Intubation Research Articles

A Comparison of Airway Ultrasound and Clinical Parameters for Predicting Difficult Laryngoscopy in the Emergency Department: A Study Protocol.

Airway assessment plays an important part in airway management. Over the years, ultrasound has emerged as an alternative modality for airway assessment. We aim to assess the accuracy of clinical parameters, ultrasonographic upper airway parameters, and laryngoscopic grade, using the Cormack-Lehane classification, to predict difficult laryngoscopy in the emergency department (ED). The primary objective is to determine the accuracy of ultrasonography parameters compared to Cormack-Lehane grading in predicting difficult laryngoscopy in adults. The secondary objective is to assess the accuracy of clinical parameters compared to Cormack-Lehane grading in predicting difficult laryngoscopy in adults. A sample of 62 adult patients over 18 years who come to the emergency department and require endotracheal intubation will undergo an ultrasonographic examination of the upper airway. During this examination, an emergency medicine physician will measure the skin-to-epiglottis distance and tongue thickness using the GE Healthcare (Chicago, IL) ultrasound and color Doppler (model: Logic E). The results of the study will be drawn in 2025 upon its completion. The conclusion will be drawn regarding the correlation between ultrasound parameters and Cormack-Lehane grading and clinical parameters in predicting difficult laryngoscopy.

Tracheal gas insufflation for refractory hypercapnia

A 65 year male patient got admitted to ICU after alleged intake of ~ 250 ml of Chlorpyrifos (Organophosphate insecticides which cause cholinergic toxidrome) and cypermethrin (Synthetic pyrethroid) and presented with cholinergic toxidrome with severe hypercapnia (supercarbia). All conventional and advanced modes of ventilation failed to ventilate the patient because of severe bronchospasm and a prolonged expiratory time constant with high airway pressures and high auto-peep. As a last resort, we resorted to unconventional modes, as the patient could not afford ECMO. Tracheal gas insufflation was done using a coaxial flow of humidified oxygen at 8 lpm with a suction catheter and ventilator parameter were adjusted to match the added gas flows. Tracheal gas insufflation can be delivered by a thin catheter placed through the endotracheal tube (terminating within 1 to 2 cm of the main carina) or via a modified endotracheal tube with channels embedded in the walls of the tube. Tracheal gas insufflation flow can be forward (toward the alveoli) or reversed in direction toward the proximal end of the endotracheal tube. Keywords: TGI, Hypercapnia, organophosphate toxicity

FDA Warns Facilities to Stop Using Medtronic EMG Endotracheal Tubes

FDA Warns Facilities to Stop Using Medtronic EMG Endotracheal Tubes

Awake Seldinger technique-based tracheal intubation in near-total laryngeal obstruction.

Awake Seldinger technique-based tracheal intubation in near-total laryngeal obstruction.

Performance and safety of volume guarantee ventilation in neonates using the fabian ventilator, a multicenter study.

To evaluate the performance (i.e., agreement between set and measured parameters) and safety (adverse events, device malfunctions, and ventilator alarms) of the fabian HFOi neonatal ventilator in volume guaranteed (VG) mode during conventional ventilation. To analyze the impact of leakage around the endotracheal tube and the set maximum allowed inflating pressure (Pmax). Prospective multicenter observational study. Clinical and ventilator data were collected from 71 infants receiving VG ventilation for ≥12 h in four neonatal intensive care units (NICUs). Ventilator settings, parameters, and alarms were downloaded with 0.5 Hz sampling rate. Data from 4,341 h of ventilation were analyzed. The median (interquartile range, IQR) of the absolute difference between the target and measured expired tidal volume was 0.76 (0.51-1.16) mL/kg. It was less when leak was <50% (median 0.36, IQR: 0.25-0.64 mL/kg, p < .001) and even less when the required peak inflating pressure (PIP) was also below Pmax (median: 0.09 mL/kg, IQR: 0.00-0.16 mL/kg, p < .001). On NICUs setting Pmax higher, tidal volume was maintained significantly closer to target. In 56 patients VG was continued until extubation. Two ventilator malfunctions were reported, none of them resulting in patient harm. "Tidal volume not reached" alarm occurred 32 times hourly, usually lasting for <10 s. The fabian HFOi ventilator maintains tidal volume close to its target, particularly when leak is <50% and when PIP is below Pmax. In most patients VG can be continued until extubation. Despite frequent ventilator alarms, ventilator malfunctions occur very rarely.

