Intubation-related Complications Research Articles

Endoscopic Screening for Laryngotracheal Complications in Children Following Prolonged Mechanical Ventilation Maintained Through Endotracheal Intubation: A Cross-Sectional Pilot Project

Background: An endoscopic screening program following successful weaning from prolonged mechanical ventilation maintained through endotracheal tube (ET; prolonged intubation) may be justified to assess the upper (laryngotracheal) airway in children who may not always be symptomatic for intubation-related complications. Objectives: To evaluate effects of prolonged intubation in children through endoscopic screening of the laryngotracheal airway. Methods: In this cross-sectional pilot project, children (2 months-12 years) successfully extubated following prolonged intubation were selected, irrespective of having symptoms, for a 1-time flexible nasolaryngoscopy at third to sixth month post-extubation (follow-up window). Laryngotracheal airway changes, if present, were noted. Results: Out of 122 children, 42 developed symptoms of complications. Five of them attended within 3 months post-extubation, the rest were evaluated in the follow-up window. Eighty children aged ≤6 years and 4 children >6 years were intubated with uncuffed ET. Symptoms, when present, included respiratory distress (100%), noisy breathing (~36%), cough (~29%), and dysphagia (~12%). Screening revealed positive findings in 40 out of 42 symptomatic children, and in 8 out of 80 asymptomatic children (χ2 = 80.314; after Yate’s correction; significant at P < .0001). The commonest lesion was subglottic stenosis (~54%) and intubation granuloma (~48%). Relationship between the nature of ET (cuffed/uncuffed) and complications of prolonged intubation was statistically significant (χ246.553; significant at P < .0001). Conclusion: The present study proposes the potential utility of follow-up endoscopic screening of upper (laryngotracheal) airway in children successfully weaned from prolonged intubation. A statistically significant relationship existed between prolonged intubation and upper airway complications that were not always symptomatic.

Impact of universal use of the McGrath videolaryngoscope as the first option for all intubations in the operating room: The multicentre prospective before-after VIDEOLAR-SURGERY study protocol

IntroductionStandard tracheal intubation performed in the operating room is based on direct laryngoscopy using a standard Macintosh laryngoscope. Several authors recommend the universal use of a video laryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath video laryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases intubation-related complications. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicentre, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9 months [2600 intubations]), 35 anaesthesiologists from 8 hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2 months), each anaesthesiologist is given a McGrath Mac video laryngoscope and trained in its use. During the post-implementation period (interventional-phase, 6-9 months [2600 intubations]), the 35 anaesthesiologists perform all tracheal intubations using a McGrath Mac video laryngoscope as the first intubation option. The main objective of this study is to evaluate whether the use of a McGrath Mac video laryngoscope as the first intubation option increases the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved on 2 May 2023 by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered on the Clinicaltrials.gov clinical trials registry under No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If video laryngoscopy improves easy intubation compared with Macintosh direct laryngoscopy in all operating room intubations, its use may well become standard practice, thereby decreasing the risks of intubation-related complications.

Mucus-inspired lubricative antibacterial coating to reduce airway complications in an intubation cynomolgus monkey model

Endotracheal intubation-related complications are common in clinical, and there are currently no effective strategies to address these matters. Inspired by the biological characteristics of human airway mucus (HAM), an artificial airway mucus (ARM) coating is straightforwardly constructed by combining carboxymethyl chitosan with methyl cellulose. The ARM coating exhibited excellent lubricity (coefficient of friction (CoF) = 0.05) and hydrophilicity (water contact angle (WCA) = 21.3°), and was capable of coating both the internal and external surfaces of the endotracheal tube (ETT). In vitro experiments demonstrated that the ARM coating not only showed good broad-spectrum antibacterial activity, but also significantly reduced nonspecific protein adhesion. Through an in vivo intubation cynomolgus monkey model, ARM-coated ETT potently mitigated airway injury and inflammation, and was highly potential to prevent bacterial infection and catheter blockage. This work offers a promising avenue for the development of airway-friendly invasive devices.

