to-face skills day for virtual delivery during the COVID-19 pandemic. Whilst we recognize that virtual training is not a substitute for doing, we were able to maintain essential education during highly pressured times. Feedback demonstrates that our virtual teaching programme was well received and useful. It also emphasizes the value of actual practice and the urgency to restore hands-on training as soon as possible.

A COMPARATIVE STUDY OF MODIFIED MALLAMPATI CLASSIFICATION WITH NECK CIRCUMFERENCE ALONG WITH UPPER LIP BITE TEST IN MORBIDLY OBESE PATIENTS

INTRODUCTION: Anaesthesia in morbidly obese patients can present many challenges. The overriding concern of most anaesthesiologists is airway management, as obese patients have been thought to be at greater risk of difcult airway and/or difcult intubation, when compared with the general population. The term 'difcult airway' has been dened by the American Society of Anaesthesiologists (ASA) taskforce as the clinical situation in which a conventionally trained anaesthesiologist experiences problems with mask ventilation or tracheal intubation or both. AIMS AND OBJECTIVES- To assess the positive predictive value,sensitivity and specicity of MMPC, NC along with ULBT and compare it with Cormack Lehane grading intraoperatively. MATERIALS AND METHOD- Preoperative airway assessment of 200 patients posted for surgery under general anaesthesia was carried out to evaluate the usefulness of multiple screening tests in predicting the ease or difculty of laryngoscopy in obese patients undergoing laparoscopic bariatric surgery. Modied Mallampati test grade III or IV, Upper Lip Bite test grade III, Neck Circumference >40cm were considered as predictors of difcult laryngoscopy. Laryngoscopy was considered difcult if the view on laryngoscopy was Cormack and Lehane grade III or IV. The results were evaluated on the basis of sensitivity, specicity, positive and negative predictive value and accuracy of these tests. RESULT- Group A (ULBT+MMPC) identied 65% of the patients with difcult intubation (sensitivity of 92.86 % & specicity of 33.3 %), whereas Group B (ULBT+NC) identied 75% of the patients with difcult airway (sensitivity 93.75% & specicity of 25%). Pearson Correlation analysis was applied to know the correlation between the various tests and the Cormack Lehane Classication, both the groups had p value of 0.001 , which was highly signicant. CONCLUSION-When multiple predictors are taken into consideration there was a considerable reduction in false negatives with signicant improvement in accuracy of test and hence prediction of difcult laryngoscopy was made easy. Application of multiple predictors in combination can reduce the frequency of unanticipated difculty and unnecessary interventions related to over prediction of airway difculty.

Clinical Features of E-cigarette, or Vaping, Product Use–Associated Lung Injury in Teenagers

The authors described the spectrum of disease seen in patients admitted with electronic cigarette or vaping product-use–associated lung injury (EVALI). This is the first focused case series of EVALI in children.All patients aged 13 to 18 years admitted to the authors’ tertiary care, university-affiliated children’s hospital (Dallas, TX) with a diagnosis of EVALI.This was a retrospective chart review of patients admitted with EVALI from December 2018 to November 2019.A total of 13 patients were admitted with EVALI. Patients endorsed usage of δ-9-tetrahydrocannabinol (THC) (12), nicotine and THC (7), and nicotine (1). Symptoms included subjective fever (100%), respiratory symptoms (85%), and GI symptoms (85%). A total of 23% of abnormal lung CTs were identified on abdominal computed tomography scans in patients undergoing a primary gastrointestinal evaluation. Respiratory support included room air (1), nasal cannula (8), bilevel positive airway pressure (2), intubation (1), and venovenous extracorporeal membrane oxygenation (1). Four patients required supplemental oxygen at discharge. Five patients had pulmonary function tests pre- and postglucocorticoid administration. forced expiratory volume in 1 second and forced vital capacity both increased significantly after glucocorticoids.The clinical severity of EVALI in adolescents is variable. The majority of admitted patients required some form of oxygenation support. Glucocorticoids were a successful treatment with objective improvement in pulmonary function tests postglucocorticoid administration.This is an important case series for pediatricians to learn from, regarding EVALI. As we learn more about this potentially fatal condition, common threads have emerged that are supported by these findings, including the use of vaping products for THC and various alterations to the vaping device. It is important for pediatricians and all health care professionals who work with adolescents to recognize the dangers associated with vaping and e-cigarette use as well as learn skills to communicate these risks with individual patients. Although federal and state regulations have been enacted to try and limit the use of these products in children and adolescents, millions remain vulnerable.

