Laryngoscopy Research Articles

Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial.

The number of tracheal intubation attempts required to reach proficiency in videolaryngoscopy with hyperangulated blades is unknown. Understanding this training requirement might guide training for clinicians who perform laryngoscopy. We therefore performed a planned sub-analysis of a randomised controlled trial comparing tracheal intubation success with videolaryngoscopy vs. direct laryngoscopy to determine the number of tracheal intubations with a hyperangulated videolaryngoscope blade needed to provide an acceptable first-attempt success rate. We included clinicians from a randomised controlled trial who were familiar with direct laryngoscopy and Macintosh-blade videolaryngoscopy but inexperienced with hyperangulated videolaryngoscopy. Cumulative sum statistics were used to generate learning curves with acceptable success rates of 85% and unacceptable success rates of 70% for the primary outcome of first-attempt tracheal intubation success. We included 223 clinicians (25 consultants; 35 certified registered nurse anaesthetists; 36 student registered nurse anaesthetists; 46 fellows; and 81 residents) who attempted tracheal intubation in 4312 procedures. The median (IQR [range]) number of tracheal intubations per clinician was 15 (8-25 [1-77]). First-attempt failure was low, with only 72 failed first attempts overall, and was comparable across clinician groups. In total, 133 (60%) clinicians crossed the acceptable success rate boundary while the remaining 90 (40%) clinicians crossed neither the acceptable nor unacceptable success rate boundaries. Among clinicians who crossed the acceptance boundary, the median (IQR [range]) number of attempts for learning was 12 (12-12 [12-26]). Clinicians experienced in tracheal intubation with direct laryngoscopy but unfamiliar with hyperangulated-blade videolaryngoscopy can achieve proficiency after approximately 12 attempts.

Outcome of video laryngoscopy versus direct laryngoscopy for emergency tracheal intubation in emergency department: a propensity score matching analysis

BackgroundThe high incidence of airway management failure in the emergency department (ED) necessitates a comparative analysis of laryngoscopy methods. This study aims to compare the success and complications associated with video-assisted laryngoscopy (VL) and direct laryngoscopy (DL) in emergency tracheal intubation in ED.MethodsThis retrospective cohort study was conducted at the ED of Thammasat University Hospital. It involved adult patients undergoing emergency tracheal intubation using either VL (GlideScope®) or DL (Macintosh®). The outcomes assessed were success rates of intubation and occurrence of peri-intubation adverse events. Propensity score matching and multivariable risk regression analysis were employed for statistical evaluation.ResultsThe study included 3,424 patients, with 342 in the VL group and 3,082 in the DL group. The initial analysis revealed no significant differences in the intubation success rates between the two methods. However, the VL group experienced fewer peri-intubation adverse events (33% compared to 40%). After propensity score matching, a higher first-attempt success rate was observed in the DL group (88.9% vs. 81.3%, risk difference: 7.6, 95% CI: 1.9 to 13.2, p=0.009), but there was no statistically significant difference in peri-intubation adverse events. VL had a lower first-attempt success rate among low-experience intubators. Subgroup analyses of intubators with moderate and high experience, as well as patients who received both induction agents and neuromuscular blocking agents, show results consistent with the analysis of the entire cohort.ConclusionBoth VL and DL have comparable first-attempt success rates and peri-intubation adverse events. VL is particularly beneficial when used by moderately or highly experienced intubator. The choice of intubation method, combined with clinical experience and technique plays a critical role in the success and safety of emergency intubations.

Evaluation and Treatment of Acute Laryngeal Injury at Time of Tracheostomy for Prolonged Intubation.