Indications and success rate of endotracheal emergency intubation in clinical acute and emergency medicine

Securing the airway in the emergency department (ED) is ahigh-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was aretrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications. Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent asix-week training program including atwo-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with aplaced laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate. During the study period 499 patients were intubated by the core ED team and 28patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527(2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08). In clinical acute and emergency medicine, astandardized approach utilizing video laryngoscopy and a bougie following astructured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting.

Channelled versus nonchannelled Macintosh videolaryngoscope blades in patients with a cervical collar: a randomized controlled noninferiority trial

PurposeChannelled blades have the advantage of avoiding stylet use and potential airway injury during videolaryngoscopic intubation. Nevertheless, the effectiveness of channelled Macintosh-type blades has not yet been fully established. We sought to assess the utility of channelled Macintosh-type blades for videolaryngoscopic intubation under cervical spine immobilization.MethodsWe conducted a randomized controlled noninferiority trial in neurosurgical patients with a difficult airway simulated by a cervical collar. Videolaryngoscopic intubation with a reinforced tracheal tube was performed using a channelled Macintosh-type blade without a stylet (channelled group, n = 130) or a nonchannelled Macintosh-type blade with a stylet (nonchannelled group, n = 131). The primary outcome was intubation success rate. Secondary outcomes included time to intubation and incidence or severity of intubation-related complications (subglottic, lingual, and dental injuries; bleeding; sore throat; and hoarseness).ResultsThe initial intubation success rate was 98% and 99% in the channelled and nonchannelled groups, respectively, showing the noninferiority of the channelled group (difference in proportions −0.8%; 95% confidence interval [CI], −4.8% to 2.9%; predefined noninferiority margin, −5%; P = 0.62). Fewer participants in the channelled group had subglottic injuries than in the nonchannelled group (32% [32/100] vs 57% [54/95]; difference in proportions, −25%; 95% CI, −39% to −11%; P < 0.001). There were no significant differences between the two groups in the overall intubation success rate, time to intubation, and incidence or severity of other intubation-related complications.ConclusionsFor videolaryngoscopic intubation in patients with a cervical collar, channelled Macintosh-type blades are an alternative to nonchannelled Macintosh-type blades, with a noninferior initial intubation success rate and a lower incidence of subglottic injury.Study registrationCRIS.nih.go.kr (KCT0005186); first submitted 29 June 2020.

To NIRS or not: understanding clinical decision-making of respiratory support management related to acute respiratory failure using Critical Decision Method

Clinical decisions related to noninvasive respiratory support (NIRS) for acute respiratory failure patients are complex. NIRS strategies have favorable benefits for patients when successful but NIRS failure comes with longer ICU stays, increased mortality, and more intubation-related and mechanical ventilator-associated complications. Our goal is to understand how physicians make decisions regarding NIRS and explore the differences between emergency physicians and critical care physicians—who commonly make these decisions. We used the critical decision method to conduct ten semi-structured interviews with five emergency physicians and five critical care physicians from ten different healthcare systems across the United States. We found that physicians similarly use objective and subjective clinical cues but differentially use temporal and contextual cues in their decision-making. Several insights identified in our study can be helpful in the design and development of clinical decision support systems for respiratory support decision-making. Specifically, we recommend two customized distinct clinical decision support systems for respiratory support decision-making, one for each designated clinical setting (i.e., ED and ICU) with tailored designs that support the different decision-making processes.

Frequency of tracheal intubation associated adverse events and contributing factors in the Pediatric Intensive Care Unit (PICU).

