Introduction: Endotracheal airway is essential in children undergoing dental general anaesthesia (DGA). Paediatric dentists’ (PD) work with anaesthetists who use both nasal and oral intubation routes. Thus the study aimed to assess Gulf Cooperation Council (GCC) PDs’ preference of oral or nasal endotracheal intubation and their perception regarding a modified oral intubation technique that avoids occlusal interference using a Ring, Adair and Elwyn “RAE” tube. Materials and Method: PDs in GCC were surveyed about their preference of endotracheal intubation and the modified RAE oral intubation method via a web-based questionnaire. Responses were analyzed by χ2 and Exact Fischer’s test. Statistical significance was set as p <0.05. Results: A total of 73 PDs who perform DGA responded, a majority of whom (79.5%) preferred the nasal route. Male PDs were more familiar with RAE (p=0.031). More PDs within the ages 36-45 years agreed on using the proposed modified technique (p=0.027). Considering the reported complications associated with nasotracheal and traditional oral intubation, 49 PD (67.1%) believed that the modified technique was worth consideration. Conclusion: Most PDs preferred the nasal route, but more than half would consider utilizing the RAE-modified oral intubation technique. Further research and hands-on workshops of the modified RAE oral tube for DGA are suggested.

Laryngoscopy and endotracheal intubation can cause significant hemodynamic changes, resulting in potentially life-threatening complications. This study aimed to compare the hemodynamic effects of traditional endotracheal tube and fiberoptic bronchoscope methods in patients undergoing maxillofacial fracture surgery. In this randomized clinical trial, 60 patients with jaw fractures at an institutional tertiary hospital in Kerman, Iran, in 2020 were enrolled. Participants were randomly assigned to either the traditional endotracheal tube group (n=30) or the fiberoptic bronchoscope group (n=30). Hemodynamic parameters, including systolic and diastolic blood pressure, heart rate, and arterial oxygen saturation (SpO2), were recorded at baseline, and 1, 3, 5, 10, and 15 minutes after anesthesia. Additional assessments included time to peak blood pressure, frequency of SpO2 drop, and postoperative nausea, vomiting, and hoarseness. There were significant differences in systolic, diastolic, and mean arterial blood pressures, as well as heart rate, between the two groups (p 0.05). The highest hemodynamic values occurred 3 minutes after anesthesia in the traditional intubation group and immediately after intubation in the fiberoptic group. SpO2 levels remained stable at 99% throughout the study in both groups. Hemodynamic values declined by the 10th and 15th minutes post-anesthesia. The study reveals that fiberoptic intubation is associated with lower early hemodynamic fluctuations compared to traditional intubation. This is particularly important as it suggests that fiberoptic intubation may mitigate the risk of cardiovascular complications, which can be life-threatening in vulnerable patient populations. Fiberoptic intubation resulted in lower early hemodynamic fluctuations compared to the traditional method, suggesting it may be a safer option for reducing cardiovascular stress during maxillofacial surgery. The current article presents a novel comparison of hemodynamic effects between traditional endotracheal intubation and fiberoptic bronchoscope methods specifically in the context of maxillofacial fracture surgery.