The primary objective was to assess incidence and severity of acute laryngeal injury (ALgI) following intubation at time of tracheostomy using a proposed grading scale. The secondary objective was to evaluate what factors influence the rate of decannulation. Single institution cohort study with review of prospectively maintained database including patients from October 2021 to October 2022 who underwent tracheostomy for prolonged intubation/critical illness. Severity of ALgI was graded as mild, moderate, or severe based on intraoperative endoscopic findings (laryngeal mucosal ulceration and/or granulation tissue). Rates of tracheostomy decannulation were collected as the secondary outcome measure. Twenty-eight patients met criteria for inclusion. About 60.7% (n = 17) patients were female. Average age was 59.0 ± 13.2 years old. Average body mass index was 32.3 ± 14.0 kg/m2. The most common endotracheal tube size was 7.5 (range = 6.0-8.0) inner diameter (ID) for men and 7.0 (range = 5.5-8.0) ID for women. Average Charlson Comorbidity Index (CCI) was 4.8 ± 2.4. Length of intubation was 15.7 ± 6.5 days (range = 5-30). Direct laryngoscopy at the time of tracheostomy demonstrated ALgI in 92.8% (n = 26) of patients. This was graded as mild (25.0%, n = 7), moderate (42.9%, n = 12), or severe (25.0%, n = 7). Severe ALgI was correlated with a reduced rate of tracheostomy decannulation compared to no/mild/moderate ALgI (28.5% vs 81.2%, P = .04). ALgI is highly prevalent in patients undergoing tracheostomy for prolonged intubation. Severe injury is associated with reduced rates of decannulation. Direct laryngoscopy at time of tracheostomy is warranted to diagnose ALgI and guide interventions. Determining the extent of laryngeal injury is prognostic and could help tailor follow-up and management strategies. 4.

Anesthetic Challenges in a Patient with Nodular Sclerosing Classical Hodgkin’s Lymphoma complicated by Cervical Metastasis and SVC Syndrome: A Case Report

This case presents the anesthetic complexities involved in managing a patient with nodular sclerosing classical Hodgkin’s Lymphoma, who presented with severe airway compromise, limited neck mobility due to C7 vertebra involvement, and superior vena cava syndrome. The patient, with an extensive anterior neck mass extending into the mediastinum, post-auricular, and axillary areas, exhibited symptoms such as dyspnea, orthopnea, facial swelling, and upper extremity edema, complicating traditional airway management techniques. Faced with these challenges, the team anticipated significant difficulty with ventilation, direct laryngoscopy, and invasive airway access. To address the airway obstruction effectively before initiating radiotherapy, the anesthesiologists employed awake nasotracheal intubation using a fiberoptic scope with minimal sedation using Remifentanil. This approach successfully secured the airway and facilitated an extended tracheostomy. The patient tolerated the procedure well and was eventually discharged. This case underscores the critical role of fiberoptic intubation in managing complex airway scenarios, particularly in patients with complex malignancies and associated complications.

A systematic review of ultrasonography-guided transcutaneous fine needle aspiration cytology in the diagnosis of laryngeal malignancy.

Direct laryngoscopy and biopsy is the gold standard for obtaining a tissue diagnosis in patients with suspected laryngeal cancer. In patients with advanced disease or other medical comorbidities, this may come with significant anaesthetic risks, including tracheostomy. Ultrasonography-guided biopsy has been widely used in the diagnosis of malignancy involving cervical lymph nodes but it is not commonly employed in the diagnosis of laryngeal tumours. A systematic review was undertaken to assess the literature looking at whether ultrasonography-guided transcutaneous fine needle aspiration cytology (FNAC) is an adequate method in diagnosing laryngeal malignancy. Two independent researchers conducted a systematic review of the literature using the MEDLINE® and Cochrane Library databases in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A total of 568 studies were identified from the search, of which 3 met the inclusion criteria, resulting in 162 patient episodes. The pooled accuracy of transcutaneous FNAC in acquiring a sample adequate for histological diagnosis was 74.9%. Data on complications were limited, with a few cases of mild haemoptysis being recorded. Transcutaneous FNAC can be considered a safe and quick method for establishing a histological diagnosis of laryngeal lesions, particularly in patients who may be severely comorbid, and it could therefore could reduce the risks of general anaesthesia and tracheostomy prior to commencing definitive treatment.