Objective: To determine the frequency of adverse events associated with immediate tracheal intubation in children (1-18 years) from Pediatric Intensive Care Unit of Tertiary Care Hospital of Karachi, Pakistan. Study Design: Observational study. Setting: PICU of the Aga Khan University Hospital Karachi. Period: September 2020 to August 2021. Methods: A total of 183 intubations occurred during the study period. Data was extracted using the pre-designed peri-intubation proforma, data recorded on the checklist by the observer (Staff) who was fully trained by the Physician, later on compared by the researcher using the video recorded laryngoscopy used during the intubation procedure. Results: There were 183 intubations occurred during study period. Maximum intubations were in age group of 1-5 years (27.3%) and among total intubations, there were 11(6%) intubation related complications occurred. 6 (3.3%) cases have hypoxia, 3 (1.6%) bradycardia and 2 (1.1%) others (hypotension and esophageal intubation). Majority of the complications were observed during morning hours with statistically significant association. 63.60% TI related cases survived whereas 36.40% of them expired, 54.5% stayed in PICU for 0-10 days. Conclusion: Tracheal intubation related adverse events were 6% and majority of them lead to hypoxia. Physiological and mechanical complications with the procedure do occur inspite of our best efforts. Recognizing the complications associated with tracheal intubation can help physicians better care for patients requiring intubation.

A European Multicenter Outcome Study of Perioperative Airway Management Policies following Midface Surgery in Syndromic Craniosynostosis.

Perioperative airway management following midface advancements in children with Apert and Crouzon-Pfeiffer syndromes can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications. A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc or Le Fort III procedures. A total of 275 patients (monobloc surgery, n = 129; Le Fort III surgery, n = 146) were included. Sixty-two patients received immediate extubation and 162 received delayed extubation; 42 had long-term tracheostomies, and 9 had perioperative short-term tracheostomies. In most centers, short-term tracheostomies were reserved for selected cases. Patients with delayed extubation remained intubated for 3 days (interquartile range, 2 to 5 days). The rate of no or only oxygen support after extubation was comparable between immediate and delayed extubation groups (58 of 62 patients [94%] and 137 of 162 patients [85%], respectively). However, the immediate extubation group developed fewer cases of postoperative pneumonia than did the delayed group (0 of 62 [0%] versus 24 of 161 [15%]; P = 0.001). Immediate extubation also appeared safe in moderate to severe obstructive sleep apnea, as 19 of 20 patients (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation. Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no or mild obstructive sleep apnea, and should be the aim in moderate to severe obstructive sleep apnea cases after careful assessment. Therapeutic, III.

Comparative study of percutaneous tracheostomy versus standard surgical tracheostomy

Abstract Background The tracheostomy is an oldest invasive procedure done for critically ill patients. Now, it is usually performed for better weaning and less risk of intubation-related complications either surgically intraoperative or percutaneous procedure which is easily performed at the bedside by an intensivist. The aim of this study is to compare between surgical and percutaneous tracheostomy (PT) in critically ill patients with prolonged ventilation who needed tracheostomy. Methods This randomized controlled study was done at the respiratory ICU - Chest Department, Operating Room of the Otorhinolaryngology Department at Tanta University Hospitals, and respiratory ICU Air Forces Hospital. 30 critically ill patients with prolonged mechanical ventilation were divided into two groups. Group I (15 patients) underwent surgical tracheostomy (ST) and group II (15 patients) underwent fiberoptic bronchoscopic-guided PT, from August 2020 to December 2021. Results 30 patients were enrolled in this study. Neck circumference (cm) was significantly higher in surgical group (P = 0.013). Also, the most important is that the duration of procedure is shorter in percutaneous group (P &lt; 0.001). Regarding delayed complications were insignificantly different between both groups except for stomal infection which was higher in surgical group (P = 0.042). Regarding secondary outcomes of the procedure, successful decannulation, permanent tracheostomy, and death due to primary disease were insignificantly different between the studied groups. Conclusion Percutaneous tracheostomy is safer, faster, time saving and less complicated than surgical tracheostomy.