Dear Editor, Use of ultrasonography to confirm endotracheal intubation is well documented. However, its use to direct the placement of endotracheal tube (ETT) in real time is less practiced. A50-year-old male patient with carcinoma tongue who underwent excision 2 weeks back under local anesthesia was posted for wide excision. He had 4cm mouth opening, slightly restricted tongue protrusion due to pain, normal neck extension, and Mallampati class II airway. Following preoxygenation and intravenous induction, after ensuring mask ventilation, vecuronium was given as we did not anticipate difficult airway. Direct laryngoscopy revealed Cormack–Lehane grade 4 view. Patient was mask ventilated, and videolaryngoscope was requested. As ultrasound machine was available in the theater we decided to attempt nasal intubation under ultrasonographic guidance while waiting for videoscope. We placed the probe on the neck transversely just above the suprasternal notch and moved it up till the vocal cords were visualized. Keeping the probe there, a 7.0-mm-sized nasal tube was introduced through the right nostril and passed gently down to oropharynx and advanced slowly. We observed the esophagus being opened by ETT by the side of trachea with a double trachea sign [Figure 1a] as the ETT initially entered the esophagus. The ETT was then withdrawn to oropharynx, head was extended, and the ETT was reintroduced. This time, the advancing ETT with some medial rotation entered the trachea. We visualized a brief flutter of vocal cords, and a hyperechoic shadow was seen in the trachea [Figure 1b]. Correct placement was confirmed with end-tidal carbon dioxide waveforms (ETCO2) and auscultation. Introduction of ETT nasally till the appearance of ETCO2 took <1 min. We used Sonosite SII ultrasound system (FUJIFILM SonoSite, Inc., Bothell, WA, USA) and a linear probe (6–13MHz).Figure 1: (a) Esophageal intubation, (b) tracheal intubationEndotracheal intubation can be confirmed either statically or dynamically using ultrasound. Following intubation, ultrasound probe is used to identify either the bullet sign or the double tract sign in static confirmation. In dynamic confirmation, a probe is used during intubation to visualize increase in artifact as the ETT passes into trachea or the appearance of artifacts as it enters the esophagus. Dynamic confirmation has been described with the probe placed transversely just above the suprasternal notch[1,2] or just below the cricoid cartilage.[3]In case of tracheal intubation, only one air–mucosal (A–M) interface with reverberation artifact and posterior shadowing could be seen. If two A–M interfaces with posterior shadowing are noticed (double tract sign/double trachea sign), it indicates esophageal intubation.[4]Similarly, the probe placed transversely at the level of the thyrohyoid membrane can be moved caudally until a view of vocal cords and surrounding hypopharyngeal tissue is obtained. Appearance of hyperechoic shadowing and widening of the vocal cords could be visualized when ETT enters the trachea.[5] We did not aid the ultrasound-guided intubation process with direct laryngoscopy. If intubation was unsuccessful, either videoscope- or intubating bronchoscope-assisted intubation would have been performed. It is concluded that following failed intubation in patients with unanticipated difficult airway who can be mask ventilated, ultrasound-guided intubation is an option to be considered while advanced airway gadgets are awaited. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and that due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Guidance methods during nasal endotracheal intubation

Comparison of the Outcomes of Oral Versus Nasal Endotracheal Intubation in Neonates and Infants Undergoing Cardiac Surgery: A Randomized Controlled Study

The cuff pressures > 30 cmH2O may create a seal in the trachea. The objective of this study was to identify risk factors associated with lack of tracheal sealing by an endotracheal cuff inflated to > 30 cmH2O in patients undergoing mechanical ventilation. This prospective cross-sectional study was conducted from 2019 to 2020 in the cardiothoracic intensive care unit and respiratory medical care unit of a Hospital in Nantong, China. Patients aged >16 years undergoing cardiothoracic surgery with mechanical ventilation using endotracheal intubation were included. Patient characteristics and ventilator parameters were analyzed. Cuff pressure was maintained with the minimum leak technique (MLT) and measured with a cuff pressure gauge. Cuff pressure was measured for 30 seconds when ventilation was accompanied by no leak, simultaneously detected by the ventilator or auscultation with a stethoscope. Of 352 patients undergoing mechanical ventilation, 51 patients (14.5%) had a cuff pressure of >30 cmH2O. Multivariable analysis showed that cuff manufacturer (Guangzhou Weili) and nasal endotracheal intubation significantly increased the risk of an unsealed trachea. Peak inspiratory pressure, cuff diameter and male sex had a strong inverse association with an unsealed trachea. These findings suggest that an endotracheal cuff pressure of 20 to 30 cmH2O is adequate for most patients, but lack of a tracheal seal still occurs in a small number of people. An unsealed trachea is most likely because cuff and tracheal diameters do not match. Clinical Trial Registration: http://www.chictr.org.cn/index.aspx Unique identifier: ChiCTR-COC-15006459.

