Intubation Procedure Research Articles

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study.

SummaryThe current international COVID‐19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air‐purifying respirators and powered air‐purifying respirators during simulated difficult airway scenarios. Twenty‐five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.

COVID-19 / Coronavirus Outbreak: Protecting The Airway - Endotracheal Intubation

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff to reduce the risk of infection. COVID patients often need mechanical ventilation due to progredient respiratory insufficiency, so an endotracheal intubation becomes a critical procedure in managing these patients. This procedure has an increased risk of infection due to aerosol formation and working with an unsecured airway. Patient safety should not be neglected, and complications like hypoxaemia and aspiration should be avoided. At the same time, personal protection from infection is of utmost importance becuase human resources in a pandemic crisis must be preserved. This video shows the procedure of endotracheal intubation while taking personal infection protection into account.

Three-Dimensional Assessment of Pharyngeal Volume on Computed Tomography Scans: Applications to Anesthesiology and Endoscopy.

Pharyngeal volume is important in anesthesiology for correctly assessing intubation procedures. However, most of studies are based on patients in upright position and do not assess possible relationships between pharyngeal volume and cranial size. This study aims at measuring pharyngeal volume in CT-scans and to assess possible statistically significant differences according to sex.Eighty healthy subjects (40 males and 40 females) aged between 21 and 86 years were retrospectively chosen from a hospital database of maxillofacial CT-scans; 3D segmentation was performed separately for naso-, oro- and laryngopharyngeal portion through ITK-SNAP software, and their volume was calculated. Three cranial measurements were obtained: distance between anterior and posterior nasal spine, upper facial height (nasion-prosthion) and biorbital breadth (ectoconchion-ectoconchion distance).The effect of sex on volume for each pharyngeal portion was assessed through one-way ANCOVA test using each of the 3 cranial measurements as covariate (P < 0.05).On average, the volume of nasopharynx, oropharynx and laryngopharynx was 7.2 ± 2.7 cm, 7.5 ± 4.2 cm, 3.5 ± 2.2 cm respectively in males, and 6.4 ± 2.9 cm, 5.2 ± 2.1 cm, 3.0 ± 1.8 cm in females. Statistically significant differences according to sex were found only for oropharyngeal volume, independently from cranial measurements (P < 0.05).This study provides data concerning volume of pharyngeal air space in supine subjects: these reference standards can be useful for anaesthesiologic procedures.

Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic - a narrative review.

Personal protective equipment has become an important and emotive subject during the current coronavirus disease 2019 epidemic. Coronavirus disease 2019 is predominantly caused by contact or droplet transmission attributed to relatively large respiratory particles which are subject to gravitational forces and travel only approximately 1 metre from the patient. Airborne transmission may occur if patient respiratory activity or medical procedures generate respiratory aerosols. These aerosols contain particles that may travel much longer distances and remain airborne longer, but their infective potential is uncertain. Contact, droplet and airborne transmission are each relevant during airway manoeuvres in infected patients, particularly during tracheal intubation. Personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from coronavirus disease 2019 cross-infection. Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet or airborne. Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol generating procedures. Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.

Navigating Healthcare Supply Shortages During the COVID-19 Pandemic: A Cardiologist's Perspective.

Navigating Healthcare Supply Shortages During the COVID-19 Pandemic: A Cardiologist's Perspective.

Protecting against COVID-19 aerosol infection during intubation.

