Airway Intubation Research Articles

Airway Anesthesia for Awake Tracheal Intubation: A Review of the Literature.

Airway topicalization is frequently utilized by anesthesiologists to facilitate open airway procedures, aid intubation for a difficult airway, and prevent adverse respiratory events. This review article summarizes the techniques available for airway topicalization for a patient who is deemed to be difficult to intubate. We focus on the indications for use, local anesthetic maximum dosages and safety profiles, sedation techniques, and trials and pitfalls during airway topicalization for difficult intubation.

A Comparative Study of Airway Nerve Blocks and Atomized Lidocaine by the Laryngo-Tracheal Mucosal Atomization Device (LMA MADgic) Airway for Oral Awake Fiberoptic Intubation.

BackgroundAwake intubation is used most commonly in patients with a predicted difficult airway. There are situations where the safest method to secure an airway is to place an endotracheal tube in an awake and spontaneously breathing patient. Our aim was to compare the two modalities, airway nerve blocks and atomized lidocaine by the Laryngo-Tracheal Mucosal Atomization Device (LMA MADgic)airway for awake fiberoptic intubation (AFOI).MethodsA total of 50 patients with anticipated difficult airway requiring AFOI were randomly allocated into two groups. Group A received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal nerve) each with 2 ml of 2% lidocaine and group B received airway anesthesia through atomized lidocaine by LMA MADgic using 10 ml of 2% lidocaine. Fiberoptic guided orotracheal intubation was then performed in both the groups using LMA MADgic as the conduit. The primary outcome measured was intubation time and the secondary outcome included quality of intubation, hemodynamic variables, and any adverse events.ResultsThe intubation time was found to be significantly lower in Group A (63.80±7.86 seconds) as compared to Group B (184.96±13.38 seconds) (p=0.0001). The ease of intubation, intubating condition, and patient comfort were better in patients who received airway blocks. Group B had an increased number of coughing/gagging episodes as compared with Group A. Between the two groups, group A showed better hemodynamics and fewer episodes of desaturation than group B.ConclusionUpper airway nerve blocks provide faster intubation, adequate airway anesthesia, and less patient discomfort to aid in AFOI in patients with anticipated difficult airway as compared to topical anesthesia using an atomizer.

Growth Rates of Infants Randomized to Continuous Positive Airway Pressure or Intubation After Extremely Preterm Birth

To evaluate the effects of early treatment with continuous positive airway pressure (CPAP) on nutritional intake and in-hospital growth rates of extremely preterm (EPT) infants. EPT infants (240/7-276/7weeks of gestation) enrolled in the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT) were included. EPT infants who died before 36weeks of postmenstrual age (PMA) were excluded. The growth rates from birth to 36weeks of PMA and follow-up outcomes at 18-22months corrected age of EPT infants randomized at birth to either early CPAP (intervention group) or early intubation for surfactant administration (control group) were analyzed. Growth data were analyzed for 810 of 1316 infants enrolled in SUPPORT (414 in the intervention group, 396 in the control group). The median gestational age was 26weeks, and the mean birth weight was 839g. Baseline characteristics, total nutritional intake, and in-hospital comorbidities were not significantly different between the 2 groups. In a regression model, growth rates between birth and 36weeks of PMA, as well as growth rates during multiple intervals from birth to day 7, days 7-14, days 14-21, days 21-28, day 28 to 32weeks PMA, and 32-36weeks PMA did not differ between treatment groups. Independent of treatment group, higher growth rates from day 21 to day 28 were associated with a lower risk of having a Bayley-III cognitive score <85 at 18-22months corrected age (P = .002). EPT infants randomized to early CPAP did not have higher in-hospital growth rates than infants randomized to early intubation.

The hypoxic pulmonary vasoconstriction: From physiology to clinical application in thoracic surgery.

More than 70 years after its original report, the hypoxic pulmonary vasoconstriction (HPV) response continues to spark scientific interest on its mechanisms and clinical implications, particularly for anesthesiologists involved in thoracic surgery. Selective airway intubation and one-lung ventilation (OLV) facilitates the surgical intervention on a collapsed lung while the HPV redirects blood flow from the “upper” non-ventilated hypoxic lung to the “dependent” ventilated lung. Therefore, by limiting intrapulmonary shunting and optimizing ventilation-to-perfusion (V/Q) ratio, the fall in arterial oxygen pressure (PaO2) is attenuated during OLV. The HPV involves a biphasic response mobilizing calcium within pulmonary vascular smooth muscles, which is activated within seconds after exposure to low alveolar oxygen pressure and that gradually disappears upon re-oxygenation. Many factors including acid-base balance, the degree of lung expansion, circulatory volemia as well as lung diseases and patient age affect HPV. Anesthetic agents, analgesics and cardiovascular medications may also interfer with HPV during the perioperative period. Since HPV represents the homeostatic mechanism for regional ventilation-to-perfusion matching and in turn, for optimal pulmonary oxygen uptake, a clear understanding of HPV is clinically relevant for all anesthesiologists.