Comparative evaluation of first-attempt intubation success rate using direct laryngoscope with Macintosh blade and video laryngoscope during rapid sequence induction in patients undergoing emergency surgery: A prospective randomised controlled trial.

Airway management skills form the cornerstone of routine anaesthesia practice. Its role becomes more significant in emergency areas where time is of the essence. Patients presenting for emergency surgery require definitive airway management with endotracheal intubation. Rapid sequence induction with direct laryngoscopy using a Macintosh blade has been used consistently with varying success. With the advent of video laryngoscopes, their utility is being explored in emergency areas. We aimed to assess the role of a video laryngoscope (Medizintechnik, Sulz, Germany) in rapid sequence induction and intubation during emergency surgeries. We hypothesised that video laryngoscope would improve the first-attempt intubation success rate in patients undergoing emergency surgery. In total, 76 patients presenting for emergency surgery were enrolled and randomly assigned into two groups (38 each), who were intubated with either a video laryngoscope or Macintosh blade during rapid sequence induction. This study aimed to compare and evaluate direct laryngoscopy using a Macintosh blade and a video laryngoscope during rapid sequence induction. The two groups were similar in the type and indication for surgery. Airway characteristics were also compared, and there were no significant differences in all airway parameters, including mouth opening, thyromental distance, Mallampati grading and neck circumference. The first-attempt intubation success rate was significantly higher in the video laryngoscope group (p = 0.017, χ2 = 5.684). The Cormack-Lehane grade distribution was compared in both groups, with better glottis visualisation in group video laryngoscope (p = 0.028, χ2 = 9.123). This prospective, randomised, controlled study aimed to compare the first-attempt intubation success rate using direct laryngoscopy with a Macintosh blade and a video laryngoscope during rapid sequence induction in patients undergoing emergency surgeries and observed that first-attempt intubation success rate was significantly higher in group video laryngoscope (86.8%) than in group direct laryngoscopy (63.2%). Therefore, video laryngoscopy offers an attractive alternative to conventional laryngoscopy while securing the airway in patients presenting for emergency surgery.

Abstract A007: Transient elevation of ctHPVDNA in human papilloma virus-mediated oropharynx squamous cell carcinoma patients following diagnostic surgical procedures

Abstract Background: Circulating tumor DNA (ctDNA) is now widely used across a variety of malignancies as a viable “liquid biopsy” method, with applications in early detection, treatment response evaluation, prognostication, and recurrence monitoring. Recently, ctDNA derived from the tumor-integrated HPV (ctHPVDNA) has borne promising results in HPV-associated cancers, including HPV+ oropharyngeal squamous cell carcinoma (OPSCC). Studies indicate that undetectable ctHPVDNA after complete surgical excision in HPV+ OPSCC corresponds with improved prognosis. However, ctHPVDNA kinetics after diagnostic procedures such as transoral robotic surgery (TORS) in head neck squamous cell carcinoma from an unknown primary (HNSCCUP) or unknown primary has not been extensively studied. The purpose of this study is to show an unexpected trend in NavDx levels following these procedures. Methods: Patients undergoing TORS at Stanford University (September 2023 and August 2024) were prospectively screened and enrolled. A commercially available ctHPVDNA assay (NavDx) was collected at baseline, immediate postoperative (24-48 hours), 7-14 days following surgery, 3 months post- treatment and every 3 months thereafter up to 12 months. Results: Eight patients presented with HNSCCUP, 87.5% (7/8) had detectable baseline ctHPVDNA levels ranging from 2 to 1237. 75% (6/8) of the patients were confirmed p16+ by immunohistochemistry (IHC), while 25% (2/8) tested HPV+ by in situ hybridization (ISH). Diagnostic TORS was performed in 75% (6/8), while 25% (2/8) underwent direct laryngoscopy, with all primary tumors found in the oropharynx, 100% (8/8). Notably, 85.7% (6/7) of patients showed an unexpected elevation in total tumor mutational volume (TTMV) scores post-diagnostic procedure compared to baseline, with ctHPVDNA levels ranging from 30 to 2466, including one case where levels nearly quintupled. One patient had no post-diagnostic procedure TTMV score due to a negative baseline. However, in one other case, there was a negative post-procedure level. Among those with elevated post ctHPVDNA, 71.4% (5/7) underwent complete TORS excision, resulting in decreased postoperative ctHPVDNA levels in all patients, consistent with recent studies. Conclusion: This study provides insight that diagnostic procedures, such as TORS or direct laryngoscopy, in patients with p16+ HPV-mediated oropharyngeal cancer may lead to transient and unexpected elevations in ctHPVDNA levels, measured by TTMV scores. Although most patients showed a subsequent decrease in ctHPVDNA levels following a complete tumor resection, the observed post-diagnostic elevation emphasizes the importance of considering the timing of ctHPVDNA measurements. These findings suggest surgical manipulation may temporarily influence ctHPVDNA kinetics that could impact clinical decision-making and postoperative monitoring. Further research is needed to understand the implications of these transient elevations and optimizing the timing of ctHPVDNA assessments in clinical practice. Citation Format: Hlu Vang, Joanne Soo, Nikita Bedi, Andrea Garofalo, Michelle M Chen, Andrey Finegersh, Floyd Christopher Holsinger. Transient elevation of ctHPVDNA in human papilloma virus-mediated oropharynx squamous cell carcinoma patients following diagnostic surgical procedures [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr A007.