Bronchial Blocker Versus Endobronchial Intubation in Young Children Undergoing One-Lung Ventilation: A Multicenter Retrospective Cohort Study.

Thoracic surgery and one-lung ventilation in young children carry significant risks. Approaches to one-lung ventilation in young children include endobronchial intubation (mainstem intubation) and use of a bronchial blocker. We hypothesized that endobronchial intubation is associated with a greater prevalence of airway complications compared to use of a bronchial blocker. The Multicenter Perioperative Outcomes Group database was queried from 2004 to 2022 for one-lung ventilation cases in children, 2 months to 3 years of age, inclusive. Airway notes and free-text comments were manually reviewed for airway complications. Documented airway complications were considered the primary outcome and were divided into "Moderate" and "Critical." Moderate airway complications were bronchial blocker or endotracheal tube movement leading to loss of isolation, hypoxemia requiring ventilatory intervention, bronchial blocker migration into the trachea, significant impairment of ventilation, and other. Critical complications included reintubation or airway replacement intraoperatively, complete endotracheal tube occlusion, cardiac arrest or airway-related bradycardia, and procedure aborted due to an airway issue. An adjusted propensity score-matched analysis was then used to assess the impact of a bronchial blocker on the outcomes of moderate and critical complications. After exclusions, 704 patients were included in the primary analysis. In unadjusted analyses, no statistically significant difference was observed in moderate airway complications between endobronchial intubation and bronchial blocker cohorts: 37 of 444 (8.3%; 95% confidence interval [CI], 5.9%-11.3%) vs 28 of 260 (10.8%; 95% CI, 7.3%-15.2%) with P = .281. In the unadjusted analysis, the prevalence of critical airway complications was significantly higher in the endobronchial intubation cohort compared to the bronchial blocker cohort: 28 of 444 (6.3%; 95% CI, 4.2%-9.0%) vs 5 of 260 (1.9%; 95% CI, 0.6%-4.4%) with P = .008. In the propensity-matched cohort analysis, endobronchial intubation was associated with a slightly increased risk of critical complications compared to use of a bronchial blocker: 14 of 243 (5.8%; 95% CI, 2.8%-8.7%) vs 5 of 243 (2.1%; 95% CI, 0.3%-3.8%) with P = .035. Endobronchial intubation might be associated with a slightly increased risk of critical airway complications compared to use of a bronchial blocker in young children undergoing thoracic surgery and one-lung ventilation. Further, prospective studies are needed before a definitive change in practice is recommended.

Laryngeal mask vs. laryngeal tube trial in paediatric patients (LaMaTuPe): a single-blinded, open-label, randomised-controlled trial.