Abstract 11045: Pre-Hospital Airway for Out-of-Hospital Cardiac Arrest: A Nationwide Multicenter Study

Introduction: This study investigated whether use of pre-hospital advanced airway management (AAM) is associated with improved survival of adults with out-of hospital cardiac arrest (OHCA) compared to conventional bag-valve-mask ventilation (BVM). Method: The study subjects were derived from Korean Cardiac Arrest Research Consortium (KoCARC), a multi-center OHCA registry of Korea. Patients who underwent AAM or BVM using supraglottic airway, oropharyngeal airway, or endotracheal intubation were compared. The differences in baseline clinical characteristics were adjusted using propensity scoring matching (PSM) or inverse probability of treatment weighting (IPTW). The primary outcome was 30-day survival with neurologically favorable status of cerebral performance category ≤2. The outcome was also compared according to the duration of low-flow time. Results: Of 9,616 patients enrolled, (median age = 71, male sex = 65%) there were 7,583 AAM and 2,033 BVM patients. The unadjusted survival to with neurologically favorable status was lower in AAM compared to BVM (HR = 1.27, 95% confidence interval (CI) = 1.20 - 1.34, p<0.001). However, there was no significant difference of survival to with neurologically favorable status between AAM and BVM after PSM or ITPW-adjusted comparisons (p>0.05, all). This finding was consistent irrespective of duration of low-flow time. Conclusion: In this nationwide real-world data of out-of hospital cardiac arrest study, prehospital advanced airway management compared to bag-and-mask ventilation did not result in an improved clinical outcome at 30 days.

Abstract 13110: Novel Application of Thoracic Impedance to Characterize Ventilations During Cardiopulmonary Resuscitation in the Pragmatic Airway Resuscitation Trial

Introduction: Controlled ventilation is important in OHCA resuscitation, but there are few validated methods for accurate detection of ventilations. We sought to utilize changes in thoracic impedance (TI) to characterize resuscitation ventilations in the Pragmatic Airway Resuscitation Trial (PART). Methods: We analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Ft Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signal. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases of the ventilation impedance signal (Figure 1). We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test. Results: We included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71Ω, Ae 0.70Ω vs LT: Ai 0.46Ω Ae 0.45Ω, p<0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22Ω, Ae 1.14Ω VS LT: Ai 0.74Ω, Ae 0.68Ω, p<0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups. Conclusion: Compared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.

Abstract 13071: Supraglottic Airway Devices Are Associated With Asphyxial Physiology Upon Arrival for ECPR in Patients With Refractory OHCA Treated With Prolonged CPR

Introduction: Multiple clinical trials have failed to show significant differences in survival between use of endotracheal intubation (ETI) and supraglottic airway devices (SGA) in patients with out-of-hospital cardiac arrest (OHCA). However, treatment in these trials was limited to standard ACLS, which favors short duration of CPR. We sought to compare the physiological effect of ETI versus SGA use in patients treated with prolonged CPR and extracorporeal pulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia (VT/VF) by the Minnesota Mobile Resuscitation Consortium (MMRC). Methods: Consecutive refractory VT/VF OHCA patients transported by the MMRC to the University of Minnesota for ECPR between 2015 and 2021 were included in this retrospective analysis. Patients were considered ineligible for ECPR if they failed specific arterial blood gas metabolic criteria (lactic acid >18 mmol/L, PaO2 <50 mmHg, and ETCO2 <10 mmHg). Metabolic parameters at presentation and survival were compared between patients receiving ETI and SGA. Results: Among 260 patients (58.0±11.8 years), 46.5% received ETI and 53.5% received SGA. During the index hospitalization, 78/260 (30%) achieved neurologically favorable survival. Compared to those receiving ETI, patients receiving SGA had lower PaO2 (116.8±118.7 versus 135.8±128.3 mmHg, p=0.03), higher PaCO2 (69.7±28.9 versus 60.7±25.6 mmHg, p=0.01), and lower pH (7.00±0.19 versus 7.06±0.21, p=0.008). Significantly more patients who received SGA had PaO2 <50mmHg (29.1% versus 16.9%, respectively; p=0.02) and ≥1 ECPR exclusion criteria (33.1% versus 20.7%, respectively; p=0.03). Among patients excluded for PaO2 <50 mmHg, the presenting PaO2 was 35.5±11.0 mmHg and the presenting PaCO2 was 94.5±26.2 mmHg, suggestive of absence of effective ventilation (asphyxia) at presentation. Survival with CPC 1-2 was 34.7% versus 25.9% for ETI versus SGA, respectively (p=0.12). Conclusion: Use of SGA, during prolonged CPR in refractory VT/VF OHCA, was associated with a significant increase in the proportion of patients presenting with significant hypoxemia and asphyxial physiology, thus increasing ineligibility for ECPR.