New Formula for Nasal Endotracheal Intubation in Extremely Low–Birth Weight Infants in the Emergency Transport Setting: The “Genoa Formula”

Dental treatment of young pediatric patients can be confounded by lack of cooperation for dental rehabilitation procedures and even examination and/or radiographs. With the recent US Food and Drug Administration warning applied to many anesthetic/sedative agents for children less than 3 years old, a retrospective review of general anesthesia (GA) cases from 1 private pediatric dental practice was studied for age, gender, body mass index, anesthetic duration, airway management used, extent of dental surgical treatment, recovery time, and cardiac/pulmonary complications. For the 2016 calendar year, 351 consecutive GA cases were identified with patients aged 2-13 years. Of these, 336 underwent nasal endotracheal intubation. Forty-six of 351 patients (13%) were younger than 3 years. Median anesthesia duration was approximately 1.7 hours for all age groups. Dental treatment consisting of 8-9 teeth including crowns, fillings, and extractions was most frequently encountered. One hundred sixty-eight patients (48%), however, required care for 10-18 teeth. There were no episodes of significant oxygen desaturation. The overall complication rate was 1.1%, with 2 cases of postextubation croup, 1 case of mild intraoperative bronchospasm, and 1 case of intraoperative bradycardia. Complications did not correlate with children being overweight or obese.

Objective To compare the effects of different surface anesthesia on conscious sedation and slow induction of fiberoptic bronchoscopy guided by nasal endotracheal intubation. Methods Forty-six patients with ASA Ⅰ-Ⅱ grade before the elective surgery expected difficult airway were randomly divided into two groups: group I used nasal cavity combined with fiberoptic bronchoscope to spray surface anesthesia, and group II used nasal cavity combined with fiberoptic bronchoscope to spray surface anesthesia through catheter. Nasal endotracheal intubation TCI to the same sedation depth were administered after. Before TCI (baseline), predict the sedation score (T0), intubation immediately (T1), minute after intubation (T2), the levels of HR, MBP, SpO2 were recorded. The bronchoscope into the nasal cavity to the intubation process response score, tube score, intubation time, the expected concentration of propofol at the desired sedation score, the satisfaction of operation, patient satisfaction, a successful case of intubation, assisted respiratory cases, and vascular drug intervention were recorded. Results There was no significant difference in HR, MBP or SpO2 between the two groups(P>0.05). HR, MBP decreased slightly with time, 1 minute after intubation and remained stable with the base value, SpO2 intubation immediately decreased, then returned to normal, HR, MBP, SpO2 were in the normal range of fluctuations. There was no significant difference in CE value or intubation time between the two groups (P>0.05), and there was significant difference in the score of intubation reaction and the score of tube resistance reaction (P 0.05), and the difference in operation satisfaction and patient satisfaction was significant (P<0.05). Conclusions Both the two surface anesthesia methods are suitable for conscious sedation and slow induction of bronchoscopy to guide nasal endotracheal intubation. Nasal combined with fiberoptic bronchoscopy by catheter spray surface anesthesia is superior in intubation reaction, refractory response and patient satisfaction. Key words: Sober sedation; Surface anesthesia; Catheter injection

Objective To evaluate the application of nasal endotracheal intubation guided by ultrathin fibreoptic bronchoscope in awake patients with respiratory failure.Methods 105 awake patients with respiratory failure were ventilated by respiratory machine through nasal endotracheal intubation guided by ultrathin fibreoptic bronchoscope.102 awake patients with respiratory failure were ventilated by respiratory machine through nasal endotracheal intubation guided by fibreoptic bronchoscope.The successful rate and complications were compared between two groups.Results The successful rate of nasal endotracheal intubation in ultrathin fibreoptic bronchoscope group was higher than that in the control group (100.0％ vs 73.5％,x2=31.96,P ＜0.05).Nasal bleeding rate in ultrathin fibreoptic bronchoscope group was lower than that in the control group (5.7％ vs 20.0％,x2=8.66,P ＜0.05).Conclusions Application of nasal endotracheal intubation guided by ultrathin fibreoptic bronchoscope plays an important role in treatment of awake patients with respiratory failure.It is safe and rapid with high successful rate,so it should be popularized in clinical practices. Key words: Ultrathin fibreoptic bronchoscope ; Endotracheal intubation; Respiratory failure