Physiologic and Pathophysiologic Responses to Intubation

The placement of an endotracheal tube provides definitive airway control for the anesthesiologist and protects the patient from aspiration, hypoventilation and hypoxemia. Airway instrumentation and intubation, however, cause physiologic changes that may have negative effects especially in patients with systemic disease. An abundance of sensory receptors and nerve endings exist in the upper airway that respond to noxious stimulation by activation of the autonomic nervous system, which cause brief but profound cardiovascular and neurologic effects. Stimulation of upper airway receptors may elicit reflexes such as sneezing, coughing, gagging, swallowing, vomiting, laryngospasm and bronchospasm. The presence of the endotracheal tube also bypasses the normal conduit for air movement and changes the airway physiology. This review contains 4 figures, 3 tables, and 45 references. Keywords: intubation, sympathetic response, coronary artery disease, aortic dissection, aortic aneurysm, intracranial pressure, attenuating response, airway devices

In situ simulation improves perceived self-efficacy of OR nurses and anaesthesiologists during COVID-19 pandemic

IntroductionSelf-efficacy is defined as people’s internal beliefs about their ability to have an impact on events that affect their lives. As part of the COVID-19 pandemic, we carried out in...

Anesthesia for Airway Endoscopy and Micro-Laryngeal Surgery

Pre- and intra-operative anesthetic management considerations for airway endoscopy and micro-laryngeal surgery are covered in this chapter. Often presenting with critically obstructed or otherwise compromised airways, a carefully devised induction and airway control plan is essential. Unique to this type of surgery is the shared surgical field, requiring the utmost level of communication and cooperation between the surgical and anesthesia teams. Included is a discussion of ventilation options, routine and otherwise, and associated airway instrumentation such as jet ventilation catheters. Challenges of patient management during suspension laryngoscopy, are presented. Also addressed are laser basics, specific anesthetic considerations including risks and potential harms in the setting of these high-risk for fire procedures. This review contains 5 figures, 2 tables, and 40 references. Keywords: airway endoscopy, micro-laryngeal surgery, anesthetic considerations, obstructed airway, preoperative evaluation, airway intubation, laryngeal microsurgery, fire, OR

Hemodynamic Responses during Insertion of Laryngeal Mask Airway versus Conventional Intubation

Aim: To determine the hemodynamic response during insertion of laryngeal mask airway versus conventional intubation. Study design: Randomized controlled trial. Place and duration of study: Department of Anaesthesia, Jinnah Postgraduate Medical Centre, Karachi from 9th June 2016 to 10th December 2016. Methodology: One hundred and fifty-eight patients were enrolled, and they were divided in two groups; Group A (laryngeal mask airway) and patients falling in group B (conventional method). Baseline haemodynamic parameters were noted, and all patients were induced with propofol 2mg.kg 1. In group B, succinylcholine 1.5mg.kg-1 was used to facilitate intubation. After induction appropriate size endotracheal tube or laryngeal mask airway were inserted for airway control. For first five minutes after intervention, analgesics and any other stimulation were avoided, in order to prevent any haemodynamic alteration. All airway interventions were done by anaesthesiologist who had more than 5 years post fellowship experience. Mean arterial pressures were recorded. Initial haemodynamic parameters were measured when the patient enter the operating room and then second reading taken just after induction of anaesthesia, third reading recorded one minute and fourth reading 5 minutes after the intervention (i.e., after passing either endotracheal tube or laryngeal mask airway). Results: The average mean arterial pressure during process of intubation of patients in Group laryngeal mask airway group was 105.21±5.90 while in conventional group the average mean arterial pressure was 102.21±4.29 with P-value=0.001. Conclusion: Intubation through intubating laryngeal mask airway is accompanied by minimal cardiovascular responses than those associated with direct laryngoscopic tracheal intubation, so it can be used for patients in whom a marked pressor response would be deleterious. Keywords: Intubating laryngeal mask airway, Conventional laryngoscopy, Hemodynamic responses, Airway morbidity,