Abstract 10874: Evaluation of Intensive Care Unit and Ventilator-free Days as Alternative Outcomes in Out-of-Hospital Cardiac Arrest Trials

Objective: Compared with traditional out-of-hospital cardiac arrest (OHCA) trial outcomes such as hospital survival, alternative outcomes such as intensive care unit-free (IFD) and ventilator-free days (VFD) have potential advantages including requiring smaller sample sizes to detect significant differences. Few studies have evaluated these outcomes in OHCA. We sought to evaluate the utility and validity of IFD and VFD as candidate outcomes for OHCA trials. Methods: We analyzed data from the Pragmatic Airway Resuscitation Trial (PART), which tested laryngeal tube (LT) vs. endotracheal intubation (ETI) airway strategies in adult OHCA. We defined IFD as the number of days alive and permanently out of ICU during the first 30 days after the OHCA event. We examined IFD distribution and correlation with Modified Rankin Scale (MRS). To test associations with trial interventions, we applied a range of analytic strategies, including modeling IFD as continuous (Generalized Estimating Equations - GEE), non-parametric (Wilcoxon Rank-Sum test - WRS) and count (zero-inflated negative binomial regression - ZINB) data. We also modeled time-to-ICU discharge using a survival model with death as a competing risk. We repeated the analysis assessing VFD. Results: IFD was available for 2,898 of 3,004 patients. IFD was skewed and J-shaped; 91% IFD=0 and 5.3% IFD≥22. Mean (±SD) IFD was 2.0±6.6 days; 21.2±7.5 days for survivors. IFD varied by intervention (LT 2.4±7.2, ETI 1.6±5.8 days). IFD and VFD strongly correlated with MRS (ρ= -0.88, -0.89). LT was associated with increased IFD using GEE, WRS, and ZINB, but not competing risks model. (Table) LT was associated with increased VFD using GEE and WRS, but not ZINB or competing risks models. Conclusion: IFD and VFD differentiated OHCA interventions, suggesting their utility. IFD and VFD were highly correlated with MRS, suggesting validity. IFD and VFD have important features that may influence OHCA trial design.

Aero-Sim: A User-Centred Testbed for the Evaluation of Devices as Protection from Droplets and/or Aerosol Contaminations.

Concerns over high transmission risk of SARS-CoV-2 have led to innovation and usage of an aerosol box to protect healthcare workers during airway intubation in patients with COVID-19. However, only a few studies have examined the impact of these aerosol boxes on the dispersion of droplets and aerosols, which are both thought to be significant contributors to the spread of COVID-19. In addition, to our knowledge, only a few studies have included in the concerned testbeds elements of the work context, which nevertheless have an impact on the use of the device.

Red Blood Cells from COVID-19 Patients Show Evidence of Increased Oxidative Stress and Increased Lactate Influx

