Intubation Trials Research Articles

The benefits of the video-laryngoscope in learning intubation for undergraduate medical students: A randomized crossover study in airway manikin

IntroductionDirect laryngoscopy is the most widely used procedure for learning intubation. Video-laryngoscopy has become a well-established tool in managing of difficult laryngoscopies. Its contribution to teaching intubation for novices remains unclear.The aim of this study was to compare video-laryngoscopy using Medcaptain® laryngoscope and direct laryngoscopy using Macintosh laryngoscope in learning tracheal intubation on a low-fidelity manikin by novice learners. MethodsThis was a cross-sectional, randomized, cross-over study, including 35 inexperienced in laryngoscopy students in the 5th year of medical studies. It was carried out on a low fidelity upper airway management dummy. We did not include learners who had previously practiced intubation. After randomization, 18 learners started learning by procedural simulation with video-laryngoscopy (type Medcaptain®) then direct laryngoscopy (type Macintosh) and 17 learners started with direct laryngoscopy then video-laryngoscopy. Then, all learners performed 3 intubation trials by using direct laryngoscopy and video-laryngoscopy according to the pre-established order. The primary endpoint was the time needed to intubate. Secondary endpoints were, Cormack classification, difficulties encountered and learners’ satisfaction. ResultsThere was no significant difference in time needed to intubate between groups for the three attempts (p = 0.18, p = 0.45 and p = 0.1). The time needed to intubate by direct laryngoscopy was lower on the 1st and 3rd trials for learners who had started their training with video-laryngoscopy first (p = 0.02 and p = 0.01; respectively). There was no significant difference regarding the rate of successful intubation. The video-laryngoscopy allowed better visualization of vocal cords with more frequently noted Cormack I classification (p < 0.001, p = 0.002 and p < 0.001). The main difficulties encountered were the handling of the epiglottis and the tongue by the blade and the inserting the tracheal tube with no significant difference between the 2 techniques. Learners’ satisfaction was comparable. ConclusionVideo-laryngoscopy improved vocal cord exposure during intubation on a manikin for novice learners. Clinical trial registrationThis study has been registered in Clinical Trials database NCT05859542.

Experimental Analysis of the Efficiency and Usability of Tylke Versus Magill Forceps.

The procedure of nasotracheal intubation (NI) has long been performed utilizing the Magill forceps as developed by Sir Ivan Magill in the 1920s. While used for nearly a century, several serious patient safety concerns remain including torn tube cuffs, vocal cord trauma, and inefficient tube placement. The Tylke forceps have been developed as a modification to the largely unchanged form of Magill forceps. In the present investigationwe compared the efficacy, number of clasps, and muscle activation involved in NI using the Tylke forceps versus the Magill forceps in previously untrained individuals. Tylke forceps showed faster successful NI over the standard Magill forceps at an average intubation time of 6.54s vs. 13.73s, respectively. Tylke forceps also had fewer clasps per intubation over the Magill. The trapezius, deltoid, and brachioradialis muscle activation was also compared in Tylke vs Magill forceps intubation trials. Tylke forceps required less lower muscle activation in the brachioradialis and trapezius over the Magill forceps with Tylke forceps resulting in higher deltoid muscle activation. Tylke forceps were more efficacious and reduced the number of clasps over the Magill forceps when used in successful NI with different muscle activation patterns.

RAE ENDOTRACHEAL TUBES SIZES FOR CHILDREN UNDERGOING CLEFT LIP AND PALATE SURGERY.

Background: Appropriate sizes (internal diameters) of RAE endotracheal tubes in children with cleft lip and palate, who generally have delayed growth and development in early infancy have not been explained. Objectives: The aim of the current study was to identify the proper size of REA endotracheal tube for intubation used for cleft lip and palate surgery and intubation outcomes in these patients. Material and methods: 60 cleft lip and palate patients were selected for analytic cross-sectional study. The proper tube size was determined by normal children formula. Then tube size was confirmed by patients' minimum resistance to intubation, proper ventilation, and appropriate air leakage at an airway pressure of 15-20 cm H2O. Number of attempts of intubation and the largest endotracheal tube size were recorded. Results: The average age, weight and height of patients were 22.40±4.85 months, 9.88±1.28 kg, 72.40±24.50 cm respectively. The average RAE endotracheal tube size and frequency of intubation trials were 4.25±0.78 and 1.62±0.70, respectively. 6 cases required RAE endotracheal tube size smaller than the recommended size. Conclusions: In cleft lip and plate child, the predicted RAE endotracheal tube size was similar to standard normal child tube size. Smaller RAE tube size was required for subglottic stenosis.

