Intubation Practice Research Articles

Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions.

Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.

Enhancing Laryngoscopy Mastery: The Impact of Autonomous Practice with Feedback-Providing Simulators.

Mastery learning with fixed end points and variable training time leads to more consistent expertise but is difficult to implement. Here we piloted mastery learning of laryngoscopy with independent practice. 35 learners participated in independent mastery learning on a manikin that provides automated performance feedback. A pre- and postpractice assessment of intubation skills was completed. After an average of 21 minutes of open practice, the percentage of subjects that met mastery criteria improved from 24% to 89% (P < .05). Independent intubation practice with manikin feedback facilitated mastery learning, enhanced procedural education, and may impact clinical care.

Difficult Airway Assessment Based on Multi-View Metric Learning.

The preoperative assessment of difficult airways is of great significance in the practice of anesthesia intubation. In recent years, although a large number of difficult airway recognition algorithms have been investigated, defects such as low recognition accuracy and poor recognition reliability still exist. In this paper, we propose a Dual-Path Multi-View Fusion Network (DMF-Net) based on multi-view metric learning, which aims to predict difficult airways through multi-view facial images of patients. DMF-Net adopts a dual-path structure to extract features by grouping the frontal and lateral images of the patients. Meanwhile, a Multi-Scale Feature Fusion Module and a Hybrid Co-Attention Module are designed to improve the feature representation ability of the model. Consistency loss and complementarity loss are utilized fully for the complementarity and consistency of information between multi-view data. Combined with Focal Loss, information bias is effectively avoided. Experimental validation illustrates the effectiveness of the proposed method, with the accuracy, specificity, sensitivity, and F1 score reaching 77.92%, 75.62%, 82.50%, and 71.35%, respectively. Compared with methods such as clinical bedside screening tests and existing artificial intelligence-based methods, our method is more accurate and reliable and can provide a reliable auxiliary tool for clinical healthcare personnel to effectively improve the accuracy and reliability of preoperative difficult airway assessments. The proposed network can help to identify and assess the risk of difficult airways in patients before surgery and reduce the incidence of postoperative complications.

Flexible endoscopic intubation in emergency medicine: A mixed-methods needs assessment.

This needs assessment aimed to improve understanding of flexible endoscopic intubation training and practice in emergency medicine (EM), providing insights to educators and practice leaders seeking to improve education and practices. We conducted a multicenter, mixed-methods needs assessment of emergency physicians (EPs) incorporating focus groups and a survey. Focus groups comprised community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts using grounded theory, qualitatively describing EM endoscopic intubation. The qualitative analysis shaped our survey instrument, which we deployed in cross-sectional fashion. We report survey data with descriptive statistics. Focus groups with 13 EPs identified three themes: indications for use of endoscopic intubation, factors impacting a physician's decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Of 257 surveyed EPs (33% response rate), 79% had received endoscopic intubation training during residency, though 82% had performed this procedure 10 or fewer times in their career. Despite 97% acknowledging the necessity of competency, only 23% felt highly confident in their ability to perform endoscopic intubation. Participants (93%) reported scarce opportunities to perform the procedure and identified factors believed to facilitate competency acquisition and maintenance, including opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%). While most EPs acknowledged the importance of competency in endoscopic intubation, they reported scarce procedural opportunities and commonly expressed low confidence. Further research is needed on this topic, and we propose avenues to enhance education and practices related to endoscopic intubation. These include development of robust procedural curricula, support of local champions, and incorporating nasopharyngoscopy into EM practice.

Critical Care: What You May Have Missed in 2023.

Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.

Intubation Decision Based on Illness Severity and Mortality in COVID-19: An International Study.