Red Blood Cells from COVID-19 Patients Show Evidence of Increased Oxidative Stress and Increased Lactate InfluxCorona Disease 19 (COVID-19) is caused by SARS-CoV-2, a novel, highly infectious, single stranded RNA virus. In severe cases, excess oxidative stress produced by a ‘cytokine storm’ may generate excess reactive oxygen species (ROS) and lead to tissue damage in the lungs and elsewhere. As the potential role of RBCs in the pathophysiology of COVID-19 remains controversial (1), we investigated for evidence of increased oxidative stress and increased thrombotic tendency in RBCs from patients with COVID-19 infection.Following ethical approval and written informed consent, we used flow cytometry (BD FACSCanto II) to measure baseline RBC ROS following incubation with 2‘-7‘-dichlorofluorescein diacetate (DCF). RBC ROS were also measured following pre-incubation with hydrogen peroxide (H2O2) (2mM) +/- antioxidant N-acetyl cysteine (NAC) (0.6mM). We also measured RBC surface expression of adhesion molecules CD44, CD47 and CD242, as well as CD147. Results were expressed as mean +/- standard deviation (SD).RBC ROS were measured in 22 COVID-19 positive patients and in 10 age matched healthy controls. One patient died from respiratory failure, whilst only 3 others required ITU admission for continuous positive airway pressure (CPAP) or intubation. There was no statistical difference in mean basal RBC DCF mean fluorescence intensity (MFI) levels between COVID-19 positive patients and controls. However, mean increase in RBC DCF MFI following H2O2 incubation was significantly higher in the COVID-19 positive group (1105.7+/-336.3) compared to the control group (843.4+/-256.7)( p= 0.042). The increase in RBC DCF MFI in the COVID-19 positive group correlated with CRP (p=0.014) but not with D-dimer, serum ferritin or any complete blood count (CBC) parameters. Incubation of RBC with 0.6 mM NAC for 30 minutes prior to H2O2 exposure caused a mean reduction in DCF MFI of 26.7% in the COVID-19 positive group. RBC expression of CD44, CD47, CD242 and CD147 were measured In a separate cohort of COVID-19 positive patients (n=32), and in 22 age matched controls. There were no statistically significant differences in mean expression levels of CD44, CD47 and CD242 between the 2 groups. However, mean RBC CD147 MFI expression was higher in the COVID-19 group (1319.64+/-374.76) compared to controls (1061.59+/-253.33) (p=0.018). There was no significant correlation between RBC CD147 MFI and D-dimer, CRP, serum ferritin or any CBC parameters in the COVID-19 positive group. However, 21 of the 32 COVID-19 positive patients had blood lactate levels measured and there was a positive correlation between CD147 MFI expression and blood lactate (R=0.56, p=0.0077).Induction of oxidative stress by H2O2 resulted in a greater increase in ROS in RBCs from COVID-19 patients compared to controls and with correlation to CRP, despite the fact that there were very few patients with severe disease in the study. This suggests a role for oxidative stress in disease pathogenesis. Pre-incubation with NAC attenuated this increase in ROS, suggesting a possible role for antioxidants in therapy. Increased RBC cell surface expression of adhesion molecules CD44, CD47 and CD242 can facilitate RBC interaction with platelets and/or endothelial cells, potentially contributing to thrombosis. We found no increase in their expression in COVID-19 patients compared to controls although RBCs may contribute to thrombosis in COVID-19 infection by other means (1). CD147 is tightly associated with and enables proper expression of monocarboxylate transporter 1, the lactate transporter for RBCs. We found increased surface expression of CD147 on RBCs of COVID-19 patients, whilst CD147 expression showed a moderate correlation with serum lactate levels, suggesting that RBCs in COVID-19 infection may be acting as a lactate sink to protect against lactic acidosis.In summary, our study suggests that COVID-19 infection causes increased oxidative stress and increased lactate influx in RBCs. Further studies are warranted into the role of RBCs in COVID-19 infection.Reference:(1) Murphy P, Glavey S, Quinn J. Anemia and red blood cell abnormalities in COVID-19. Leuk Lymphoma 2021;62:1539 DisclosuresQuinn: Takeda: Honoraria. Glavey: Abbvie: Research Funding; Celgene and BMS company: Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding.

Предоперационная подготовка и особенности индукции в анестезию при острой кишечной непроходимости (клиническая лекция)

В статье представлены основные направления предоперационной подготовки в случае тяжелой острой кишечной непроходимости (ОКН) и подчеркнуто, что данная подготовка должна быть ограниченной во времени и не задерживать проведение оперативного вмешательства. При тяжелой ОКН вместе с тщательной оценкой витальных функций и определением ведущих нарушений крайне важно оценить больного по шкалам и определить основные риски развития осложнений. Общая анестезия, как правило, является методом выбора при ОКН, однако для улучшения интра- и послеоперационного обезболивания она может быть дополнена и методами регионарной анестезии. При подготовке к проведению общей анестезии в первую очередь следует определять риски сложной интубации, а также регургитации и аспирации желудочного содержимого, что позволяет целенаправленно подходить к выбору техник интубации и предотвращать возникновение этих грозных осложнений. Прием Селлика уже не обязателен для использования у таких пациентов, а вместо него во время интубации может быть применена бимануальная ларингоскопия. Артериальная гипотензия является частым осложнением во время индукции в анестезию при тяжелой ГКН, и у таких больных всегда следует проводить инфузионную терапию, а также коррекцию водно-электролитных нарушений. Вместе с тем для предотвращения отека кишечника и развития интраабдоминальной гипертензии инфузионная терапия должна быть ограничена как во времени, так и в объеме. Если невозможно полностью скорректировать гиповолемию, для снижения риска возникновения существенной артериальной гипотензии во время индукции в анестезию быстрой последовательности следует с профилактической целью назначать вазопрессоры.