To study sevoflurane inhalation general anesthesia using the laryngeal mask airway (LMA) and nasal endotracheal (ET) intubation to maintain the airway in pediatric day-case dental surgery. A total of 171 children aged 2 to 7 years received elective day-case dental surgical procedure under general anesthesia. Children were randomly grouped into LMA groups (L) and nasal ET intubation group (N). In L groups, LMA was inserted after induction of anesthesia using 8% sevoflurane and were allowed to breathe spontaneously. Rocuronium and remifentanil were given intravenously during 8% sevoflurane induction by nasal ET intubation in the N group . The time of anesthetic induction, maintenance, recovery, surgical access, and bispectral index score were recorded. Postoperative nausea and vomiting and the incidence of adverse events during induction and recovery period were also recorded. The insertion time of LMA was significantly shorter than nasal ET (P < 0.05). The incidence of airway complications, the surgeons' access, and bispectral index were not different between the 2 groups. However, recovery time was significantly shorter in group L (P < 0.05). The incidence of sore throat and postoperative nausea and vomiting (P < 0.01) were much less in group L as well. Sevoflurane inhalation anesthesia through LMA is a safe and reliable method for pediatric day-case dental surgery.

Efficacy and Safety of Dexmedetomidine Versus Propofol for the Sedation of Tube-Retention After Oral Maxillofacial Surgery

Root cause analysis for failed airway establishment in post-operative oral cancer patients and propose the managements

Analysis of ventilator associated pneumonia (VAP) studies in Egyptian University Hospitals

To determine the risk factors for respiratory intensive care unit (RICU)-acquired colonization of multidrug-resistant Acinetobacter baumannii (MDR-AB). From January 2010 to June 2011, active screening was performed to define patients with RICU-acquired colonization of MDR-AB. And environment surveillance was carried out and patient data were collected. Logistic regression was applied to identify the risk factors of RICU-acquired colonization of MDR-AB. Active screening for MDR-AB was performed for 110 patients in RICU and 50 patients turned out to be positive. After eliminating 3 input positive patients, the RICU-acquired colonization rate of MDR-AB was 43.9% (47/107). The environmental contaminated rate of MDR-AB was 66.0% (31/47) for 47 positive patients and 33.9% (19/56) for 56 negative ones (χ(2) = 10.494, P < 0.01). Five risk factors were associated with the colonization of MDR-AB through univariate analysis: consciousness disturbance, use of carbapenems, nasal feeding tube, endotracheal intubation and mechanical ventilation (all P < 0.05). The Logistic regression equation contained 3 risk factors of conscious disturbance, use of carbapenems and mechanical ventilation (OR = 3.412, 3.211, 3.002; 95% CI: 1.165 - 9.992, 1.117 - 9.233, 1.101 - 8.182). Three risk factors are independently associated with the RICU-acquired colonization of MDR-AB: consciousness disturbance, use of carbapenems and mechanical ventilation.

ABSTRACTObjective. To assess critical care transport (CCT) crews’ endotracheal intubation (ETI) attempts, success rates, and peri-ETI oxygenation. Methods. Participants were adult and pediatric patients undergoing attempted advanced airway management during the period from July 2007 to December 2008 by crews from 11 CCT programs varying in geography, crew configuration, and casemix; all crews had access to neuromuscular-blocking agents. Data collected included airway management variables defined per national consensus criteria. Descriptive analysis focused on ETI success rates (reported with exact binomial 95% confidence intervals [CIs]) and occurrence of new hypoxemia (oxygen saturation [SpO2] dropping below 90% during or after ETI); to assess categorical variables, Fisher's exact test, Pearson χ2, and logistic regression were employed to explore associations between predictor variables and ETI failure or new hypoxemia. For all tests, p < 0.05 defined significance. Results. There were 603 total attempts at airway management, with successful oral or nasal ETI in 582 cases, or 96.5% (95% CI 94.7–97.8%). In 182 cases (30.2%, 95% CI 26.5–34.0%), there were failed ETI attempts prior to CCT crew arrival; CCT crew ETI success on these patients (96.2%, 95% CI 92.2–98.4%) was just as high as in the patients in whom there was no pre-CCT ETI attempt (p = 0.81). New hypoxemia occurred in only six cases (1.6% of the 365 cases with ongoing SpO2 monitoring; 95% CI 0.6–3.5%); the only predictor of new hypoxemia was pre-ETI hypotension (p < 0.001). A requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (Fisher's exact p = 0.13). Conclusions. CCT crews’ ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO2 derangement. CCT crews’ ETI success rates were equally high in the subset of patients in whom ground emergency medical services (EMS) ETI failed prior to arrival of transport crews.