Complications and degree of difficulty of orotracheal intubation in the Intensive Care Unit before and after the establishment of an intubation protocol for critically ill patients: a prospective, observational study

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015–January 2019) and post-protocol (February 2019–July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack–Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Complicaciones y grado de dificultad de la intubación orotraqueal en la unidad de cuidados intensivos pre-post instauración de un protocolo de intubación para el paciente crítico. Estudio prospectivo y observacional

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an intensive care unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over two periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated —437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥2b in 7.6% vs 29.8%, P<.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs 17.4%, P<.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (P=.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Epithelial lining inspired protective shield for prolonged endotracheal intubation

Endotracheal intubation often suffers from side effects due to inherent defects of the endotracheal tube (ETT) itself, posing a formidable challenge for minimally invasive medical interventions. Inspired by biological functions of the epithelial lining, a novel concept of a protective shield is proposed and engineered onto the surface of commercially-available ETTs via a gas-phase fluorination technology. The direct gas-solid reaction enables fluorinated decoration adaptively to both outer and inner surfaces of ETTs for all-round protection. The protective shield composed by the fluorinated coating not only shows high stability to harsh conditions, excellent hydrophilic lubrication, and good biocompatibility, but also exhibits a favorable anti-biofouling property to a broad spectrum of biofoulings and strong antimicrobial activity against Klebsiella pneumoniae. Crediting the above merits, in vivo experiments affirm that the ETT with the protective shield is efficacious to migrate intubation-related complications in two aspects: reducing mucosal injury and inflammation caused by the outer surface friction, and preventing biofilm formation and airway obstruction to maintain inner tube patency. This work opens an avenue for updating EETs to meet clinic needs and holds promise towards the development of invasive biomedical devices.

The Effect of the Ultrasonography Measurement Method and the Conventional Measurement Method Used in Endotracheal Tube Size Selection in the Pediatric Patient Group on Postextubation Complications and Patient Recovery.

In this study, we aimed to compare the cuffed intubation tube selected with the Cole formula and tracheal ultrasonography (USG) measurement method regarding postextubation complications in providing airway patency and determine its effects on patient recovery. Between 01 July 2022 and 30 June 2023, American Society of Anesthesiologists (ASA) risk group I-III, 4-6-year-old patients who underwent pediatric orthodontic surgery (multiple tooth extraction) were included in the study. Data of age, gender, weight, ASA risk group, history, Cole formula, USG measurement results used in the endotracheal tube (ETT) selection (one of the two whichever application was used), fasting time, intubation success, operation time, 30th-minute modified Aldrete recovery score (MASS), and postoperative complications due to intubation (within the first postoperative hour) were analyzed retrospectively. The patients were divided into two groups according to the method used by the anesthesiologists in selecting the ETT at the beginning of the operation. The group that used Cole formula management was named I, while the group that used the USG measurement method was called II. Intubation-related complication data of the patients in the first 1 hour postoperatively and MASS values at the 30th minute were compared between the groups. In this study, 52.5% of the cases were male (n=42), 47.5% were female (n=38), the mean age was 4.84±0.84 years, and the mean body weight was 22.56±7.58 kilogram. There was no statistically significant difference between the groups regarding age, gender, body weight, ASA score, operation time, and period without oral consumption. ETT diameter measurement values according to groups were 4.73±0.46 mm in Group I and 4.41±0.61 mm in Group II. Postoperative 30th-minute MASS values were median 7 in Group I and median 8 in Group II (p<.001). MASS values were significantly higher in the Group II patient group. Intubation-related complications (postoperative cough, stridor, laryngospasm, tachypnea, wheezing, dysphonia) were observed in Group I with a rate of 40% within the first postoperative hour, while complications were marked with a rate of 17.5% in Group II (p=0.026). Complications in group II were significantly lower. In the pediatric age group, especially under the age of 6, trachea measurement with USG and ETT selection is an effective, safe, and noninvasive method compared to other conventional methods. ETT size selection with USG accelerates postoperative patient recovery and reduces the risk of intubation-related complications. In addition, inflating the tube cuff under USG guidance can prevent cuff-related complications.