In hypoxemic children with difficult airway, or for minor elective procedures, the use of a supraglottic airway device may be preferred to endotracheal intubation, whether with a laryngeal mask or laryngeal tube. Second-generation laryngeal masks may offer a better safety profile. Whether they should be preferred to laryngeal tubes is unknown. This study aimed to compare the efficacy and safety of second-generation laryngeal masks and laryngeal tubes in children. This randomised-controlled trial was conducted in a single university hospital in children <18 years undergoing elective anaesthesia in urology, minor paediatric surgery and gynaecology. Patients were 1 : 1 randomised to the laryngeal mask or laryngeal tube group. Children were allocated a second-generation laryngeal tube or a second-generation laryngeal mask as the primary airway device. The primary endpoint was insertion time. Secondary endpoints included first-attempt success, overall success and complications, which included hypoxia (SpO2 < 90%), laryngospasm, bronchospasm, aspiration and bleeding. In total, 135 patients were randomised, with 61 allocated to the laryngeal tube and 74 to the laryngeal mask group, with a median age of 5.4 and 4.9 years, respectively. Median insertion time was significantly longer in the laryngeal tube group (37 vs. 31 s; difference of medians: 6.0 s; 95% confidence interval: 0.0-13.0). The laryngeal tube had a significantly lower first-attempt (41.0%) and overall success rate (45.9%) than the laryngeal mask (90.5% and 97.3%, respectively). Those allocated to the laryngeal tube group had a higher ratio of complications (27.8%) compared to the laryngeal mask group (2.7%). This randomised-controlled trial reported that in children undergoing elective anaesthesia, the use of a laryngeal tube was associated with a longer insertion time.

Comparison of Clinical Performance of I-gel and Fastrach Laryngeal Mask Airway as an Intubating Device in Adults: A Systematic Review and Meta-Analysis.

The supraglottic airway device (SGD) was introduced as a breakthrough in airway management. The Fastrach emerged as the first commercially available intubating SGD, drawing extensive investigation. I-gel is a more recent device that has gained popularity, can be used as an intubating SGD, and replaced Fastrach in many institutions. However, there is uncertainty regarding the comparison between these devices in terms of efficacy for intubation and ventilation, and safety in an airway rescue situation. PubMed, EMBASE, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing I-gel and Fastrach SGD in adult patients undergoing intubation. The primary outcome was the first-pass success rate for tracheal intubation. Secondary outcomes were tracheal intubation time, SGD insertion time and success, and complications. We computed risk ratios (RRs) to assess binary end points and weighted mean differences (WMDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome and its subgroup analysis (P < .05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P < .01 was considered statistically significant). This study included a total of 14 RCTs encompassing 1340 patients. The results indicated a significant difference in the first-pass success rate favoring Fastrach (RR, 0.81; 95% CI, 0.67-0.98; P = .03; I² = 91%). In the subgroup analysis, when a flexible scope was utilized through I-gel, providers achieved a better tracheal intubation first-pass success rate (RR, 1.05; 95% CI, 1.01-1.11; P = .03; I² = 0%), compared with the Fastrach. Overall intubation success rates (RR, 0.92; 99% CI, 0.82-1.04; P = .08, I² = 92%) and time (WMD - 1.03 seconds; 99% CI, -4.75 to 2.69; P = .48; I² = 84%) showed no significant difference irrespective of the device used. There was no significant difference regarding device insertion time by the providers (WMD -6.48 seconds; 99% CI, -13.23 to 0.27; P = .01; I2 = 98%). Success rates of the providers' initial SGD insertion and complications such as sore throat (RR, 1.01; 99% CI, 0.65-1.57; P = .95, I² = 33%) and blood presence post-SGD removal (RR, 0.89; 99% CI, 0.42-1.86; P = .68, I² = 0%) showed no significant difference. Based on our findings, a higher first-pass success rate was observed with the use of Fastrach when compared to I-gel. However, the use of I-gel might result in a better intubation success rate with the flexible scope-guided intubation. There are no significant differences in performance in terms of the success rate for intubation overall, time for device insertion, or time to intubation or complications regardless of the device used.

Depression of cortical neuronal activity after a low-dose fentanyl in preterm infants.