Difficult Airway Anthropometric Measurements in Patients with Obstructive Sleep Apnea According to Sleep Endoscopy Scores

Aim: The aim of the study was to determine the measures to evaluate difficult intubation and predictors of intubation difficulties in the preoperative period in patients undergoing obstructive sleep apnea syndrome (OSAS) surgery. With these measurements, both the modified Cormack Lehane score and obstructions during sleep endoscopy were evaluated. &#x0D; Material Methods: The study included 40 patients who presented at the outpatient clinic with the complaint of snoring, underwent polysomnography, and were diagnosed with OSAS between August 2018 and December 2019. Measurements were taken of the modified Mallampati Index, mouth opening, thyromental distance, and sternomental distance. The modified Cormack Lehane scoring system was applied after anesthesia induction.&#x0D; &#x0D; Results: A statistically significant correlation was observed between thyromental distance and the Modified Cormack Lehane Scoring-system (MCLS) (p = 0.017) and between intubation time and MCLS (p = 0.012). As MCLS increased, the average intubation time increased. A statistically significant correlation was observed between external compression and MCLS (p = 0.001) and between the number of intubation trials and MCLS (p = 0.035). A positive correlation was found between MCLS and the desaturation index (p = 0.035, r = 0.343) and between the MCLS and the hypopnea index (p = 0.031, r = 0.342)&#x0D; Conclusion: There was found to be interdependence with the measurements related to difficult intubation according to both the sleep position and the apnea hypopnea index and hypopnea index

An intubation method for mono-pulmonary ventilation in patients with difficult airway.

This study aimed to compare the clinical effect between thermal softening PVC double-lumen tube (DLT) and single-lumen tube (SLT) guided by laryngoscope and bronchoscopy in patients with difficult airways. 72 patients with chest surgery in need of mono-pulmonary ventilation, aged 20-70 years old, with ASA rating I-III and Arné scoring ≥ 11, were enrolled. Patients were categorized randomly into two groups with 36 patients in each: the D group (DLT was used) and the S group (SLT was used). Bronchoscopy was used for guiding the intubation and aligning in both groups. Laryngoscope would also be used immediately after failure in two trials of intubation. Intubation resistance, intubation success rate, laryngoscopy assist rate, time for intubation, time for alignment, incidence of catheter dislocation, VAS score for post-operative throat pain, and the damage extent of vocal cord were recorded. No significant differences were seen between two the groups in terms of intubation resistance, intubation success rate, laryngoscopy assist rate, time for intubation, VAS score for post-operative throat pain, and the damage extent of vocal cord. However, shorter time for alignment and lower incidence of catheter dislocation were observed in the D group than in the S group (both p < 0.05). For intubation in patients with difficult airway, the thermal softening DLT was as safe as the SLT, but simpler in alignment and had a lower dislocation incidence. Meanwhile, video laryngoscope could increase the success rate of intubation with either tube.

Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan

Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial. To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA. The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020. Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period. The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed. A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2. In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion. ClinicalTrials.gov Identifier: NCT02967952.

Bearing witness in the time of COVID

My patient was an octogenarian with numerous comorbidities. He had now been intubated for 10 days with acute respiratory distress syndrome from COVID-19. He had previously lived in a nursing home and caught the virus at the facility. On arrival at the hospital, he reversed his previous status of “do not intubate” and agreed to a trial of intubation. As the oncoming intensive care unit (ICU) fellow in the COVID unit, I recognised he had developed multiorgan failure and was not going to leave the ICU, despite our aggressive interventions.

Rabbit model of consistently survivable subglottic stenosis using a modified brush technique

IntroductionSeveral animal models of subglottic stenosis (SGS) have been described in the literature, however many result in severe stenosis that requires early intervention and carry a high mortality rate. This limits the application of the model and may require the use of additional animals to achieve desired results due to procedural complications. A novel endoscopic method of inducing SGS in a rabbit model was developed as part of a larger investigation on the treatment of this condition. The objective of this study was to develop an animal model for survivable subglottic stenosis. Methods12 New Zealand white rabbits underwent 2 trials of prolonged intubation that were not successful in inducing SGS. A partially sheathed nylon brush injury technique was then designed and implemented. Airway assessment consisted of rigid bronchoscopy 6 weeks and 8 months after injury. Results12 rabbits undergoing subglottic brush injury had focal posteriorly based subglottic stenosis on bronchoscopy at 6 weeks and 8 months post-injury. One rabbit was euthanized after the brush induced subglottic injury but prior to 6 week bronchoscopy due to an unrelated orthopedic injury. This animal was therefore excluded from analysis and replaced. No rabbits required early airway intervention or sacrifice. All survived a period of 8 months. ConclusionInducing subglottic injury with a partially-sheathed nylon brush safely and reliably creates a controlled SGS with zero procedure-related mortality over 8 months. This model could be the basis for a longer-term evaluation of subglottic scar evolution and intervention.