Acute laryngeal lesions following endotracheal intubation: Risk factors, classification and treatment

Laryngeal stenosis is certainly one of the most severe complications of airway intubation in children, eventually leading to tracheostomy and sometimes to additional surgical procedures. Primary prophylaxis through modification of its risk factors and secondary prophylaxis through the management of post-extubation laryngeal acute lesions seem to be key to avoidance of this fearful complication.The present article addresses known risk factors for the development of laryngeal acute lesions with emphasis on sedation level and intubation time. It also discusses available classification systems proposed in medical literature, especially the Classification of Acute Laryngeal Injuries (CALI) conceived by our research group, and its positive predictive value for the development of chronic lesions. Finally, debate focuses on treatment of each individual lesion. Despite excellent results observed with endoscopic methods for treating these lesions, there is still doubts pending over their management, and there is need for further studies to define adequate treatment for each patient and for each type of lesion.

The Performance of Flexible Tip Bougie™ in Intubating Simulated Difficult Airway Model.

This prospective, randomized, cross-over study compared the performance of the novel Flexible Tip Bougie™ (FTB) with a conventional bougie as an intubation aid in a simulated difficult airway manikin model among anaesthesiology trainees with regards of first pass success rate, time to intubation, number of attempts and ease of use. Sixty-two anesthesiology trainees, novice to the usage of FTB, participated in this study. Following a video demonstration, each participant performed endotracheal intubation on a manikin standardized to a difficult airway view. Each participant performed direct laryngoscopy and intubated the manikin using a conventional bougie and FTB, at least 1 day in between devices, in a randomized order. The first pass success rate was significantly higher with FTB (98.4%) compared to conventional bougie (85.5%), p = 0.008. The median time to intubation was significantly faster when using FTB, median = 32.0 s [Interquartile range (IQR): 23.8–41.3 s] compared to when using conventional bougie, median = 41.5 s (IQR: 31.8–69.5 s), p < 0.001. The FTB required significantly less intubation attempts compared to conventional bougie, p = 0.024. The overall ease of use, scored on a Likert scale from 1 to 5, was significantly higher in the FTB (4.26 ± 0.53) compared to the conventional bougie (3.19 ± 0.83), p < 0.001. This simulated difficult airway manikin study finding suggested that FTB is a useful adjunct for difficult airway intubation. The FTB offered a higher first pass success rate with a faster time to intubation and less required attempts.

Awake Tracheal Intubation during COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) pandemic has significantly affected routine healthcare including cancer care across the world. Head and neck cancer (HNC) is the most common cancer in India and has a good prognosis if treated surgically in early stages. HNC patients often present with difficult airway with reduced mouth opening requiring awake tracheal intubation (ATI). Health professionals are at a risk of getting infected with COVID-19 during ATI, a potential aerosol-generating procedure. We aimed to evaluate the modifications of ATI techniques used during the COVID-19 pandemic in our institution. Methodology: This retrospective observational study was conducted in a tertiary cancer care centre. All patients who had ATI performed between 25th March 2020 and 31st May 2020 were included in the study. The type of barrier methods used to prevent aerosol spread and the methods used to provide topical anaesthesia of the airway were documented and analysed. Results: Twenty-three patients underwent ATI during that period. Barrier methods such as aerosol box or transparent plastic drapes to prevent aerosol spread were used in 48% of patients. Lignocaine nebulisation and transtracheal lignocaine injection were administered in 70% and 87% of patients, respectively, during the study period. Spray-as-you-go lignocaine topicalisation and oral lignocaine spray for airway topicalisation were used in 22% and 39% of patients, respectively, during this period. Five techniques were used for ATI – conventional, under aerosol box (single anaesthesiologist and two anaesthesiologists) and under transparent plastic drape (in one technique, both airway topicalisation and intubation were done under the drape; in another, only intubation was performed under the drape). Conclusions: With modifications of the routine technique, ATI can be performed safely during the COVID-19 pandemic.