Opioids might be harmful to the developing brain and dosing accuracy is important. We aimed at investigating fentanyl effects on cortical activity in infants using computational re-analysis of bedside recorded EEG signals. Fifteen infants born at median 26.4 gestational weeks (range 23.3-34.1), with a birth weight 740 grams (530-1420) and postnatal age 7 days (5-11) received fentanyl 0.5 or 2 μg/kg intravenously before a skin-breaking procedure or tracheal intubation, respectively. Cortical activity was continuously recorded using amplitude-integrated electroencephalography (aEEG). Analyses using three computational EEG features representing cortical synchrony and signal power, were conducted five minutes pre- and 10 minutes post the drug administration. Visual assessment of trends displayed from the EEG metrics did not indicate systematic changes. However, the magnitude of the changes in the parietal and right hemisphere signals after the dose was significantly correlated (ρ < -0.5, p < 0.05) to the EEG amplitude and frequency power level before drug administration. This effect started after 3-4 min. Fentanyl, even in small doses, may affect cortical activity in the preterm brain. The effect is robustly related to the state of cortical activity prior to drug treatment, which must be taken into account when analysing the effects of sedative drugs.

Outcomes of infants with birthweights less than 501 g compared to infants weighing 501-750 g at a center utilizing first intention high frequency jet ventilation.

Data on clinical outcomes of infants with birthweights less than 501 g (ELBW<501) are limited. To evaluate management strategies and clinical outcomes of ELBW<501infants compared to infants weighing 501-750 g (ELBW501-750). A retrospective study of all ELBW<501 and ELBW501-750 infants born between 2012 and 2022 at a center utilizing first intention high frequency jet ventilation was performed. Patient characteristics, clinical and outcome data were compared between the two groups. A total of 358 infants (92 ELBW<501 infants and 266 ELBW501-750) were included. The survival rate for the ELBW<501 group was 60.9% compared to 86.5% for ELBW501-750. ELBW<501 infants required more frequent use of 2.0 mm endotracheal tubes, required higher FiO2 and longer duration of mechanical ventilation. Compared to ELBW501-750 group, the ELBW<501 group were more likely to be SGA (68.2% vs. 16.5%) and more premature (23.2 vs. 24.3 weeks) with lower survival, longer length of stay, higher incidence of ROP and lower weight at discharge but comparable rates of IVH, grade 3 BPD, discharged on supplemental oxygen, and tracheostomy. ELBW<501 infants are at risk for significant morbidity and mortality. However, with specialized obstetric and neonatal care, survival rates of 60% are possible with respiratory outcomes comparable to ELBW501-750 infants. However, the increased risk of severe ROP for ELBW<501 requiring either surgical or medical intervention is concerning and warrants optimal surveillance.

Predictors and outcomes of patients with COVID-19 admitted to intensive care units in Pakistan and the development of nosocomial fungal infections: Findings and implications

ObjectivesPatients with COVID-19 admitted to intensive care units (ICUs) typically have many complications and co-morbidities, including secondary bacterial and fungal infections, which increase morbidity and mortality. The first step to address this is to measure the prevalence rates, predictors of fungal infections, and outcomes of patients with COVID-19 admitted to ICUs in Pakistan. MethodsRetrospective review of medical records of patients admitted with COVID-19 to the ICUs of six tertiary care hospitals in Pakistan between March 2020 and June 2023. ResultsA total of 636 patients were included; 68.9% were aged ≥50 years and 62.6% were male. Diabetes mellitus was the commonest co-morbidity (23.7%). A total of 67.8% of patients had severe COVID-19, with 23% critical cases. Antibiotics and antipyretics (all patients) were the most frequently prescribed medicines, along with corticosteroids (72.5%). A total of 63 nosocomial fungal infections developed in 53 patients, with mechanical ventilation and tracheal intubation being significant predictors of secondary fungal infections among patients with COVID-19. The mortality rate was 4.9%, with secondary fungal infections significantly associated with higher mortality. ConclusionsApproximately 8% of patients with COVID-19 admitted to the ICUs of tertiary developed secondary fungal infections associated with greater mortality. The key factors associated with secondary fungal infections need to be carefully monitored to reduce future mortality in these patients. We will continue to monitor the situation.

Index of Consciousness monitoring may effectively predict and prevent circulatory stress induced by endotracheal intubation under general anesthesia: a prospective randomized controlled trial

BackgroundThe primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA).MethodsWe enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups.ResultsThe mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05).ConclusionThis promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management.Trail registration Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022).