Developing a Profile of Procedural Expertise: A Simulation Study of Tracheal Intubation Using 3-Dimensional Motion Capture.

Improving the assessment and training of tracheal intubation is hindered by the lack of a sufficiently validated profile of expertise. Although several studies have examined biomechanics of tracheal intubation, there are significant gaps in the literature. We used 3-dimensional motion capture to study pediatric providers performing simulated tracheal intubation to identify candidate kinematic variables for inclusion in an expert movement profile. Pediatric anesthesiologists (experienced) and pediatric residents (novices) were recruited from a pediatric institution to perform tracheal intubation on airway mannequins in a motion capture laboratory. Subjects performed 21 trials of tracheal intubation, 3 each of 7 combinations of laryngoscopic visualization (direct or indirect), blade type (straight or curved), and mannequin size (adult or pediatric). We used repeated measures analysis of variance to determine whether various kinematic variables (3-trial average for each participant) were associated with experience. Eleven experienced and 15 novice providers performed 567 successful tracheal intubation attempts (9 attempts unsuccessful). For laryngoscopy, experienced providers exhibited shorter path length (total distance traveled by laryngoscope handle; 77.6 ± 26.0 cm versus 113.9 ± 53.7 cm; P = 0.013) and greater angular variability at the left wrist (7.4 degrees versus 5.5 degrees, P = 0.013) and the left elbow (10.1 degrees versus 7.6 degrees, P = 0.03). For intubation, experienced providers exhibited shorter path length of the right hand (mean = 61.1 cm versus 99.9 cm, P < 0.001), lower maximum acceleration of the right hand (0.19 versus 0.14 m/s, P = 0.033), and smaller angular, variability at the right elbow (9.7 degrees versus 7.9 degrees, P = 0.03). Our study and the available literature suggest specific kinematic variables for inclusion in an expert profile for tracheal intubation. Future studies should include a larger sample of practitioners, actual patients, and measures of the cognitive and affective components of expertise.

Comparison of glottis views with fixed-height pillow versus adjustable-pillow height by pressure infusion bag for successful intubation

Background: This study aimed to get optimal sniffing position for successful intubation rate and measuring intubation time. The classical rationale for the sniffing position is that the alignment of the mandibular axis, pharyngeal axis, and laryngeal axis is facilitated, permitting successful direct laryngoscopy. Patients and Methods: A total of 100 patients without any anticipated difficult airway were enrolled after informed consent is given. After induction of anesthesia, patients were randomly divided into two groups. In Group PB, a deflated pressure infusion bag was put under the nape of the neck and occiput. The anesthetist performed laryngoscopy with the left hand while inflating the bag with the right hand up to the best glottic view without external pressure is achieved. The height of the bag was measured. In Group PI, 10-cm fixed-height noncompressible pillow was placed behind the head up to the shoulder. The best glottic view of the entire glottis without external pressure was noticed. Grading of glottic opening grade, SPO2, intubation time, and intubation trials were also noted. Results: Failure to intubate was noted in one patient in Group PB and two in Group PI. Intubations successful in 45 (90%) patients in Group PB as compared to 38 (76%) patients in Group PI (P < 0.05). Laryngoscopic view in Group PB was superior to that with Group PI (P < 0.05), with mean pressure bag height of 4.86 cm. Conclusion: The use of pressure infusion bag for adjustable-pillow height provides more success in intubation condition by head elevated position than the fixed height of 10 cm.

The use of USB endoscope (borescope) to guide nasal tracheal intubation: a pilot study

Background In spite of the presence of multiple videolaryngoscopes in the market, financial restrains prevent their routine use in many clinical practices. Patients and methods The endoscope USB camera was inserted in a conventional endotracheal tube which could be inserted nasally (6.5 or 7 cuffed endotracheal tube). Sterile K-Y lubricating gel was used to facilitate the insertion of the borescope. This was used for nasal intubated in eight patients. Results Nasal intubation trials were done by an experienced physician for eight patients. All eight patients were Mallampati class 1 or 2. One patient was intubated at the first attempt, three were intubated at the second attempt, and one was intubated at the third attempt. There was failure in three cases (secretions and blood). Conclusion Borescope can be used as a cheap option for nasal airway management. Randomized studies need to be done for its evaluation compared with other videolaryngoscopy devices.

Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study

ObjectivesMultiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization. MethodsWe conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED. ResultsOf 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p < 0.01) were independent prognostic variables. ConclusionsWe found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization.

Use of video laryngoscopes by inexperienced personnel in difficult intubations

The current gold standard in securing airway patency remains to be endotracheal intubation. It is the only method, which allows for nearly 100% protection of the bronchial tree from aspiration of gastric contents as well as providing the most ideal circumstances for control of ventilation parameters. Endotracheal intu- bation, although in many aspects superior to other methods of securing airways, can only be performed by skilled and experienced personnel in ideal conditions. An example of such conditions are in an operating room in the preoperative period when an anesthesiologist is able to proficiently perform the task with all of the tools and equipment needed at hand. However, in many situations, especially in emergencies, such ideal conditions are difficult or impossible to achieve. One of the many reasons behind this is often the lack of experienced personnel at the scene of an emergency. Another significant difficulty arises from trauma patients who must maintain an immobilized cervical spine, as well as those patients who are undergoing active cardiopulmonary resuscitation when providing high quality chest compressions is the highest priority. Therefore, it seems reasonable to look for the methods which on one hand will secure an airway with a tube inserted directly into the larynx, and on the other hand will make the procedure more accessible to less expe- rienced personnel by maintaining the proper patient safety throughout the whole procedure. A noteworthy method, which achieves this goal, is the use of the video laryngoscopes for endotracheal intubation. The participation in a short introductory training, regarding the use of the device itself, is sufficient to allow for the efficient intubation. The parameters which can be used to compare these different intubation methods include the ease of use, the rate of effectiveness of the first intubation trial as well as the total time needed for the procedure. The authors of this article attempt to compare classic laryngoscopes to video-assisted laryngoscopes.

Manual ventilation to prevent hypoxaemia during endotracheal intubation of critically ill adults: protocol and statistical analysis plan for a multicentre randomised trial

IntroductionHypoxaemia is the most common complication during endotracheal intubation of critically ill adults, and it increases the risk of cardiac arrest and death. Manual ventilation between induction and intubation has...

O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

BackgroundMacintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. MethodsEndotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group‐MM and Group‐MV used Macintosh laryngoscopes; Group‐VV and Group‐VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group‐MM and Group‐VM and videolaryngoscopes used in Group‐VV and Group‐MV. ResultsSuccess rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group‐VM (p=0.008). ConclusionsThe success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

The role of videolaryngoscope in endotracheal intubation training programs

BackgroundMacintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. MethodsEndotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV. ResultsSuccess rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group-VM (p=0.008). ConclusionsThe success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

Difficult airway intubation simulation using Bonfils fiberscope and rigid fiberscope for surgical training

IntroductionPediatric otolaryngologists are frequently called to assist in difficult airway management in newborns with Pierre Robin Sequence (PRS) who have microretrognathia, glossoptosis, and an anterior larynx. The Bonfils fiberscope (BF) is a curved rigid scope designed to provide superior visualization in the anterior larynx. Objective(1) to assess whether BF provides an improvement in intubation success rate, time to intubation, or airway visualization as compared to rigid fiberscope (RF) in a difficult airway simulation setting and (2) to determine whether a training program for BF can improve time to intubation through practice trials. MethodsSix right-handed trainees completed five trials on each of the three following airway models using the BF and RF: normal anatomy, anterior larynx and PRS. The normal larynx model was intubated only with RF. Main outcome measures were the time needed for tracheal intubation and Cormack–Lehane classification (1–4). ResultsThe majority of the intubation trials showed a statistically significant difference between first and last completion times (p < .05) suggesting construct validity. Only the anterior larynx trials with BF did not demonstrate an improvement in time to intubation between first and last attempts (p < .3125). For the PRS retrognathia model, there was no statistically significant difference in time to intubation between using the BF and the RF (p < .44); in the anterior larynx model, the RF yielded a faster time to intubation than the BF on the final trial attempts (p < .0313). By Cormack–Lehane classification measures, laryngeal visualization by the BF was better than RF in the PRS manikin (p < .0022) while there was no significant difference in grade scores for the anterior larynx manikin (p < .45). All six trainees reported an improved visualization of the larynx with the BF compared to the RF for both the anterior larynx and PRS manikins; at the end of the trial runs, all participants noted an improvement in comfort level using the BF. ConclusionThe difficult airway simulation model is feasible for surgical training. BF adds superior visualization of the anterior larynx in PRS. Otolaryngology training programs may include BF as a supplemental tool in addition to RF as a part of the airway equipment training since there is significant improvement in time to intubation with consecutive practice trials and superior laryngeal visualization.