DEAR EDITOR, We read with great interest the review article regarding the outbreak of coronavirus disease 2019 (COVID-19) by Wu et al.1 According to recent figures posted on worldometer,2 there are over 1.2 million confirmed cases of coronavirus resulting in over 66 5000 deaths worldwide. The novel coronavirus was first reported in Wuhan, China, in late December of 2019.3 China issued a lockdown on all major cities to prevent and contain the spread of the virus; unfortunately, it was too late. Sporadic cases began to first appear in Asia, then Europe and the Americas, and finally affecting 208 countries and territories.2 This pandemic has caught global healthcare workers off-guard. As human to human transmission4 became evident, a surge of infected patients needing hospitalization and requiring mechanical ventilation increased exponentially. Recently it has been reported that the virus responsible for COVID-19 can be viable in aerosols for up to 3 hours and remain detectable on plastic and stainless steel surfaces for approximately 72 hours.5 Personal protective equipment (PPE) including face mask, goggles, gloves, and gown has become a necessity to minimize the exposure to the deadly pathogenic virus. Stringent protection procedures should be conducted for high-risk procedures such as endoscopy, Ambu bagging, and endotracheal tube intubation.1 During the intubation process, medical personnel are at the highest risk of being exposed and infected. As a preventive measure, a simple, low-cost device was invented to give physicians extra protection from any aerosol particles that could be released during the intubation procedure. The device consists of a transparent acrylic box with an opening on one side allowing it to fit over the patient’s chest and neck, while the opposite side has two small holes where the doctor’s hands can be inserted during the intubation. The “aerosol box” has been registered under a Creative Commons license and is free to the public as long as it is properly attributed to the designer and not used for commercial purposes. The schematics is available at https://sites.google.com/view/aerosolbox/home. This device has already been adopted by some hospitals in Taiwan, Hong Kong, Philippines, Canada, United Kingdom, and the United States. A group from Boston Medical Center developed a prototype with the design and streamed a video showing the effectiveness of using the aerosol box to protect clinicians during the intubation procedure.6 Changes to the original design may be necessary to fit the respective needs of the physician and/or patient—availability of video-assisted laryngoscope, large hands, and patient body mass index (BMI). As of now, various medications are being investigated and vaccine trials have been initiated by numerous countries. Before being able to find the most effective treatment, protecting, diminishing exposure, securing, and insulating our healthcare workers from possible infection is the biggest challenge to safeguard the health of our patients. We hope that this innovative “aerosol box” design can provide an extra layer of protection to clinicians performing high-risk procedures.

Plexiglas barrier box to improve ERCP safety during the COVID-19 pandemic

Since December 2019, more than 1.5 million cases of COVID-19 infection have been recorded worldwide, and the number of infected patients is rapidly increasing. Medical personnel are at great risk for acquiring COVID-19 infection because of their high exposure to patients’ body fluids and the aerosol generated during GI endoscopic procedures. With the idea of minimizing the spread of aerosols during endoscopy, we are using a specially designed transparent Plexiglas box (length 90 cm, width 70 cm, height 60 cm) with a smaller opening on the side for the endoscope (diameter 60 mm) and 2 openings for the anesthesiologist’s maneuvers and the passage of various equipment cables (each diameter 150 mm) (A). During ERCP, the patients are sedated in the prone position with both arms extended next to the head to facilitate the approach of the anesthesiologist (B). The Plexiglas box does not limit necessary access to the patient, the endoscopic procedure, or the quality of the flouroscopic view. We have not specifically tested our box model for limitation of aerosol spread, but our device seems to be similar to the device studied for endotracheal intubation recently published by Canelli et al in the New England Journal of Medicine. All authors disclosed no financial relationships. Commentary Necessity is the mother of invention. The COVID crisis of 2019 to 2020 has made it clear to all concerned that endoscopy in this setting needs to be performed safely, from the perspective of both patients and healthcare providers. The authors in this case have enclosed their patient's head in a clear Plexiglas box to reduce the spread of aerosolized GI secretions. In theory, this device (or a device like it) could be used for any upper or lower endoscopic procedure, including bronchoscopy. The authors note that they have not tested the actual ability of this device to reduce the spread of disease, but perhaps this will come with time. It should be noted that the patient in this case is not intubated and that intubation in the context of general anesthesia is another highly effective way to reduce or nearly eliminate aerosolization of GI secretions (after the intubation procedure itself is complete, of course). Douglas G. Adler, DMD, FASGE, GIE Senior Associate Editor, University of Utah School of Medicine, Salt Lake City, Utah Mohamed O. Othman, MD, Associate Editor for Focal Points