Comparative evaluation of Intubating Laryngeal Mask Airway (ILMA), I-gel and Ambu AuraGain for blind tracheal intubation in adults.

Background and Aims:The supraglottic airway devices (SADs) that allow direct (without an intermediary device like Aintree or airway exchange catheters) tracheal intubation can be invaluable for field use in conditions ideally managed by intubation. Whilst fiberscope-guided intubation is the method of choice, if these ‘direct-intubation’ SADs could provide high success rates for blind tracheal intubation, their scope of use can increase tremendously. Our study assesses intubating laryngeal mask airway (ILMA), i-gel and Ambu AuraGain for blind tracheal intubation in adults.Material and Methods:Ninety adults undergoing elective surgery were randomized into three equal groups. After induction of anesthesia, the group-specific SAD was inserted and on achieving adequate ventilation, blind tracheal intubation was attempted over two attempts. Success rates and time of achieving adequate device placement and tracheal intubation through these were evaluated. Data were analyzed using SPSS version 17.0 and P < 0.05 was considered statistically significant.Results:All three devices could achieve adequate ventilation within two allowed attempts. Successful tracheal intubation rates were significantly better with ILMA than i-gel on first attempt (87% vs. 27%, P < 0.001) and after second attempt that was supplemented with optimization maneuvers (100% vs. 40%, P < 0.001). No patient could be intubated through Ambu AuraGain within two attempts. Time taken for successful tracheal intubation did not differ significantly (P = 0.205) with ILMA or i-gel.Conclusion:Out of ILMA, I-gel and Ambu AuraGain, ILMA is the best device for blind tracheal intubation in adults with normal airways.

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial.

Background: The data on long-term nasotracheal intubation among mechanically ventilated critically ill children is limited. The purpose of this study was to compare the rate of post-extubation airway obstruction (PEAO) with nasotracheal and orotracheal intubation.Methods: This open-label randomized controlled trial was conducted in PICU of a tertiary care and teaching hospital in North India from January-December 2020 involving intubated children aged 3 months−12 years. After written informed consent, children were randomized into nasotracheal and orotracheal intubation groups. Post-extubation, modified Westley's croup score (mWCS) was used at 10-timepoints (0-min, 30 min, 1, 2, 3, 6, 12, 24, 36, and 48-h after extubation) to monitor for PEAO. The primary outcome was the rate of PEAO; and secondary outcomes were time taken for intubation, number of intubation attempts, complications during intubation, unplanned extubation, repeated intubations, tube malposition/displacement, endotracheal tube blockade, ventilator associated pneumonia, skin trauma, extubation failure/re-intubation, duration of PICU stay, and mortality.Results: Seventy children were randomized into nasotracheal (n = 30) and orotracheal (n = 40) groups. Both the groups were similar in baseline characteristics. The rate of PEAO was similar between nasotracheal and orotracheal groups (10 vs. 20%, p = 0.14). The maximum mWCS and mWCS at 10-timepoints were similar in two groups. The time taken for intubation was significantly longer (85 vs. 48 s, p < 0.001) in nasotracheal group, whereas other secondary outcomes were similar in two groups.Conclusion: The rate of PEAO was not different between nasotracheal and orotracheal groups.Clinical Trial Registration:http://ctri.nic.in, Identifier: CTRI/2020/01/022988.

Novel application of thoracic impedance to characterize ventilations during cardiopulmonary resuscitation in the pragmatic airway resuscitation trial

BackgroundSignificant challenges exist in measuring ventilation quality during out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Since ventilation is associated with outcomes in cardiac arrest, tools that objectively describe ventilation dynamics are needed. We sought to characterize thoracic impedance (TI) oscillations associated with ventilation waveforms in the Pragmatic Airway Resuscitation Trial (PART). MethodsWe analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Fort Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signals. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases. We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test. ResultsWe included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71 Ω, Ae 0.70 Ω vs LT: Ai 0.46 Ω, Ae 0.45 Ω; p < 0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22 Ω, Ae 1.14 Ω VS LT: Ai 0.74 Ω, Ae 0.68 Ω; p < 0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups. ConclusionCompared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.