The evaluation of using new trachea and skin manikins for practicing emergency anterior neck access

Emergency anterior neck access may be performed if intubation and ventilation fail. Practicing this life-saving procedure with manikins before facing a real-life emergency anterior neck access is required to do this procedure successfully when we encounter a difficult airway situation. The current manikins are expensive and thus are sometimes difficult to acquire in low-cost settings such as Thailand. We devise a cost-effective training manikin using less expensive materials but retaining the simple design of the trachea and skin areas which are flexible polyurethane (PU) foam and silicone, but which still had the same utility as the current manikins. Five items were evaluated, and then scores were rated by experienced physicians from 1 to 5 points for each item, 1 being the least and 5 the highest. The mean score concerning the appropriate size of the manikins was 4.55 ± 0.56. The mean score of the ease of use for practicing was 4.58 ± 0.59. The mean score of the similarity of the skin of the manikins to human skin was 3.85 ± 0.66. The mean score of the similarity of the trachea of the manikins to the human trachea was 3.80 ± 0.69. The mean score of the sensation of inserting the tube in the manikin compared to a real trachea was 3.90 ± 0.67. The mean overall benefit score of practicing on the manikins was 4.38 ± 0.45. Our trial indicates that this low-cost and simply designed manikin can be useful for practicing emergency airway management procedures to save patients who are struggling with lack of oxygen or intubation failure or failure of ventilation or other airway equipment such as endotracheal intubation and supraglottic airway devices (SGA).

Risk assessment for surgeries during COVID-19 pandemic in Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia

Introduction: Surgeries are potential procedures for Coronavirus Disease 2019 (COVID-19) transmission due to the presence of a multidisciplinary team and high-risk activities such as airway assessment and intubation. This study was carried out to assess risk of surgeries conducted at the main referral hospital in Aceh province, Indonesia during COVID-19 pandemic.Method: A Medical necessary, Time-Sensitive (MeNTS) score was used to assess risk of emergency and elective surgeries conducted at Aceh main referral hospital, Dr. Zainoel Abidin, from July to August 2020. In total, 463 surgeries were screened, consisted of 126 emergency surgeries and 337 elective procedures.Result: Orthopaedic department contributed the most with 129 patients (27.9%), while ear, nose, throat (ENT) departments contributed the least with only 16 patients (3.4%). Orthopedic surgeries had the lowest MeNTS score (36.23), while neurosurgeries had the highest MeNTS score (46.91). Most of the surgeries were elective (72.8%), and the MeNTS score for elective surgeries was higher than emergency procedures (41.0 to 39.6).Conclusion: Neurosurgeries were the highest risk procedures conducted in Aceh main referral hospital, Indonesia, followed by ENT, thoracic-vascular, and digestive surgeries. MeNTS scoring can be used as an additional screening tool in the Department of Surgery, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia to minimize the risk of COVID-19 transmission during surgical procedures.

Abstract PO-054: Development of machine learning based early warning for rapid response system in a single cancer center

Abstract Background: Rapid response systems identify deteriorating hospitalized patients and prevent unexpected mortality by providing immediate interventions. But there are also difficulties in costs and human resources for clinical implementation. Machine learning is an application of artificial intelligence that provides systems the ability to automatically learn and improve from experience without being explicitly programmed. We try to develop a machine learning based early warning system to predict intubation and cardiopulmonary resuscitation (CPR) using vital signs and laboratory values. Methods: The training set was composed of all patients admitted to a cancer hospital named Chonnam National University Hwasun Hospital for two years (event group 277 vs. non-event group 3576 cases), and the test set was made from all patients admitted to non-cancer hospital named Chonnam National University Hospital for four months (event group 61 vs. non-event group 2334 cases). The time point at which the patient's clinical deterioration was recognized in the ward was defined as ‘detection time’, and the time point at which the patient suffered airway intubation or CPR was defined as ‘event time’. The algorithm is developed using five vital signs (blood pressure, heart rate, body temperature, respiratory rate and oxygen saturation) and laboratory values. We compared the efficacy of developed models which were ensemble model, recurrent neural network (RNN), low gradient boosting (LGB), extreme gradient boosting (XGB) and random forest with established modified early warning score (MEWS) using receiver operating characteristic area under curve (ROC AUC) and precision recall AUC (PR AUC) analyses. Results: The ROC AUC value of the ensemble model using five vital signs was 0.9219 and the PR AUC was 0.0732. After adding laboratory values, the ROC AUC values of the ensemble, RNN, LGB, XGB, random forest improved to 0.9964, 0.9814, 0.9950, 0.9862 and 0.9962. The PR AUC values were also increased to 0.2326, 0.2140, 0.3252, 0.2095 and 0.1985, respectively. The developed models showed higher performance than MEWS (ROC AUC: 0.7253, PR AUC: 0.0468) Conclusion: Machine learning based early warning system using vital signs and laboratory results was feasible. And the performance was better than traditional MEWS model because the ensemble model showed highest value in ROC AUC and LGB showed highest value in PR AUC. Citation Format: Bo-Gun Kho, Min-Seok Kim, Tae-Ok Kim, Cheol-Kyu Park, Young-Chul Kim, Soo-Hyung Kim, In-Jae Oh. Development of machine learning based early warning for rapid response system in a single cancer center [abstract]. In: Proceedings of the AACR Virtual Special Conference on Artificial Intelligence, Diagnosis, and Imaging; 2021 Jan 13-14. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(5_Suppl):Abstract nr PO-054.