Analysis of bronchoscope-guided tracheal intubation in 12 cases with coronavirus disease 2019 under the personal protective equipment with positive pressure protective hood

Endotracheal intubation is an independent risk factor for respiratory infectious diseases. We conducted a retrospective study in 12 cases with COVID-19 who underwent endotracheal intubation at ICU of the Guangzhou eighth hospital from January 20 to February 10, 2020. The intubation procedure, anesthetic regimen, and complication were collected and analyzed. The 9 healthcare workers who involved in intubation received virus nucleic acid test and 14 days temperature monitoring. All 12 patients were successfully intubated under the guidance of bronchoscope, without any complications. Midazolam, Propofol and Morphine or fentanyl were used for sedation and analgesia, avoiding patients cough and agitated during the procedure. The 9 healthcare workers were protected under the Personal Protective Equipment(PPE) with positive pressure protective hood. The detection of oropharyngeal swab virus nucleic acid were negative in all 9 healthcare workers, none of them had fever or any respiratory symptoms. The PPE with positive pressure protective hood should be needed to perform bronchoscope-guided endotracheal intubation in patients with COVID-19, it could strengthen to protect healthcare workers from virus exposure.

A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures.

Hypoxemia is a common complication in the pediatric operating room during endotracheal intubation and airway procedures and is a precursor to serious adverse events. Small children and infants are at greater risk of hypoxemia due to their high metabolic requirements and propensity to alveolar collapse during general anesthesia. To improve the care and safety of this vulnerable population, continued efforts must be directed to mitigate hypoxemia and the risk of subsequent serious adverse events. Apneic oxygenation has been shown to significantly prolong the safe apnea time until desaturation in infants, children, and adults and may reduce the incidence of desaturation during emergency intubation of critically ill patients. Successful apneic oxygenation depends on adequate preoxygenation, patent upper and lower airways, and a source of continuous oxygen delivery. Humidified, high-flow nasal oxygenation systems have been shown to provide excellent conditions for effective apneic oxygenation in adults and children and have the added benefit of providing some carbon dioxide clearance in adults; although, this latter benefit has not been shown in children. Humidified, high-flow nasal oxygenation systems may also be useful during spontaneous ventilation for airway procedures in children by minimizing room air entrainment and maintaining adequate oxygenation allowing for a deeper anesthetic. The use of apneic oxygenation and humidified, high-flow nasal oxygenation systems in the pediatric operating room reduces the incidence of hypoxemia and may be effective in decreasing related complications.

Management of Hemodialysis Patients with Suspected or Confirmed COVID-19 Infection: Perspective of Two Nephrologists in the United States.

The coronavirus disease 2019 (COVID-19) pandemic is unprecedented and information about the severe acute respiratory syndrome coronavirus 2 is evolving rapidly. New York is one of the epicenters of the COVID-19 outbreak in the United States, reporting >1000 confirmed cases as of March 17, 2020, and cases are escalating exponentially. The majority of cases are in Westchester County ( n =220) and New York City (NYC; n =463), which includes Bronx (1). The local index patient case was a Westchester man who became ill on February 22, was not associated with a recent travel exposure to a country on the watch list (China, Iran, South Korea, and Italy), or known to have had direct contact with a COVID-19–confirmed patient. At the present time it is estimated that community-wide transmission accounts for 87% of confirmed cases. Nephrologists in the Bronx have been handicapped in managing patients with ESKD during the early weeks of the COVID-19 pandemic due to the limitations of available rapid testing for severe acute respiratory syndrome coronavirus 2. Montefiore Medical Center, located in the north Bronx in close proximity to Westchester, has been one of the main tertiary care hospitals in NYC caring for persons under investigation (PUIs) and for COVID-19–confirmed patients. Our nephrology division’s clinical faculty care for approximately 850 patients with ESKD (approximately 800 on hemodialysis and approximately 50 on peritoneal dialysis) in 12 outpatient hemodialysis facilities (two Fresenius and 10 DaVita facilities) in the Bronx. We report our experience with caring for the ESKD population and patients who are hospitalized with AKI in the Bronx during the first 3 weeks of the local NYC COVID-19 pandemic. Strategies proposed for the prevention and management of COVID-19 transmission for patients with ESKD in the outpatient dialysis facilities have been dynamic. The American Society of Nephrology’s (ASN’s) Nephrologists Transforming …