Predicting optimal endotracheal tube size and depth in pediatric patients using demographic data and machine learning techniques.

Use of endotracheal tubes (ETTs) with appropriate size and depth can help minimize intubation-related complications in pediatric patients. Existing age-based formulae for selecting the optimal ETT size present several inaccuracies. We developed a machine learning model that predicts the optimal size and depth of ETTs in pediatric patients using demographic data, enabling clinical applications. Data from 37,057 patients younger than 12 years who underwent general anesthesia with endotracheal intubation were retrospectively analyzed. Gradient boosted regression tree (GBRT) model was developed and compared with traditional age-based formulae. The GBRT model demonstrated the highest macro-averaged F1 scores of 0.502 (95% CI 0.486, 0.568) and 0.669 (95% CI 0.640, 0.694) for predicting the uncuffed and cuffed ETT size (internal diameter [ID]), outperforming the age-based formulae that yielded 0.163 (95% CI 0.140, 0.196, P < 0.001) and 0.392 (95% CI 0.378, 0.406, P < 0.001), respectively. In predicting the ETT depth (distance from tip to lip corner), the GBRT model showed the lowest mean absolute error (MAE) of 0.71 cm (95% CI 0.69, 0.72) and 0.72 cm (95% CI 0.70, 0.74) compared to the age-based formulae that showed an error of 1.18 cm (95% CI 1.16, 1.20, P < 0.001) and 1.34 cm (95% CI 1.31, 1.38, P < 0.001) for uncuffed and cuffed ETT, respectively. The GBRT model using only demographic data accurately predicted the ETT size and depth. If these results are validated, the model may be practical for predicting optimal ETT size and depth for pediatric patients.

Factors associated with tracheal intubation-related complications in the prehospital setting: a prospective multicentric cohort study.

Background Emergency tracheal intubation is routinely performed in the prehospital setting. Airway management in the prehospital setting has substantial challenges. Objective The aim of the present study was to determine risk factors predicting tracheal intubation-related complications on the prehospital field. Setting A prospective, multicentric, cohort study which was conducted in three mobile ICUs (MICUs; service mobile d'urgence et de réanimation).Outcome measures and analysis Tracheal intubation-related complications were defined as the occurrence of at least one of the following events: oxygen desaturation (SpO2 < 90%) during tracheal intubation, aspiration (regurgitation visualized during laryngoscopy), and vomiting. Difficult intubation was defined as more than two failed direct laryngoscopic attempts, or the need for any alternative tracheal intubation method. Multivariate logistic regressions were used. Results During the 5-year study period, 1915 consecutive patients were intubated in the MICUs participating in the study. Overall, 1287 (70%) patients were successfully intubated after the first laryngoscopic attempt, with rates of 90, 74, 42, and 30% for Cormack-Lehane grade 1, 2, 3, and 4, respectively. Tracheal intubation was difficult in 663 cases (36%). Tracheal intubation-related complications occurred in 267 (14%) patients. In the multivariate analysis, we found that the leading risk factors for tracheal intubation-related complications were Cormack and Lehane grade 3 and 4 [odds ratio (OR) = 1.65; 95% confidence interval (CI), 1.05-2.61; and OR = 2.79; 95% CI, 1.56-4.98, respectively], a BMI of more than 30 (OR = 1.61; 95% CI, 1.13-2.28), when intubation was difficult (OR = 1.72; 95% CI, 1.15-2.57), and when tracheal intubation required more than one operator (OR = 2.30; 95% CI, 1.50-3.49).Conclusions In this prospective study, we found that Cormack and Lehane more than grade 2, BMI >30, difficult intubation, and tracheal intubation requiring more than one operator were all independent predictors of tracheal intubation-related complications in the prehospital setting. When these risk factors are identified on scene, adapted algorithms that anticipate the use of a bougie should be generalized to reduce morbidity on the prehospital field.