Effect of Head Position on the Success Rate of Blind Intubation through Air Q Laryngeal Mask in Morbidly Obese Patients

Aim: To evaluate the effect of head positioning whether neutral or sniffing position on the conduct of intubation through air Q in morbidly obese patients. Patients and method: This study was conducted on 90 patients with body mass index equal or above 40 who were scheduled for surgery under GA and were randomly divided into 2 equal groups: Group N (Gn) in which blind intubation through air Q was done in neutral position. Group S (Gs) in which blind intubation was done in sniffing position. Proper airway assessment of the patients was done. Basic monitoring was attached; Induction of anaesthesia was achieved by Fentanyl 2 ug/kg, Propofol 1.5 - 2.5 mg/kg and Atracurium 0.5 mg/kg. Maintenance of anaesthesia was achieved by Sevoflurane, Atracurium, oxygen and air. When neuromuscular blockade was complete, the head of the patient was adjusted according to their group. The supraglottic device was inserted and connected to capnography, thereafter a well lubricated proper sized ETT was passed through the air Q. We recorded a baseline reading of HR, SBP, DBP, MBP, and oxygen saturation. A second reading was taken after induction of anesthesia, just before intubation. The third reading was recorded after intubation while further readings were measured 1, 3, 5, 10, 15 min after intubation. After ETT removal, we observed the patients in the recovery room at 0, 3 & 24 hours for possible postoperative complications. Results: There was no statistical difference between the two groups regarding the demographic data. Although the intubation in sniffing position has a higher success rate from the first time than the neutral position, the results were statistically insignificant, regarding the mean duration of blind intubation trials through the Air Q and postoperative complications. Conclusion: Although the sniffing position improves glottic visualization, the change of head position had no effect on the success rate of blind intubation through air Q in obese patients.

Non-Convulsive Status Epilepticus (NCSE) in ICU

Background: This study aimed to get optimal sniffing position for successful intubation rate and measuring intubation time. The classical rationale for the sniffing position is that the alignment of the mandibular axis, pharyngeal axis, and laryngeal axis is facilitated, permitting successful direct laryngoscopy. Patients and Methods: A total of 100 patients without any anticipated difficult airway were enrolled after informed consent is given. After induction of anesthesia, patients were randomly divided into two groups. In Group PB, a deflated pressure infusion bag was put under the nape of the neck and occiput. The anesthetist performed laryngoscopy with the left hand while inflating the bag with the right hand up to the best glottic view without external pressure is achieved. The height of the bag was measured. In Group PI, 10-cm fixed-height noncompressible pillow was placed behind the head up to the shoulder. The best glottic view of the entire glottis without external pressure was noticed. Grading of glottic opening grade, SPO2, intubation time, and intubation trials were also noted. Results: Failure to intubate was noted in one patient in Group PB and two in Group PI. Intubations successful in 45 (90%) patients in Group PB as compared to 38 (76%) patients in Group PI (P

Praziquantel delivery via moist pellets to treat monogenean parasites of yellowtail kingfish Seriola lalandi: efficacy and feed acceptance.

Praziquantel (PZQ) is registered for oral use against Benedenia seriolae infecting Seriola spp. in Japan, but its bitter taste causes poor palatability. Incorporating PZQ in a moist pellet may help mask the flavor to improve intake. Altering delivery, however, may influence efficacy. We assessed the minimum effective concentrations of PZQ in moist pellets delivered by intubation for the monogeneans Zeuxapta seriolae and B. seriolae infecting yellowtail kingfish Seriola lalandi in flow-through tanks. The optimised dose was then evaluated in a sea-cage of S. lalandi to assess feed acceptance and efficacy. During intubation trials, efficacy was assessed as a percent reduction compared to control groups; in the field trial, efficacy was assessed by a percent reduction after treatment. PZQ delivered by intubation at 70 mg kg-1 body weight (BW) for 3 d was 99.7 and 81.7% effective against Z. seriolae and B. seriolae, respectively. Increasing the dose to 120 mg kg-1 BW for 3 d had a similar efficacy against Z. seriolae (98.4%) and increased efficacy against B. seriolae to 89.2%, but partial emesis of the medicated feed was sometimes noted. S. lalandi in a sea-cage at 17°C readily consumed PZQ administered daily in moist pellets at 70 mg kg-1 BW for 3 d (inclusion rate: 5.15 g kg-1), which significantly reduced Z. seriolae and B. seriolae abundance with 99.4 and 81.6% efficacy, respectively. Juvenile B. seriolae were common on the eyes of fish post-treatment which indicates a strategically timed repeat treatment is necessary.