Effects of GlideScope, Pentax Airway Scope, and Macintosh Blade on the incidence of postoperative sore throat: a cohort study of 9,881 patients

BackgroundPostoperative sore throat (POST) is a common complaint after general anesthesia. POST is defined by the presence of a self-reported foreign body sensation or a painful sensation in the throat after general anesthesia. This condition may affect recovery and patient satisfaction and is associated with many factors, including intubation tools. Previous studies have reported conflicting results on POST. This retrospective cohort study, with sample size of 9,881 patients, was conducted to confirm the hypothesis that the use of video laryngoscopy (VL) is associated with a lower incidence of POST compared with direct laryngoscopy (DL).MethodsData were extracted from a prospectively maintained quality improvement database. A total of 9,881 patients were included in the study. Statistical analysis was conducted for comparisons of demographic characteristics and to determine the effect of intubation tools on the incidence of POST.ResultsThe patients had similar baseline demographic characteristics. Compared with DL, VL was associated with a lower incidence of POST (12.98% vs. 17.49%, P < 0.001). In addition, the use of Pentax Airway Scope (AWS) was associated with a lower incidence of POST compared with the use of GlideScope (GVL, 8.14% vs. 16.25%, P < 0.001). To better adjust for possible confounding factors, mixed-effects generalized linear model analysis revealed that older age (odds ratio [OR]: 0.995, 95% confidence interval [CI]: 0.992–0.999, P = 0.006), AWS compared to DL (OR: 0.416, 95% CI: 0.350–0.494, P < 0.001), and male sex (OR: 0.836, 95% CI: 0.747–0.935, P = 0.002) are associated with reduced incidence of POST.ConclusionCompared with DL, VL is associated with a lower incidence of POST. In addition, the use of AWS is associated with a lower incidence of POST compared with the use of GVL.Trial registrationRetrospectively registered, NCT06515808, date of registration: 23/07/2024.

Rethinking the utility of comparative studies between direct and video laryngoscopy in neonates and infants.

Rethinking the utility of comparative studies between direct and video laryngoscopy in neonates and infants.

A Rare Presentation of Acute Suppurative Thyroiditis.