Efficacy and safety of video laryngoscope in indwelling gastric tube in severe coma patients: A protocol for systematic review and meta-analysis

We designed this systematic review and meta-analysis protocol to provide new medical evidence for clinical management by comparing the prognostic outcomes of visual laryngoscopy with those of conventional blinded insertion methods. We will intend to search English databases including Medicine, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, and Google Scholar. The Chinese databases, such as Wanfang, China Knowledge Network, and China Biomedical Literature Database will also be searched. The outcome measures include intubation success rate, pain score, intubation-related complications, patient satisfaction, operation time, and cost. The Jadad scale will be used to evaluate the methodological quality of each randomized controlled trial in this meta-analysis. We will use the Methodological Index of Non-Randomized Studies criteria to assess the risk of bias in non-randomized study. An I2 value greater than 50% indicates the presence of significant heterogeneity. P < .05 in a 2-tailed test is considered statistically significant. It is hypothesized that video laryngoscope will provide better outcomes compared with traditional blind gastric tube insertion. The results of our review will be reported strictly following the PRISMA criteria and the review will add to the existing literature by showing compelling evidence and improved guidance in clinic settings.

Effects of Thermal Softening of Double-Lumen Endobronchial Tubes on the Prevention of Postoperative Sore Throat in Smokers: A Randomized Controlled Trial

Tracheal intubation-related complications, such as postoperative sore throat (POST), hoarseness, and vocal cords injuries, are not uncommon. It is well known that thermal softening of double-lumen endobronchial tubes (DLTs) has been used to prevent these events from happening in non-smokers; however, no study has ever assessed the effects of thermal softening of DLTs in smokers undergoing one-lung anesthesia. The authors aimed to investigate whether thermal softening of DLT can achieve a better effect in preventing POST. A total of 258 smokers scheduled for one-lung anesthesia were randomly assigned to 1 of the following 2 groups: (1) group C (non-thermal softening group) and (2) group T (DLTs were placed in 40°C 0.9% saline for 10 minutes). Incidence and severity of POST and hoarseness were assessed until 48 hours after surgery. Vocal cords were examined using laryngoscope before intubation and immediately after extubation. Patients' hemodynamic change at intubation and extubation was recorded. The primary outcomes were the incidence and severity of POST. The secondary outcomes were the incidence and severity of hoarseness, vocal cords injuries, and patients' hemodynamic change at intubation and extubation. Sore throat and vocal cord injuries occurred less frequently in the thermal softening group than in the control group (31/129 v 60/129, p < 0.01; 21/129 v 49/129, p < 0.001; 12/129 v 35/129, p < 0.001 for sore throat; 14/70 v 27/70, risk ratio (95% confidence interval): 0.52 (0.30-0.90), p=0.025 for sore throat; 5/129 v 52/129, p < 0.05 for vocal cord injuries). Thermal softening of DLTs significantly reduced the incidence and severity of DLTs intubation-related POST within 72 hours after extubation.

Comparison of three video-assisted intubation methods: Rigid telescopes, C-MAC, flexible fiberoptic bronchoscopy, for anticipated difficult airways