Emergency Endotracheal Intubations at a Pediatric Intensive Care Unit—Incidence and Hemodynamic Complications

AbstractEmergency tracheal intubation (TI) in a critically ill child is a life-saving, high-risk procedure often associated with adverse events and complications. Efforts have been undertaken to increase the safety of TIs. Integrated checklists, simulation-based training, and video laryngoscope-assisted intubations have proven effective. The study's primary aim was to evaluate the frequency of emergency TIs at a pediatric intensive care unit (PICU) and to examine the incidence of peri-intubation hemodynamic complications. We conducted a single-center, retrospective analysis of unplanned (nonelective and emergency) intubations in a multidisciplinary PICU. Patients between 0 and 18 years admitted from January 2020 until December 2022 were included in the analysis. There was a total of 144 emergency TIs. In 92.6% of the cases, an underlying chronic disease existed. The most common indication for emergency TI was respiratory failure (61.0%). Adverse intubation-associated hemodynamic events were found in 18 (12.5%), cardiac arrest in 6 (4.2%), and emergency TI under ongoing cardiopulmonary resuscitation (CPR) in 12 (8.3%) cases. Twenty-two (15.3%) children died during the PICU stay after emergency TI due to the underlying condition. In the group of children showing adverse hemodynamic effects after TI, fewer children were on noninvasive respiratory support (50 vs. 75.2%, p = 0.007) and received catecholamine therapy more frequently before complicated emergency TI than those without complicated emergency TI (62.5 vs. 38.0%, p = 0.039). Children in the latter group had both a longer duration of mechanical ventilation (11 vs. 7 days, p = 0.045) and a longer PICU stay (18 vs. 12 days, p = 0.042) compared with the group of complicated emergency TIs. Most emergency TIs (59.0%) occurred off-hours, between 7 p.m. and 7 a.m., or on weekends. Emergency TIs occur unexpectedly, often outside regular operating hours, and are associated with a higher mortality and morbidity rate. Using noninvasive respiratory support could potentially reduce adverse intubation-associated hemodynamic events in emergency TI.

Withdrawal/Withholding of Life-Sustaining Therapies: Limitation of Therapeutic Effort in the Intensive Care Unit.

Background/Objectives: The change in critically ill patients makes limitation of therapeutic effort (LTE) a widespread practice when therapeutic goals cannot be achieved. We aimed to describe the application of LTE in a post-surgical Intensive Care Unit (ICU), analyze the measures used, the characteristics of the patients, and their evolution. Methods: Retrospective observational study, including all patients to whom LTE was applied in a postsurgical ICU between January 2021 and December 2022. The LTE defined were brain death, withdrawal of measures, and withholding. Withholding limitations included orders for no cardiopulmonary resuscitation, no orotracheal intubation, no reintubation, no tracheostomy, no renal replacement therapies, and no vasoactive support. Patient and ICU admission data were related to the applied LTE. Results: Of the 2056 admitted, LTE protocols were applied to 106 patients. The prevalence of LTE in the ICU was 5.1%. Data were analyzed in 80 patients. A total of 91.2% of patients had been admitted in an emergency situation, and 56.2% had been admitted after surgery. The most widespread limitation was treatment withholding (83.8%) compared to withdrawal (13.8%). No differences were found regarding who made the decision and the type of limitation employed. However, patients with the limitation of no intubation had a longer stay (p = 0.025). Additionally, the order of not starting or increasing vasopressor support resulted in a longer hospital stay (p = 0.007) and a significantly longer stay until death (p = 0.044). Conclusions: LTE is a frequent measure in critically ill patient management and is less common in the postoperative setting. The most widespread measure was withholding, with the do-not-resuscitate order being the most common. The decision was made mainly by the medical team and the family, respecting the wishes of the patients. A joint patient-centered approach should be made in these decisions to avoid futile treatment and ensure end-of-life comfort.