A previously healthy 17-year-old female patient initially presented with symptoms of anterior neck pain. After multiple emergency department visits, she was found to have unilateral enlargement of her thyroid gland. Laboratory studies were consistent with hyperthyroidism. Symptoms were initially attributed to subacute thyroiditis, and she was discharged with steroids and propranolol. She presented again 1 week later with complaints of nausea, vomiting, abdominal pain, and shortness of breath. She was readmitted and developed sepsis with multiorgan system infection and Lemierre syndrome. Further imaging revealed acute suppurative thyroiditis as the likely source. Direct laryngoscopy and bronchoscopy revealed ulceration of the anterior esophageal wall, a fistulous tract to the thyroid, and copious purulent drainage. Esophageal biopsies with immunostaining established a diagnosis of herpes simplex virus esophagitis as the likely cause of esophageal perforation, fistula development, and acute suppurative thyroiditis.

Impacto del uso universal del videolaringoscopio McGrath como primera opción para todas las intubaciones en el quirófano: protocolo del estudio prospectivo, multicéntrico VIDEOLAR-SURGERY con metodología pre-post

IntroductionUsual 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 videolaryngoscope 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 videolaryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases complications associated to the intubation. Methods and analysisThe VIDEOLAR-SURGERY trial is a prospective, multicenter, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9months [2600 intubations]), 35 anesthesiologists from 8hospitals 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 (2months), a McGrath Mac videolaryngoscope is provided to each anesthesiologist to train in its use. During the post-implementation period (interventional-phase, 6-9months [2600 intubations]), the 35 anesthesiologists perform all tracheal intubations using a McGrath Mac videolaryngoscope as the first intubation option. The main objective of present study is to evaluate whether the use of a McGrath Mac videolaryngoscope as the first intubation option, improves the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope. Ethics and disseminationThe study protocol was approved May 2, 2023, by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered into the Clinicaltrials.gov clinical trials registry with 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 videolaryngoscope improves easy intubation compared with Macintosh direct laryngoscope when it is used for all intubations in operating room, its use may will become standard practice, thereby decreasing complications associated with the intubation procedure.

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.

Comparison of hemodynamic responses to orotracheal intubation with Tuoren video laryngoscope and Macintosh direct laryngoscope in adult hypertensive patients

Comparison of hemodynamic responses to orotracheal intubation with Tuoren video laryngoscope and Macintosh direct laryngoscope in adult hypertensive patients

Influence of Anesthesiology Protocol on the Quality of Intraoperative Nerve Monitoring During Thyroid Surgery, One-Year Single Center Experience.

Anesthesia plays a very important role in the successful management of intraoperative neuromonitoring (IONM). The aim of our study was to investigate the impact of anesthesia induction and maintenance on the quality of signals during surgeries on the thyroid and parathyroid glands using neuromonitoring. The study included 72 patients who underwent surgery with IONM for one year. All the patients were intubated using a Glidescope videolaryngoscope with a hyperangulated blade. Two different approaches were used to facilitate intubation: succinylcholine-1 mg/kg and rocuronium bromide-0.3 mg/kg. For anesthesia maintenance, total intravenous anesthesia (TIVA) or combined anesthesia was used. Patients' body movements during operations, as well as electromyography signals from the vagus and recurrent laryngeal nerves before resection, were recorded as V1 and R1. Intraoperative unwanted movements were recorded in 25% of patients. Undesired movements were more frequently recorded in the TIVA group compared to the combined anesthesia group (p < 0.001) as well as in patients who received succinylcholine compared to patients who received rocuronium bromide (p = 0.028). Type of anesthesia maintenance as well as type of muscle relaxant did not affect the quality of recorded nerve signals. (p = 0.169 and p = 0.894, respectively). The type of muscle relaxant used significantly affects the occurrence of undesirable movements during thyroid surgery with IONM, while the type of anesthesia maintenance did not influence either the quality of the obtained signal or the occurrence of undesirable movements.