Securing an airway in children with trismus is challenging and dangerous. Sound clinical judgment is critical for timing and for selecting the method for airway intervention. We present two pediatric cases of submandibular abscess with difficult oral intubation who underwent incision and drainage. Large facial (jaw) swelling, trismus-limited mouth opening, edema, protruding teeth, and altered airway anatomy makes airway management more difficult. Chances of rupture of abscess intraorally and aspiration under General Anesthesia (GA) is a major threat. Loss of airway under muscle relaxation, difficult to ventilate, difficult to intubate and unwillingness for awake intubation in the pediatric age group makes these cases most challenging. On the basis of our experience, both cases were successfully intubated in anaesthetized, spontaneously breathing children with visual-guided fibreoptic intubation.

To the Editor.—We read with interest the article by Ghanta et al1 on the use of propofol versus morphine, atropine, and suxamethonium for neonatal endotracheal intubation. The authors demonstrated that propofol is more effective than the alternative regimen as an induction agent to facilitate neonatal nasal endotracheal intubation. More importantly, their study showed that hypoxemia was less severe with propofol, probably because spontaneous ventilation was maintained. We would like to comment on 3 aspects of their study.First, propofol is only approved for sedation in children older than 16 years in most countries.2 The authors might argue that 2.5 mg/kg constitutes an anesthetic dose; again, propofol is only approved for induction of anesthesia in infants >1 month of age in most countries.Second, conflicting with numerous previous studies,3,4 Ghanta et al demonstrated an increase in arterial blood pressure. It is well known that arterial hypotension may reduce cerebral blood flow in preterm infants, which in turn may have a negative impact on long-term neurodevelopmental outcome. Therefore, it is of great importance that future studies in preterm neonates address this issue before propofol may be considered safe in this patient cohort.Third, the authors chose to use a fixed regimen of propofol (2.5 mg/kg) for induction of sedation/anesthesia. However, previous studies have shown substantial intraindividual variability in propofol dosage in children.5 By titrating propofol until the desired level of sedation has been achieved, adverse effects (eg, arterial hypotension) may be minimized.

To the Editor .— Ghanta et al1 reported that in preterm infants (median gestational age: 27–28 weeks; median postnatal age: 3–4 days), the use of propofol is more effective than a morphine, atropine, and suxamethonium regimen as an induction agent to facilitate neonatal nasal endotracheal intubation. In their well-designed randomized, controlled clinical trial, they used a single 2.5 mg/kg intravenous dose and based their selection of this …

The purpose of this work was to compare the efficacy of propofol, a hypnotic agent, to the regimen of morphine, atropine, and suxamethonium as an induction agent for nonemergency neonatal endotracheal intubation. We hypothesized that propofol aids intubation by allowing the continuation of spontaneous breathing. We conducted a randomized, open-label, controlled trial of infants who required nonemergency endotracheal intubation. Primary outcome was successful intubation confirmed by chest auscultation and clinical examination of the infant. Infants randomly assigned to propofol (n = 33) and the morphine, atropine, and suxamethonium regimen (n = 30) were comparable in median gestational age (27 vs 28 weeks), birth weight (1020 vs 1095 g), weight at intubation (1068 vs 1275 g), and age at intubation (4 vs 3 days). Sleep or muscle relaxation were achieved within 60 seconds in both groups, but time to achieve successful intubation was more than twice as fast with propofol (120 vs 260 seconds). Blood pressure and heart rates were not different, but intraprocedural oxygen saturations were significantly lower in infants on the morphine, atropine, and suxamethonium regimen (trough arterial oxygen saturation: 60% vs 80%). Nasal/oral trauma was less common, and recovery time was shorter (780 vs 1425 seconds) in the propofol group. No significant adverse effects were seen in either group. Propofol is more effective than the morphine, atropine, and suxamethonium regimen as an induction agent to facilitate neonatal nasal endotracheal intubation. Importantly, hypoxemia was less severe, probably because of the maintenance of spontaneous breathing. A controlled environment may have promoted the ease of intubation, resulting in less trauma. The shorter duration of action would be advantageous in a compromised infant.