To evaluate the impact of intubation timing, guided by severity criteria, on mortality in critically ill COVID-19 patients, amidst existing uncertainties regarding optimal intubation practices. Prospective, multicenter, observational study conducted from February 1, 2020, to November 1, 2022. Ten academic institutions in the United States and Europe. Adults (≥ 18 yr old) confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalized specifically for COVID-19, requiring intubation postadmission. Exclusion criteria included patients hospitalized for non-COVID-19 reasons despite a positive SARS-CoV-2 test. Early invasive mechanical ventilation (EIMV) was defined as intubation in patients with less severe organ dysfunction (Sequential Organ Failure Assessment [SOFA] < 7 or Pa o2 /F io2 ratio > 250), whereas late invasive mechanical ventilation (LIMV) was defined as intubation in patients with SOFA greater than or equal to 7 and Pa o2 /F io2 ratio less than or equal to 250. The primary outcome was mortality within 30 days of hospital admission. Among 4464 patients, 854 (19.1%) required mechanical ventilation (mean age 60 yr, 61.7% male, 19.3% Black). Of those, 621 (72.7%) were categorized in the EIMV group and 233 (27.3%) in the LIMV group. Death within 30 days after admission occurred in 278 patients (42.2%) in the EIMV and 88 patients (46.6%) in the LIMV group ( p = 0.28). An inverse probability-of-treatment weighting analysis revealed a statistically significant association with mortality, with patients in the EIMV group being 32% less likely to die either within 30 days of admission (adjusted hazard ratio [HR] 0.68; 95% CI, 0.52-0.90; p = 0.008) or within 30 days after intubation irrespective of its timing from admission (adjusted HR 0.70; 95% CI, 0.51-0.90; p = 0.006). In severe COVID-19 cases, an early intubation strategy, guided by specific severity criteria, is associated with a reduced risk of death. These findings underscore the importance of timely intervention based on objective severity assessments.

A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes.

Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. Prospective, observational, and cohort study. Forty-three Spanish ICU. A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). None. At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.

Prehospital airway management by health workers in Riyadh City: A local survey

This study sought to determine the perception of healthcare workers (HCWs) about pre-hospital airway management and their experiences. Methods: This cross-sectional study was conducted among health workers at the emergency department of King Fahad Medical City in the capital of Saudi Arabia, Riyadh City. This study targeted physicians, nurses, paramedics, and respiratory therapists. Data were collected using an online questionnaire. The questionnaire included demographic characteristics, training, and experiences in airway management and a 5-item questionnaire to measure the perception of HCWs about airway management. Results: Of the 100 HCWs, 39% were doctors, and 37% were nurses. Approximately 23% had a poor experience with intubation. Traumatic injuries were the major difficulties involving airway management (44%). The overall perception of HCWs about prehospital airway management was good (68%), 31% were moderate, and only 1% were considered poor perception levels. No significant differences were observed between perception scores in relation to the demographic characteristics and experiences of HCWs in airway management (all p&amp;gt;0.05). Conclusion: Despite HCWs&amp;apos; good perception of prehospital airway management, some gaps have been identified mainly through intubation skills and experiences. This study provided evidence that perception towards prehospital airway management was not affected by profession, years of experience, regular practice of intubation, and airway management. Regular training should be implemented, with equipment and resources should be available to improve airway management and patient quality of care.

Prehospital airway management by health workers in Riyadh City: A local survey

This study sought to determine the perception of healthcare workers (HCWs) about pre-hospital airway management and their experiences. Methods: This cross-sectional study was conducted among health workers at the emergency department of King Fahad Medical City in the capital of Saudi Arabia, Riyadh City. This study targeted physicians, nurses, paramedics, and respiratory therapists. Data were collected using an online questionnaire. The questionnaire included demographic characteristics, training, and experiences in airway management and a 5-item questionnaire to measure the perception of HCWs about airway management. Results: Of the 100 HCWs, 39% were doctors, and 37% were nurses. Approximately 23% had a poor experience with intubation. Traumatic injuries were the major difficulties involving airway management (44%). The overall perception of HCWs about prehospital airway management was good (68%), 31% were moderate, and only 1% were considered poor perception levels. No significant differences were observed between perception scores in relation to the demographic characteristics and experiences of HCWs in airway management (all p&amp;gt;0.05). Conclusion: Despite HCWs\&amp;apos; good perception of prehospital airway management, some gaps have been identified mainly through intubation skills and experiences. This study provided evidence that perception towards prehospital airway management was not affected by profession, years of experience, regular practice of intubation, and airway management. Regular training should be implemented, with equipment and resources should be available to improve airway management and patient quality of care.

Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites

ObjectiveThe risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made.MethodsWe conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey (www.surveymonkey.com) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models.ResultsInvitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00).ConclusionsThis study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.