The Main Effects of the Original Oral Care Protocol Implementation in Patients on Invasive Mechanical Ventilation

Respiratory infection is the most common nosocomial infection found in intensive care units (ICUs). Dental plaques and oral mucosa can be colonized by respiratory pathogens within a few days after tracheal intubation. Oral care plays an important role in reducing the incidence of ventilator-associated infections.Aim of the study. To evaluate clinical effectiveness of the original oral care protocol in ICU patients on invasive mechanical ventilation (IMV).Materials and Methods. A multicenter, open-label, randomized, prospective, controlled study was conducted in 55 surgical ICU patients on long-term mechanical ventilation. Oral care for patients in the study group (group 1, N=30) included brushing with disposable toothbrushes and rinsing with an aqueous solution of 0.05% chlorhexidine digluconate three times daily. In the control group (group 2, N=25), patients' oral care was performed twice a day using sterile cotton swabs soaked in 0.05% aqueous chlorhexidine digluconate solution. The results were statistically processed using IBM SPSS Statistics 21. The relative risk (RR) of events was calculated with a 95% confidence interval (95% CI). The 95% CIs for event density parameters such as incidence rate (IR) and incidence rate ratio (IRR) were calculated using the exact Poisson test.Results. The incidence of ventilator-associated pneumonia (VAP) was 13.6 cases [95% CI: 4.4; 31.7] per 1,000 ventilation days in group 1 and 23.6 cases [95% CI: 7.7; 55] per 1,000 ventilation days in group 2. The incidence of VAP was 1.74 times lower [95% CI: 0.4, 7.54] in group 1 vs. group 2 (P=0.398). The identity of oral and tracheal flora on day 7 was 20% in group 1 and 50% in group 2, RR=0.4, 95% CI: 0.165–0.973, P=0.037. Serum C-reactive protein levels were significantly lower in group 1 on day 7 of ventilation compared to group 2 (P=0.04).Conclusion. The original oral care protocol, based on toothbrushing 3 times daily with a set of disposable toothbrushes and 0.05% aqueous solution of chlorhexidine digluconate, is associated with a tendency to lower VAP incidence per 1000 days of ventilation, significantly lower similarity between oral and tracheal flora, and lower serum C-reactive protein levels on day 7 of IMV. Further research on various aspects of oral care in ICU patients is needed, especially in the absence of complete clinical guidelines and clearly effective strategies for the prevention of ventilator-associated infections.

Association between early airway intervention in the pre-hospital setting and outcomes in out of hospital cardiac arrest patients: A post-hoc analysis of the Target Temperature Management-2 (TTM2) trial

IntroductionAirway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. The primary aim of this study was to describe pre-hospital airway management in adult patients post-OHCA. Secondary aims were to investigate whether tracheal intubation (TI) versus use of supraglottic airway device (SGA) was associated with patients’ outcomes, including ventilator-free days within 26 days of randomization, 6 months neurological outcome and mortality. MethodsSecondary analysis of the Target Temperature Management-2 (TTM2) trial conducted in 13 countries, including adult patients with OHCA and return of spontaneous circulation, with data available on pre-hospital airway management. A multivariate logistic regression model with backward stepwise selection was employed to assess whether TI versus SGA was associated with outcomes. ResultsOf the 1900 TTM2 trial patients, 1702 patients (89.5%) were included, with a mean age of 64 years (Standard Deviation, SD = 13.53); 79.1% were males. Pre-hospital airway management was SGA in 484 (28.4%), and TI in 1218 (71.6%) patients. At hospital admission, 87.8% of patients with SGA and 98.5% with TI were mechanically ventilated (p < 0.001). In the multivariate analysis, TI in comparison with SGA was not independently associated with an increase in ventilator-free days within 26 days of randomization, improved neurological outcomes, or decreased mortality. The hazard ratio for mortality with TI vs. SGA was 1.06, 95%Confidence Interval (CI) 0.88–1.28, p = 0.54. ConclusionsIn the multicentre randomized TTM2-trial including patients with OHCA, most patients received prehospital endotracheal intubation to manage their airway. The choice of pre-hospital airway device was not independently associated with patient clinical outcomes.Trial registration number: NCT02908308.