Endoscopic diagnosis of laryngeal precancerous lesions and early laryngeal cancer

ISince laryngeal cancer currently occupies a leading position in frequency of occurrence among all tumors of the upper respiratory tract of modern humans, the importance of its detection at an early stage of development cannot be overestimated. Existing diagnostic methods using rigid endoscopes, including direct and indirect laryngoscopy, have significant limitations in a number of patients. The use of modern video endoscopic technology allows diagnosing precancerous lesions and laryngeal cancer at an early stage of the tumor process, which significantly expands the possibilities of minimally invasive organ-preserving treatment.

Diabetes Mellitus Is Not a Risk Factor for Difficult Intubation Among Critically Ill Adults: A Secondary Analysis of Multicenter Trials

Objectives: Diabetes mellitus has been associated with greater difficulty of tracheal intubation in the operating room. This relationship has not been examined for tracheal intubation of critically ill adults. We examined whether diabetes mellitus was independently associated with the time from induction of anesthesia to intubation of the trachea among critically ill adults. Design: A secondary analysis of data from five randomized trials completed by the Pragmatic Critical Care Research Group (PCCRG). Setting: Emergency departments (EDs) or ICUs at 11 centers across the United States that enrolled in randomized trials of a pre-intubation checklist, fluid bolus administration, bag-mask ventilation between induction and laryngoscopy, and intubation using a bougie vs. stylet. Patients: Critically ill adults undergoing tracheal intubation with a laryngoscope in an ED or an ICU. Interventions: None. Measurements and Main Results: A total of 2654 patients were included in this analysis, of whom 638 (24.0%) had diabetes mellitus. The mean time from induction of anesthesia to intubation of the trachea was 169 seconds (sd, 137s). Complications occurred during intubation in 1007 patients (37.9%). Diabetes mellitus was not associated with the time from induction of anesthesia to intubation of the trachea (–4.4 s compared with nondiabetes; 95% CI, –17.2 to 8.3 s; p = 0.50). Use of a video vs. direct laryngoscope did not modify the association between diabetes mellitus and the time from induction to intubation (p for interaction = 0.064). Diabetes mellitus was not associated with the probability of successful intubation on the first attempt (85.6% vs. 84.3%; p = 0.46) or complications during intubation (39.8% vs. 37.4%; p = 0.52). Conclusions: Among 2654 critically ill patients undergoing tracheal intubation in an ED or an ICU, diabetes mellitus was not independently associated with the time from induction to intubation, the probability of successful intubation on the first attempt, or the rate of complications during intubation.

Videolaryngoscopy vs. direct laryngoscopy for tracheal intubation by experienced anaesthetists: a meta-analysis and trial sequential analysis of randomised controlled trials.

Videolaryngoscopy vs. direct laryngoscopy for tracheal intubation by experienced anaesthetists: a meta-analysis and trial sequential analysis of randomised controlled trials.

Comparison of intravenous nalbuphine and dexmedetomidine in combination with lidocaine aerosol inhalation in awake direct laryngoscopy: a randomized, double-blind, placebo-controlled trial

BackgroundThe airway should be thoroughly and accurately evaluated before anesthesia induction and endotracheal intubation. Awake direct laryngoscopy (ADL) can provide rapid, accurate, and intuitive airway assessment, especially for suspected difficult airways, and sometimes eliminates the need for fiberoptic intubation in some suspicious difficult airway cases. However, an optimal regimen has not been determined.MethodsIn this double-blind, controlled study, prior to ADL, 60 patients scheduled for general anesthesia were randomly allocated to receive 0.75 μg/kg of dexmedetomidine (Dex group, n = 20), 0.15 mg/kg of nalbuphine (Nal group, n = 20), or a placebo (control group, n = 20) intravenously over 10 min. At the same time, all study subjects received nebulized lidocaine for 15 min. The primary outcome was patient tolerance as assessed by a 5-point ADL comfort score, while secondary outcomes included satisfaction, coughing, pain, nausea and vital signs.ResultsPatients undergoing ADL in the Nal group had higher tolerance scores than those in the control and Dex groups [4 (3,4) vs. 3 (2,2.75), P < 0.017, and 4 (3,4) vs. 2 (2,2,75), P < 0.001, respectively] and higher satisfaction [7 (6,8) vs. 4 (3,5.75), P < 0.017, and 7 (6,8) vs. 5.5 (5,6), P < 0.001, respectively]. Additionally, the Nal group had significantly fewer adverse events, such as pain and nausea than the control and Dex groups. The sedation score and peripheral oxygen and saturation were significantly higher in the Nal group than in the Dex group, with no difference between the Nal and control groups (P < 0.001, P = 0.159, respectively).ConclusionsIntravenous nalbuphine in combination with lidocaine aerosol inhalation significantly improved patient tolerance and satisfaction while reducing nausea, coughing, pain, sedation, and SpO2 levels during ADL.