Post-intubation laryngotracheal stenosis: clinical presentation and management approaches

IntroductionAddressing acquired laryngotracheal stenosis presents a complex healthcare dilemma.ResultsWe present a case series of 48 acquired post-intubation laryngotracheal stenosis cases managed within our Department of ENT Surgery at Farhat Hached Tunisia. Diagnosis relied on imaging and endoscopic findings. Among these cases, 28 exhibited tracheal stenosis, with 60% falling into grade 2–3 severity. Management approaches included sole endoscopic dilation for 17 patients, surgical intervention for 19 patients, and T-tube placement for 10 patients.ConclusionsThe management of laryngotracheal stenosis poses a challenge for ENT surgeons. Prevention is paramount, encompassing various measures such as employing high-volume, high tracheostomy, and extended intubation practices.

Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019).

To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019. Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia. Critically ill children requiring TI in a PICU or pediatric cardiac ICU. None. Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021). TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

Training approaches and devices utilization during endotracheal intubation in French Emergency Departments: a nationwide survey.

Endotracheal intubation is a lifesaving procedure that is reportedly associated to a significant risk of adverse events. Recent trials have reported that the use of videolaryngoscope and of a stylet might limit this risk during emergency intubation. The objective of this study was to provide a national description of intubation practices in French Emergency Departments (EDs). We conducted an online nationwide survey by sending an anonymous 37-item questionnaire via e-mail to 629 physicians in French EDs between 2020 and 2022. A single questionnaire was sent to a sole referent physician in each ED. The primary endpoint was to assess the proportion of French EDs in which videolaryngoscopy was available for emergency intubation and its use in routine practice. Secondary endpoints included the presence of local protocol or standard of procedure for intubation, availability of capnography, and routine use of a stylet. Of the surveyed EDs, 342 (54.4%) returned the completed questionnaire. A videolaryngoscope was available in 193 (56%) EDs, and direct laryngoscopy without a stylet was majorly used as the primary approach in 280 (82%) EDs. Among the participating EDs, 74% had an established protocol for intubation and 92% provided a capnography device for routine verification of tube position. In cases of difficult intubation, the use of a bougie was recommended in 227 (81%) EDs, and a switch to a videolaryngoscope in 16 (6%) EDs. The most frequently used videolaryngoscope models were McGrath Mac Airtraq (51%), followed by Airtraq (41%), and Glidescope (14%). In this large French survey, the majority of EDs recommended direct laryngoscopy without stylet, with seldom use of videolaryngoscopy.

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

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

“Structured with contemporary education methods” regarding anaesthesiology and reanimation internship education evaluation of student feedback

Aims: This study aims to evaluate our training program, which is carried out with contemporary education methods in anaesthesia internship, for the students of our faculty, with student feedback.&#x0D; Methods: In order to evaluate the comments of the students about the internship content, 1051 feedback forms filled out since 2008 were examined. There were 16 questions in the form, 15 of which were closed-ended and 1 open-ended.&#x0D; Results: In the general evaluation of the internship program, 48.4% (n=509) of the students evaluated it as very productive and 46.1% (n=484) as productive. The percentage of respondents who said they were proficient in the "skill of vascular access," one of the abilities taught on models during clinical skills training and later used on patients, was 95.1% (n=999). 29.7% (n=312) of the students admitted that their "intubation practice" was inadequate.&#x0D; Conclusion: It is crucial that the anaesthetic internship, which teaches one of the most fundamental medical skills—airway safety—be developed in accordance with the feedback received from the students. Standardised applied training programs increase the successful outcome of anaesthesia internship education.

Awake Tracheal Intubation Is Associated with Fewer Adverse Events in Critical Care Patients than Anaesthetised Tracheal Intubation.