ObjectiveThe aim of this study was to compare the efficiency and reliability of rigid telescopes with the two most used video-assisted intubation techniques. The primary outcome of the study is the first attempt orotracheal intubation success rate and the secondary outcomes include intubation time, mucosal injury, and complications during intubation. Materials and methodsAll patients that were predicted to have difficult intubation were prepared according to the video-assisted intubation technique and were randomly divided into three groups: Group 1 (REI group; n = 49) included patients that were intubated using rigid endoscope-assisted orotracheal intubation (REI) (0°, 45°, and 70°), 18-cm rigid telescope, full-HD camera, and Macintosh blade. Group 2 (V-MAC Group; n = 51) included patients that underwent tracheal intubation using a videolaryngoscope Macintosh (V-MAC). Group 3 (FFEI group; n = 53) included patients that underwent flexible fiberoptic tracheal intubation. Groups were compared with regard to intubation success rate, intubation time, number of intubation attempts, and intubation-related complications. ResultsThe study included a total of 153 patients aged 18–60 years who were predicted to have difficult intubation and underwent intubation with phonomicrosurgery and general anesthesia under elective conditions. Demographic and airway findings of the groups were similar, and no significant difference was found among the groups with regard to the number of intubation attempts (p > 0.05). Intubation was successful at the first attempt in 110 (72%), at the second attempt in 26 (17%), and at the third attempt in 17 (11%) patients. No significant difference was found among the three groups with regard to the number of intubation attempts (p > 0.05). Intubation time was significantly longer in the FFEI group compared to the other two groups (p < 0.05). The prevalence of mucosal injury to vocal cords was significantly lower in the REI group compared to other groups (p < 0.05). ConclusionRigid telescopes can be considered in elective surgeries of patients predicted to have difficult airway since they allow for rapid assessment of the airway, minimal mucosal damage, and rapid intubation.

Mucosa‐Like Conformal Hydrogel Coating for Aqueous Lubrication

Mucosa is a protective and lubricating barrier in biological tissue, which has a great clinical inspiration because of its slippery, soft, and hydrophilic surface. However, mimicking mucosal traits on complex surface remains an enormous challenge. Herein, a novel approach to create mucosa-like conformal hydrogel coating is developed. A thin conformal hydrogel layer mimicking the epithelial layer is obtained by first absorbing micelles, followed by forming covalent interlinks with the polymer substrate via interface-initiated hydrogel polymerization. The resulting coating exhibits uniform thickness (≈15µm), mucosa-matched compliance (Young's modulus = 1.1± 0.1kPa) and lubrication (coefficients of friction = 0.018± 0.003), robust interfacial bonding against peeling (peeling strength = 1218.0± 187.9 J m-2 ), as well as high water absorption capacity. It effectively resists adhesion of proteins and bacteria without compromising biocompatibility. As demonstrated by an in vivo cynomolgus monkey model and clinical trial, applications of the mucosa-like conformal hydrogel coating on the endotracheal tube significantly reduce intubation-related complications, such as invasive stimuli, mucosal lesions, laryngeal edema, inflammation, and postoperative pain. This work offers a promising prototype for surface decoration of biomedical devices and holds great prospects for clinical translation to enable interventional operations with minimally invasive impacts.

Diagnostic Accuracy of Combined Mallampati and Wilson Score to Predict Difficult Intubation in Obese Patients: A Descriptive Cross-sectional Study

BackgroundAirway protection during anesthesia is often the primary concern of anesthetists when working with obese patients and always is a difficult task due to increased exposure to harmful effects of apnea, hypoxia, and impaired respiratory mechanics.ObjectivesThe primary goal of this research was to determine the diagnostic accuracy of combined Mallampati and Wilson score in detecting difficult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intubation as the gold standard.MethodsThis descriptive cross-sectional study was done in 300 obese patients with BMI > 29.9 kg/m2. Modified Mallampati and Wilson score was recorded preoperatively for each patient in the sitting position by the primary investigator. Endotracheal intubation grades were also recorded, and grades IIb, III, and IV were regarded as difficult intubation according to the Cormack-Lehane intubation classification.ResultsThe mean age was 46.76 ± 15.57 years. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the combined Mallampati and Wilson score for detecting difficult laryngoscopy and difficult intubation were 75.0, 98.8, 92.9, 95.0, and 94.6%, respectively.ConclusionsCombined Mallampatti and Wilson score is highly accurate in the initial diagnostic workup of obese patients at risk of difficult intubation. It is easy to calculate and lower the risk of intubation-related complications and failure.