National Trends in Laryngeal Laser Surgery: Comparison of Operative Versus Office-Based Procedures.

To analyze national trends in the prevalence of office-based laryngeal ablative procedures and compare those with traditional operative excisional procedures utilizing direct laryngoscopy. For years 2013-2022, the US Medicare Part B claims database was searched for Current Procedural Terminology (CPT) codes 31572 (flexible laryngoscopy with laser ablation of lesion), 31540 (operative direct laryngoscopy with excision of lesion), 31541 (operative direct microlaryngoscopy with excision of lesion), and 31545 (operative direct microlaryngoscopy with excision of lesion and local tissue flap reconstruction). For each CPT code, the total number of charges billed to the Medicare database in each calendar year was recorded and annual trends were analyzed. Biopsy procedures were not included. The annual number of office-based laser procedures (CPT 31572) remained relatively constant since the CPT code was introduced in 2017 (range: 18887-25241 procedures annually, trendline slope = +16, R2:0.02). Office-based laser procedures comprised a small portion of total laryngeal excisional procedures (range: 8.4%-12.1%). The total number of operative laryngeal excisions, billed by CPT 31540 and 31541, declined over the studied time frame (Trendline slope = -132, R2:0.93; Trendline slope = -950, R2: 0.93 respectively). Office-based laser procedures comprise a small fraction of procedures to remove laryngeal lesions. The number of office-based laser procedures has been relatively stable over the last 5 years. This finding contrasts with the prevailing health care trend toward office-based procedures. Further research is needed to understand the decrease in operative laryngeal lesion excision procedures observed over the last 10 years. 4 Laryngoscope, 2024.

Airway management for endoscopic treatment of laryngotracheal stenosis

ObjectivesTo describe the airway management techniques used during endoscopic management of laryngotracheal stenosis (LTS), and to identify patient, surgical, and clinician factors that are associated with use of jet ventilation, transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE), and intermittent apnea, including primary technique success vs failure and complications. MethodsRetrospective review of electronic medical records was performed for all patients undergoing direct laryngoscopy for LTS over a seven-year period. Patients with an existing tracheostoma at the time of surgery were excluded. Univariate chi-squared analyses were performed to identify patterns in airway management based on patient and surgical factors. ResultsA total of 92 endoscopic surgeries for 41 unique patients were identified. Airway management techniques differed based on the procedure performed (P < 0.001). Jet ventilation and THRIVE were particularly associated with subglottic procedures, and transtracheal jet ventilation with supraglottic procedures. There were no differences in complication rate based on airway management technique. The rate of primary airway plan failure was 50 % for THRIVE, 15 % for jet ventilation, 2 % for intermittent apnea, and 0 % for endotracheal intubation (p = 0.002). The presence of an anesthesiologist specializing in head and neck anesthesia was associated with significantly greater rates of jet ventilation and THRIVE (41 % vs 7 % for jet ventilation, 9 % vs 4 % for THRIVE; p = 0.002). ConclusionPatient and surgical factors play an important role in airway management planning for patients undergoing endoscopic laryngotracheal procedures. The presence of a head and neck anesthesiologist was associated with a more diverse array of airway management options for these patients.