Tracheal intubation in critical care is a high-risk procedure requiring significant expertise and airway strategy modification. We hypothesise that awake tracheal intubation is associated with a lower incidence of severe adverse events compared to standard tracheal intubation in critical care patients. Records were acquired for all tracheal intubations performed from 2020 to 2022 for critical care patients at a tertiary hospital. Each awake tracheal intubation case, using a videolaryngoscope with a hyperangulated blade (McGrath® MAC X-Blade), was propensity matched with two controls (1:2 ratio; standard intubation videolaryngoscopy (VL) and direct laryngoscopy (DL) undergoing general anaesthesia). The primary endpoint was the incidence of adverse events, defined as a mean arterial pressure of <55 mmHg (hypotension), SpO2 < 80% (desaturation) after sufficient preoxygenation, or peri-interventional cardiac arrest. Of the 135 tracheal intubations included for analysis, 45 involved the use of an awake tracheal intubation. At least one adverse event occurred after tracheal intubation in 36/135 (27%) of patients, including awake 1/45 (2.2%; 1/1 hypotension), VL 10/45 (22%; 6/10 hypotension and 4/10 desaturation), and DL 25/45 (47%; 10/25 hypotension, 12/25 desaturation, and 3/25 cardiac arrest; p < 0.0001). In this retrospective observational study of intubation practices in critical care patients, awake tracheal intubation was associated with a lower incidence of severe adverse events than anaesthetised tracheal intubation.

Learning curve of fiberoptic bronchoscope-guided tracheal intubation through supraglottic airway device for pediatric airway management: a manikin study

Although fiberoptic-guided endotracheal intubation using a supraglottic airway device is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves for the procedure to evaluate the efficiency of the training. We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: supraglottic airway device insertion, vocal cord identification, carina identification, and endotracheal tube insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method. All of the 30 participants acquired proficiency at the end of the practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean (±SD) procedure time was 71.3 (±50.7) s. The 4th step accounted for 86.2% of total failures and 48.0% of the total procedure time. The procedure time rapidly decreased in the 2nd trial, and a modest decline was observed thereafter. Anesthesiology residents obtained proficiency within 25 times of practice for fiberoptic-guided intubation in a pediatric manikin through an AuraGain supraglottic airway device with acceptable success rate and procedure time. The procedure time markedly decreased following the first experience.

A Market Assessment of Introducer Technology to Aid With Endotracheal Intubation.

Endotracheal intubation is a potentially lifesaving procedure. Previously, data demonstrated that intubation remains the most performed airway intervention in the Role 1 setting. Additionally, deployed data demonstrate that casualties intubated in the prehospital setting have worse survival than those intubated in the emergency department setting. Technological solutions may improve intubation success in this setting. Certain intubation practices, including the use of endotracheal tube introducer bougies, facilitate intubation success especially in patients with difficult airways. We sought to determine the current state of the market for introducer devices. This market review utilized Google searches to find products for intubation. The search criteria aimed to identify any device ideal for intubation in the emergency setting. Device data retrieved included manufacturer, device, cost, and design descriptions. We identified 12 introducer-variants on the market. Devices varied with regards to composition (latex, silicone, polyethylene, combination of several materials, etc.), tip shape, special features for ease of intubation (markings for depth and visibility, size, etc.), disposability/reuse capability, measurements, and prices. The cost of each device ranged from approximately $5 to $100. We identified 12 introducer-variants on the market. Clinical studies are necessary to determine which devices may improve patient outcomes in the Role 1 setting.

Non-Sleep Non-Apnea Nasal Fiber Optic Intubation for Difficult Airway Management: A Case Series

Introduction: Patients with tumors on the neck and mouth are known to be at risk for difficult intubation. Failing to secure the airway can lead to increased patient morbidity and mortality. This study aimed to present a case series with non-sleep non-apnea fiber optic intubation for difficult airway management.&#x0D; Case presentation: In this paper, we present three patients; a 57-year-old woman, a 59-year-old man, and a 68-year-old woman who have airway problems with a tumor located on their neck and mouth but were successfully intubated by non-sleep non-apnea nasal fiber optic intubation, one of airway management technique. Good visualization was achieved by fiber optic devices. Preparing the patient holistically and systematically during the perioperative period was the other important thing to do. MOANS score and LEMON score are used to predict the potential event of a difficult airway preoperatively. These scores help the physician to decide what step will be done with the patient.&#x0D; Conclusion: Anesthetic morbidity and mortality can be reduced with better preoperative evaluation and clear guidelines and practice for difficult intubation.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

ObjectiveIntubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative.MethodsWe conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs.ResultsOf 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status.ConclusionsDuring the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.