The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Protect Healthcare Workers and Reduce Cross Infection.

In late 2019 a novel coronavirus, SARS-CoV-2 causing Coronavirus disease 2019 (COVID-19) appeared in Wuhan China, and on 11th March 2020 the World Health Organisation declared it to have developed pandemic status. In early SARS-CoV-2 infection, viral titres of greater than 107/mL in saliva and nasal mucous can be found; minimisation of these titres should help to reduce cross infection. Povidone-iodine (PVP-I) disinfectant has better anti-viral activity than other antiseptics and has already been proven to be an extremely effective virucide in vitro against severe acute respiratory syndrome and Middle East respiratory syndrome coronaviruses (SARS-CoV and MERS-CoV). Its in vivo virucidal activity is unknown, but it retains its antimicrobial activity against bacteria in vivo intraorally and one application can reduce oral microbial flora for greater than 3 hours. PVP-I disinfectant has been shown to be safe when administered to the nasal cavity and as a mouthwash. We propose a protocolised intra-nasal and oral application of PVP-I for both patients and their attendant healthcare workers (HCWs) during the current COVID-19 pandemic to help limit the spread of SARS-CoV-2 from patients to healthcare workers and vice versa. The aim is to reduce the viral ‘load’ in two of the key areas from where droplets and aerosols containing the virus are expectorated (the lower respiratory tract being the other). The aim of use in HCWs is to destroy virus that has entered the upper aerodigestive tract before it has the opportunity to infect the host. We suggest the protocol is considered for routine use during the care of COVID-19 patients, particularly before any procedure that involves the upper aerodigestive tract, including intubation, nasal and oral procedures, endoscopy and bronchoscopy. We suggest it should be considered when such procedures are carried out in all patients during the pandemic regardless of COVID-19 status, due to the reported significant rates of asymptomatic infection The total iodine exposure proposed is well within previously recorded safe limits in those without contraindications to its use. The intervention is inexpensive, low risk and potentially easy to deploy at scale globally.We acknowledge that the proposal we present extrapolates in vitro finding into the in vivo setting and that assumptions are made that under normal circumstances we would confirm with in vivo data prior to recommendations for use. However, given the strength of in vitro evidence and the low risk, minimal cost and global applicability of the proposed intervention, which amounts to disinfection of the oro/nasal cavities, we feel that there is little to lose and potentially much to gain.

Successful endotracheal intubation following a failed first attempt during aeromedical retrieval

IntroductionFirst attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of...

Effectiveness of a new sensorized videolaryngoscope for retraining on neonatal intubation in simulation environment