Comparative Analysis of Hemodynamic Responses and Oropharyngeal Complications in Tracheal Intubation: Evaluating Conventional, Video, and Rigid Video Laryngoscopes Under General Anesthesia.

BACKGROUND This study aimed to compare the hemodynamic changes and the occurrence of oropharyngeal complications among patients undergoing tracheal intubation with an ordinary laryngoscope, video laryngoscope, and rigid video laryngoscope under general anesthesia. MATERIAL AND METHODS Patients undergoing elective tracheal intubation under general anesthesia were prospectively enrolled as study subjects. Hemodynamic indicators such as diastolic blood pressure (DBP), systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR), as well as the incidences of oropharyngeal complications, including dental injury, oral mucosal injury, hoarseness, sore throat, and dysphagia, were observed in the patients of 3 groups (group A: ordinary laryngoscope, group B: video laryngoscope, group C: rigid video laryngoscope). Observations were made after anesthesia induction (T₀), immediately after tracheal intubation (T₁), and at 5 min after intubation (T₂). RESULTS The HR at T1 in group A was significantly higher than in groups B and C (P<0.05). However, the difference in the number of tracheal intubations was statistically significant among the 3 groups (P<0.05); group C exhibited the highest first-time success rate of tracheal intubation (95%), whereas group A had the highest failure rate (5%). Significant differences were also noted in the incidences of oral mucosal injury and sore throat among the groups (P<0.05), with the highest incidence in group A and the lowest in group C. CONCLUSIONS Compared with the ordinary laryngoscope, tracheal intubation using a video or rigid video laryngoscope results in milder hemodynamic impacts and fewer intubation-related complications. The rigid video laryngoscope may be safer and more effective.

Utilizing ultrasonography to determine the minimal transverse diameter of the subglottic airway for informed selection of reinforced cuffed endotracheal tube models in children.

We explored the use of ultrasonography in determining the minimal transverse diameter of the subglottic airway (MTDSA) for the purpose of choosing an appropriate model of reinforced cuffed endotracheal tube. A total of 110 pediatric patients who received general anesthesia and tracheal intubation for selective surgeries at the hospital from February 2019 to February 2022 were chosen. They were then randomly assigned to three groups: 39 in the MTDSA group, 35 in the age formula group, and 36 in the height formula group. We assessed how accurately the appropriate endotracheal tube model was predicted in each group and compared their predictive performance. The age range of the enrolled pediatric patients was 3-6 years old. The ultrasonic measurement method demonstrated a prediction accuracy of 87.18%, while the age formula method and height formula method exhibited lower accuracy rates of 54.29% and 47.22%, respectively. Notably, the ultrasonic measurement method outperformed the other two methods significantly (P < 0.05). In the MTDSA group, 2 patients had their catheters changed during anesthesia, and the proportion of patients who changed their catheters was 5.13%. In the MTDSA group, 6 catheters were replaced, and the frequency of catheter replacement was 15.38%. In contrast, these percentages were much higher in the age formula group, at 31.43% and 45.71%, and in the height formula group, at 36.11% and 52.78%. The latter two groups had significantly higher values than the MTDSA group (P < 0.05). Regarding complications such as hoarseness, laryngeal edema, aspiration, and laryngospasm, the MTDSA group experienced a notably lower total incidence of 7.69% compared to the 37.14% in the age formula group and 41.67% in the height formula group, demonstrating statistical significance (P < 0.05). The ultrasonic measurement technique employed in MTDSA exhibits impressive precision when it comes to forecasting the specific model of a reinforced cuffed endotracheal tube for pediatric patients. This enhanced accuracy contributes significantly to minimizing the need for tube replacements during anesthesia and the associated complications. It holds immense importance in assisting clinicians in selecting the most appropriate pediatric endotracheal tube model for anesthesia induction.