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial

BackgroundChest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART). MethodsWe analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT. ResultsOf 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs. ConclusionIn the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.

Deep metric learning-based image retrieval system for chest radiograph and its clinical applications in COVID-19.

In recent years, deep learning-based image analysis methods have been widely applied in computer-aided detection, diagnosis and prognosis, and has shown its value during the public health crisis of the novel coronavirus disease 2019 (COVID-19) pandemic. Chest radiograph (CXR) has been playing a crucial role in COVID-19 patient triaging, diagnosing and monitoring, particularly in the United States. Considering the mixed and unspecific signals in CXR, an image retrieval model of CXR that provides both similar images and associated clinical information can be more clinically meaningful than a direct image diagnostic model. In this work we develop a novel CXR image retrieval model based on deep metric learning. Unlike traditional diagnostic models which aim at learning the direct mapping from images to labels, the proposed model aims at learning the optimized embedding space of images, where images with the same labels and similar contents are pulled together. The proposed model utilizes multi-similarity loss with hard-mining sampling strategy and attention mechanism to learn the optimized embedding space, and provides similar images, the visualizations of disease-related attention maps and useful clinical information to assist clinical decisions. The model is trained and validated on an international multi-site COVID-19 dataset collected from 3 different sources. Experimental results of COVID-19 image retrieval and diagnosis tasks show that the proposed model can serve as a robust solution for CXR analysis and patient management for COVID-19. The model is also tested on its transferability on a different clinical decision support task for COVID-19, where the pre-trained model is applied to extract image features from a new dataset without any further training. The extracted features are then combined with COVID-19 patient's vitals, lab tests and medical histories to predict the possibility of airway intubation in 72 hours, which is strongly associated with patient prognosis, and is crucial for patient care and hospital resource planning. These results demonstrate our deep metric learning based image retrieval model is highly efficient in the CXR retrieval, diagnosis and prognosis, and thus has great clinical value for the treatment and management of COVID-19 patients.

Dexmedetomidine vs Fentanyl for Awake Fiberoptic Intubation in Paediatric Patients with Temporomandibular Joint Ankylosis: A Retrospective Analysis

Introduction: For successful management of difficult paediatric airway intubation, proper preparation of airway along with a calm and sedated child with titrated doses of sedative agents is paramount. Aim: To compare two different classes of sedative agents (Dexmedetomidine vs Fentanyl) regarding intubating conditions and comfort score of paediatric population at the time of awake fiberoptic intubation. Materials and Methods: This retrospective study was carried out among 40 paediatric patients, aged between 5-14 years those who underwent surgery for Temporo-Mandibular Joint (TMJ) ankylosis. Clinical data relevant for this study was collected from the pre-format sheets of anaesthesia technique, attached with case files of the patients. Inj. dexmetedomidine bolus of 1 mcg/kg for 10 minutes followed by infusion at the rate 0.6 mcg/kg/hr in group A and Inj. fentanyl bolus dose of 2 mcg/kg followed by infusion 1 mcg/kg/hr in group B were compared in terms of intubating conditions and patient co-operation. For data analysis Statistical Package for the Social Sciences (SPSS) version 20 (IBM Inc.) was used. Patient characteristics in the two groups were compared using mean±SD and chi-square test. Results: All the patients had successful intubation in first attempt in both the groups. In terms of airway preparation, out of total, 14 (35%) patients in group A had no secretions as compare to 4 (10%) patients of group B (p-value was 0.002). In terms of cough score, 13 (32.5%) patients in group A had no cough as compared to 3 (7.5%) patients in group B. Patients in group A were more comfortable at the time of insertion of Flexible Fiberoptic Bronchoscopy (FOB) with no or less resistance to FOB insertion (p-value was 0.043). Vocal cord conditions were favourable in both the groups and there was no difference. Conclusion: Fiberoptic nasal intubation was found to be easier and safe in terms of patient comfort and preservation of patent airway with the use of dexmedetomidine, in paediatric TMJ ankylosis.