BackgroundIn recent years, medical training has significantly increased the use of simulation for teaching and evaluation. The retraining of medical personnel in Italy is entrusted to the program of Continuous Education in Medicine, mainly based on theoretical training. The aim of this study is to assess whether the use of a new sensorized platform for the execution of the neonatal intubation procedure in simulation environment can complement theoretical retraining of experienced health professionals.MethodsNeonatal intubation tests were performed using a commercial manikin and a modified video-laryngoscope by the addition of force and position sensors, which provide the user with feedback when the threshold is exceeded. Two categories carried out the simulation tests: anesthesiologists and pediatricians. The categories were divided into three groups each, and various configurations were tested: the first group of both specialists carried out the tests without feedback (i.e. control groups, gr. A and A1), the second groups received sound and visual feedback from the instrument (gr. B and B1) and the third ones had also the support of a physician expert in the use of the instrument (gr. C and C1). The instrumentation used by pediatricians was provided in a playful form, including a game with increasing difficulty levels.ResultsBoth in the case with feedback only and in the case with humans support, anesthesiologists did not show a specific trend of improvement. Pediatricians, in comparison with anesthesiologists, showed a positive reaction to both the presence of feedback and that of experienced personnel. Comparing the performance of the two control groups, the two categories of experienced doctors perform similar forces. Pediatricians enjoyed the “Level Game”, through which they were able to test and confront themselves, trying to improve their own performance.ConclusionsOur instrument is more effective when is playful and competitive, introducing something more than just a sound feedback, and allowing training by increasing levels. It is more effective if the users can adapt their own technique to the instrument by themselves, without any external help.

Ancillary protective gears in the COVID- 19 Era.

Ancillary protective gears in the COVID- 19 Era.

Utility of upper airway ultrasound for confirmation of endotracheal tube placement in the pediatric intensive care unit setting

Introduction: Confirmation of correct placement of the endotracheal tube (ETT) is as important as the procedure itself. Point-of-care ultrasound today is an indispensable modality in the intensive care unit (ICU) for augmenting the clinical assessment and guiding critical care procedures. In this study, we used point-of-care ultrasound to confirm ETT placement and compared the time taken to confirm the ETT placement by ultrasound and capnography (the gold standard of confirmatory ETT placement). Materials and Methods: The current study was a prospective study done in a tertiary care teaching hospital. Children between 1 month and 18 years of age were included in the study. Airway ultrasound was done during the intubation procedure by placing the probe transversely over the suprasternal notch, and the confirmation of placement of the tube in the trachea was done by visualizing the absence of double trachea sign, and later confirmed by capnography. The average time taken for confirmation by ultrasound and capnography was determined. Results: A total of 127 intubations were included. The average time taken for confirmation of placement of the ETT by airway ultrasound from the time of insertion of the laryngoscope blade was 26.8 ± 5.7 s, whereas by capnography, it was 35.5 ± 5.8 s. The study showed that airway ultrasound has a high sensitivity of 98.2% to detect tracheal intubation and specificity of 100% to detect esophageal intubation when compared to capnography. Conclusion: Airway ultrasound can serve as a novel method of confirming the ETT placement in the pediatric ICU with comparable sensitivity, specificity with the added advantage of a significantly faster time of confirmation with respect to capnography.

Neurosurgery and Neurology Practices during the Novel COVID-19 Pandemic: A Consensus Statement from India.

The COVID-19 infection outbreak has aroused increasing attention and affected thousands of people nationwide. The long incubation period, high infectious rate, varied manifestation, and absence of effective treatment make it difficult to manage the disease transmission. The intended goals are to encourage efficient management of neurological and neurosurgical patients, resource utilization, and protecting the healthcare provider during the COVID-19 epidemic. Herein, we present a consensus statement from various centers in India. In addition to the literature review, recommendations were included from neurologists and neurosurgeons from various centers in India. Every patient presenting for treatment should be treated as a potential asymptomatic infected case. Patients should be categorized based upon the priority as acute (require immediate treatment/surgery within 24 h), sub-acute (requiring treatment within a maximum of 7-10 days), or chronic (requiring treatment within a month). Non-essential elective surgeries and outpatient clinics should be avoided after informing the patient(s). There is a high risk of aerosol dispersion during intubation and certain neurosurgical procedures particularly those involving drills and endoscopes. These procedures should be performed wearing full personal protective equipment. The workflow of the operating rooms should also be modified significantly. Minor modifications in personal and professional lifestyles and routine training to use the PPE will ensure efficient management of resources. These recommendations could be used to mitigate the risks and reduce exposure to other patients, public, and healthcare staff.