Post‐intubation hypotension risk factors in patients with COVID‐19 undergoing endotracheal intubation in the emergency department: A prospective observational study

AbstractIntroductionAcute respiratory distress syndrome, a severe manifestation of COVID‐19, prompts the critical intervention of endotracheal intubation (ETI). However, ETI is associated with complications, notably post‐intubation hypotension (PIH), linked to an increased adverse prognosis. Our purpose was to investigate risk factors for PIH in COVID‐19 patients in the emergency department (ED).MethodsThis observational study was conducted at the Afzalipour Hospital, Iran. Adult COVID‐19 patients undergoing ETI were included, with data collected on demographic variables, medical history, and hemodynamic parameters. PIH was defined as the occurrence of any of the following: reduction of systolic blood pressure (SBP) to 90 mmHg or less; reduction of mean arterial pressure (MAP) to 65 mmHg or less; reduction of SBP by at least 20% of the initial value; or the need for vasopressor support during the 30 min after intubation.ResultsAmong 145 patients, the mortality rate was 82.7%, and PIH occured in 22.7%. Univariate analysis revealed associations between PIH and initial SBP (SBP‐0) and initial MAP. Multivariable regression revealed that each 1 mmHg decrease in SBP‐0 increased the risk of PIH by 5%. Patients with SBP‐0 of less than 116 mmHg had a PIH odds ratio of 4.1. A history of hypertension (HTN) or ischemic heart disease (IHD) increased the likelihood of PIH sixfold. The receiver operating characteristic curves for SBP‐0 had an area under the curve (AUC) of 0.67 (95% CI: 0.54–0.79), lower than the AUC of 0.77 (95% CI: 0.64–0.86) for the model incorporating SBP‐0, history of HTN or IHD, and total severity score. Despite this, the Z score comparing the AUCs of SBP‐0 and the multivariable model did not indicate a statistically significant difference.ConclusionsHistory of HTN or IHD, as well as low SBP‐0, are independently associated with an increased risk of PIH in COVID‐19 patients.

Impact of Nebulized BromAc® on Mucus Plug Clearance in a Mechanically Ventilated Ex Vivo Ovine Lung Model of Obstructive Respiratory Conditions.

Mucus plugging of the respiratory tract occurs in airway diseases, including asthma, chronic obstructive pulmonary disease, and cystic fibrosis. It can cause blockage of the airways, leading to breathlessness and lung failure. Here, we used a ventilatory setup to demonstrate the effect of BromAc® in dissolving mucus plugs in a novel ex vivo ovine obstructive lung model. Mucus simulant was filled into the trachea of freshly slaughtered ovine lungs and ventilated via an endotracheal tube (ETT) using Continuous Mandatory Ventilation. Predetermined single or repeated doses of Bromelain, Acetylcysteine (Ac), BromAc®, and saline control were administered via an Aerogen® vibrating nebulizer and ventilated for 30 or 60 min. Ventilatory recording of resistance, compliance, and tidal volume was conducted, and rheology pre- and post-treatment were measured. A significant decline in airway resistance (p < 0.0001) compared to the saline control was observed when treated with Bromelain, Ac, and BromAc®, with the latter showing a stronger mucolytic effect than single agents. The decline in resistance was also effective in shorter time points (p < 0.05) at lower doses of the drugs. Changes in compliance, peak pressure, and tidal volume were not observed after administration of the drugs. Rheology measurements revealed that BromAc®TM significantly reduced the viscosity of the mucin at the end of 30 min and 60 min time points (p < 0.001) compared to the saline control. BromAc® showed complete dissolution of the respiratory mucus simulant and improved ventilatory airflow parameters in the ex vivo ovine model.