C-MAC D-Blade vs Airtraq for Intubation with Manual Inline Axial Stabilisation- A Randomised Clinical Trial

Introduction: One of the most important skills in anaesthesia is securing the airway with an endotracheal tube. Difficult tracheal intubation however is considered one of the major contributors of anaesthesia related morbidity and mortality. Video laryngoscopy offers several advantages during endotracheal intubation. The view of the glottis provided by Videolaryngoscopes is better compared to the Macintosh laryngoscope in difficult airways which makes it more attractive for routine difficult airway intubations. Aim: To compare the time taken for intubation between two Videolaryngoscopes, namely C-MAC D-blade and Airtraq and to assess the quality of laryngoscopy view between the two groups. Materials and Methods: This was a randomised clinical trial conducted in 116 American Society of Anesthesiologists 1 (ASA1) and ASA2 patients undergoing elective surgeries in Pondicherry Institute of Medical Sciences. Patients are randomised into two groups, Group C-MAC D-blade and Group Airtraq by computer randomisation. Statistical analysis was performed using t-test, Repeated measures of ANOVA was used to find the significance from preinduction to 10 mins period for each group and Bonferoni’s correction for intergroup comparison. Results: The time taken for intubation was comparable in two study groups (Group C-MAC D-blade 41.88 secs) and (Group Airtraq -40.78 sec) with p-value of 0.734. Laryngoscopic view was not statistically significant with p-value of 0.083. Optimisation maneuvers were required in 63.8% in Group Airtraq on comparison with 44.8% in Group C-MAC D-blade. In both Group C-MAC D-blade and Group Airtraq, there was a significant rise in the heart rate and BP at 0 minute compared to preinduction. But after 5 minutes, the heart rate and BP were back to preinduction values. Conclusion: Both the Videolaryngoscopes, C-MAC D-blade and Airtraq performed equally, with respect to time taken for intubation and laryngoscopic view. However, External Laryngeal Manipulation (ELM) was required more in Group Airtraq and was statistically significant.

Risk of Middle Ear Complications in Intubated Patients on Mechanical Ventilation Versus Non Intubated

Patients on mechanical ventilation through artificial airway intubation may compromise their normal eustachian tube function and equilibration of middle ear pressures. Aim of the study is to evaluate the risk of middle ear complications in the positive pressure air-filled middle ears. A prospective study of patients findings with a different diagnosis, who were admitted for more than ten days duration in Intensive Care Units (ICU) in different hospitals of Benghazi city over a period of six months . Head injury and tympanic membrane rupture were excluded in this study. The approach that had been used was otoscope examination of the ears of 120 ICU patients by an ENT specialist, Results: (the age ranged from 14 days to 75 years). The comparison between two groups of intubated (40 cases) and non-intubated (80 cases) patients was performed. Among 40 mechanically ventilated patients, 37 patients (92.5%) developed middle ear complications. Whereas only nine out of 80 patients in non intubated group(11.3%) were developed middle ear complications. These results suggest that all intubated patients on mechanical ventilation for more than ten days should be routinely examined, and subjected for portable tympanometry evaluation of the middle ear. They may need tympanostomy tubes insertion.

Virtual Reality Simulation for Pediatric Airway Intubation Readiness Education.

BackgroundThe objective of this study was to provide education to inexperienced trainees regarding preparation for airway intubation using virtual reality (VR) tutorial and comparison of performance with that of experienced trainees without VR training. We hypothesized that after the VR tutorial, junior fellows and residents will have comparable recall of the proper steps as experienced trainees.MethodsThis project was initiated in the pediatric intensive care unit from July 1, 2019, to July 30, 2019. Volunteer residents and pediatric critical care medicine fellows participated. The VR group completed a 19-minute immersive tutorial and then demonstrated learned skills with a traditional manikin. Non-VR group fellows listed steps to prepare for airway intubation from memory with scoring on a 24-point timed checklist.ResultsSeventeen subjects participated; two residents were excluded. The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P=1).ConclusionVR technologies can be used for education in preparation for pediatric airway intubation. There was no difference in the performance accuracy between the two groups. Larger studies are essential to study benefits of VR in preparation and performance of airway intubation.