Application of Predictive Nursing Intervention in ICU Patients with Ventilator-associated Pneumonia Treated with Mechanical Ventilation through Airway Intubation

Application of Predictive Nursing Intervention in ICU Patients with Ventilator-associated Pneumonia Treated with Mechanical Ventilation through Airway Intubation

Evaluation of the aerosol generating potential of endoscopic dacryocystorhinostomy.

PurposeThe COVID‐19 pandemic gave rise to renewed concerns of the transmission risks posed by surgeries on sites of high viral colonization such as the nasopharynx. Endoscopic dacryocystorhinostomy (DCR) involves the creation of a new tear duct from the lacrimal sac to the nasal cavity. The purpose of this project is to determine if endoscopic DCR is an aerosol generating procedure (AGP).MethodsAn optical particle sizer (OPS) was used to intraoperatively quantify aerosol concentrations during four cases of endoscopic DCR. The OPS sampled the air once every 60 seconds throughout the operations. The time of important operative steps were documented and correlated with OPS readings. Particle concentrations during each major surgical step were compared to baseline readings by the Mann Whitney U Test.ResultsThere were statistically significant increases in median particle concentrations during laryngeal mask airway intubations for both particles 0.3 to 5.0 μm and >5.0 μm (P < .001 and P = .023, respectively). Median particle concentrations during nasolacrimal duct probing, middle meatal debridement, drilling, balloon insertion, tube insertion, and Posisef insertion were not statistically different from baseline.ConclusionsEndoscopic DCR in itself does not appear to be an AGP. It is, however, associated with other aerosol generating events such as laryngeal mask intubation, and thus requires appropriate personal protective equipment. Cautious interpretation of the results is encouraged given the limitations of OPS.Level of Evidence4.

The Urinary Uric Acid / Cr ratio as a marker of morbidity and mortality of preterm infants: a case\u2014control study

BackgroundPerinatal asphyxia is one of the main causes of preterm infant mortality. Some studies have shown that The Urinary Uric Acid / Cr (UUA/Cr) ratio may be used as an additional marker for perinatal asphyxia.This study intend to investigate the relationship of this ratio with outcomes of preterm infants admitted to NICU.MethodsThis case–control study was carried on 102 preterm newborn infants with gestational age of 30 weeks to 33 weeks and 6 days admitted in the neonatal intensive care unit.The case group, consisted of 51 premature neonates with a history of intubation, cardiopulmonary resuscitation, mechanical ventilation and Nasal continuous positive airway pressure (NCPAP) at birth, were compared with 51 matched neonates. The UUA/Cr ratio was measured in the first 24 h after birth. Complications during hospitalization, duration of hospitalization, and final outcome were evaluated.ResultsThe mean level of UUA/Cr ratio in case and control group were 5.4 ± 4.1 and 3.6 9 ± 2.9 respectively and this difference was statistically significant (p = 0.014). The UUA/Cr ratio were significantly higher in females, cesarean section delivery, Apgar score ≥ 8, neonates without any complication and neonates with less than 10 days of hospitalization. However, this ratio has no predictive value for the incidence of complications during hospitalization and long-term hospital stay for infants of the case group.ConclusionsThe Urinary Uric Acid / Cr ratio in the first 24 h after birth in preterm neonates who underwent intubation, NCPAP or cardiopulmonary resuscitation was higher than healthy neonates.

A Case of Unanticipated difficult Intubation in a patient posted for C5-C6 Posterior Fixation

Management of a “difficult airway” poses one of the most relevant and challenging tasks for anesthesiologists. Unanticipation with difficult airway and endotracheal intubation during the conduction of general anesthesia may result in complications and fatality. We report the case of a 14 yr old boy for planned C5-C6 spine fixation under general anaesthesia. Unanticipated difficult oral intubation after three failed attempts, managed by a stylleted cuffed endotracheal tube, head up tilt of the operation table, shoulder support, cricoid pressure and rotation of the endotracheal tube anticlockwise at the glottic opening.