Assessment of endotracheal intubation procedures following inadvertent esophageal intubation. A randomized crossover manikin trial.

To evaluate the success, degree of difficulty and completion time of endotracheal intubation without removing the endotracheal tube in the event of an oesophageal intubation.. The prospective, randomised crossover study was conducted at Gulhane Training and Research Hospital, Ankara, Turkey, from July 1, 2018, to August 31, 2018, and used a manikin model. Endotracheal intubation was performed using Miller, Macintosh blades and a video laryngoscope. The procedures were randomised into two groups, with group E+ being subjected to it while an endotracheal tube ETT was placed in the oesophagus (E+) simulating the oesophageal intubation, and control group E- getting the standard procedure without the endotracheal tube in the oesophagus. All methods were evaluated for their success, completion time, and degree of difficulty. Data was analysed using SPSS 22. There were 120 manikins, with 60(50%) in each of the two groups. The mean completion time with Miller in E+ group was 19.05±9.65 and for E- it was 17.55±11.95 seconds. With Macintosh, E+ had a mean completion time of 19.85±12.66 seconds and E- had 16.75±8.66. With video laryngoscope, E+ group had a mean completion time of 16.75±8.66 seconds, while E- had it 14.60±8.17. No significant difference was found in the paired group comparisons in terms of the degree of task difficulty (p>0.05). In case of inadvertent oesophageal intubation condition, leaving the tube in the oesophagus and performing subsequent endotracheal intubation attempts was not found to decrease the rate of success regardless of the laryngoscope type.

Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter

The anaesthetic management of retrosternal thyroid swellings has many associated problems. Positioning and induction may cause severe cardiorespiratory decompensation. Intubation may be difficult and may require all the gadgets for difficult intubation procedure. Rarely patients may require cardiopulmonary bypass to save life. Extubation may be difficult in patients with tracheomalacia. Post-operatively patients may require tracheostomy and ventilatory support. This is a case report outlining successful management of a patient with retrosternal goiter who underwent total thyroidectomy following partial sternotomy.

Manangement of Endotracheal Intubation in Suspected or Confirmed COVID-19 Patients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been described as a novel coronavirus causing a pandemic of the novel corona virus disease 2019 (COVID-19). It is highly contagious and the main transmission way is respiratory droplets and close contact with contaminated surfaces. The aerosol generating procedures caries additional risk for healthcare workers. Since endotracheal intubation is a vulnerable procedure for aerosol generation, the airway manangement of suspected or confirmed COVID-19 patients is high risk to staff and patient In this review we aimed to highlight the important points for the safe and effective endotracheal intubation procedure for suspected or confirmed COVID-19 patients.

Acute respiratory failure: nonintubation assist methods for the acutely deteriorating patient.

Noninvasive ventilation is strongly recommended in acute hypercapnic respiratory failure, whereas high-flow nasal oxygen therapy could be an alternative in de novo respiratory failure. High-flow nasal oxygen may improve the outcome of patients de novo respiratory failure as compared with standard oxygen. Its success within 2 h after initiation is well predicted by a ROX index (ratio of SpO2/FiO2 to respiratory rate) greater than 4.88, as failure when less than 3.85 at 12 h after initiation. However, the superiority of high-flow nasal oxygen to standard oxygen has not been confirmed in immunocompromised patients. Although noninvasive ventilation may be deleterious through barotrauma in patients with de novo respiratory failure, its use seems to be an optimal strategy for preoxygenation before intubation in preventing severe hypoxemia in most hypoxemic patients. In mild hypoxemic patient, high-flow nasal oxygen may be more efficient than bag-valve mask in preventing severe adverse events. After anesthetic induction further positive-pressure ventilation can better secure intubation procedure than absence of ventilation. Despite the growing use of high-flow nasal oxygen, new studies are needed to confirm its superiority to standard oxygen in de novo respiratory failure and others causes of acute respiratory failure in place of standard oxygen.