Single Airway Research Articles

Microbiology of cystic fibrosis persons not chronically infected with P. aeruginosa: A quasi-experimental study on two different upper airways’ sampling methods

BackgroundThe upper airways of cystic fibrosis (CF) persons are an evolutionary niche where genetically adapted bacterial strains are selected for lung infection. The microbiological studies conducted up to now on the upper airways are not easily comparable. MethodsUsing classical culture methods, we simultaneously studied the microbiological status of upper and lower airways in persons not chronically infected with P. aeruginosa. Each person had a single upper airways sampling and a concomitant lower airways sampling. Lower airways sampling was performed by oropharyngeal swab or sputum collection. Using a quasi-experimental design of study, we evaluated the performance of 2 different upper airways’ sampling methods, nasal lavage according to method described by Mainz or nasal lavage with a rhino-set. Pain was measured with appropriate scales. ResultsA total of 194 persons were enrolled in this study. Pathogenic flora was found in 128 (6.6%) of 194 upper airways samples and in 164 (84.6%) lower airways samples. A statistically significant difference between the upper airways and the lower airways was found in the isolation of S. aureus and non-fermenter gram negatives. Nasal lavage according to Mainz resulted in the isolation of more non-fermenter gramnegatives than the rhino-set (p < 0.05). No differences were found in the pain caused bythe two methods. ConclusionsIn our study population, cultures of the upper airway and lower airway differ in CF persons. In people sampled with nasal lavage according to Mainz more non-fermenter gram negatives were detected than with rhino-set. The two sampling methods were comparable with regard to the caused pain, nasal lavage according to Mainz method being quicker to perform.

Bronchial Cryo-Denervation for Severe Asthma: A Pilot Study

Introduction: Targeting the parasympathetic nervous system innervating the airway with pharmacologic products has been proved to improve the clinical outcomes of severe asthma. Bronchial cryo-denervation (BCD) is a novel non-pharmacologic treatment for severe asthma using an endobronchial cryo-balloon administered via bronchoscopy to denervate parasympathetic pulmonary nerves. Preclinical studies have demonstrated that BCD significantly disrupted vagal innervation in the lung. Methods: A total of 15 patients with severe asthma were enrolled in this prospective, single-center pilot study. Patients underwent bifurcated BCD treatment at a 30-day interval after baseline assessment. Follow-up through 12 months included assessment of adverse events, technical feasibility, and changes in pulmonary function; asthma control questionnaire-7 (ACQ-7); and asthma control test (ACT). Results: BCD was performed on all 15 severe asthma patients, with technical feasibility of 96.7%. There were no device-related and 2 procedure-related serious adverse events through 12 months, which resolved without sequelae. The most frequent nonserious procedure-related adverse event was increased cough in 60% (9 of 15) patients. Pulmonary function remained unchanged, and significant improvements from baseline ACQ-7 (mean, −1.19, p = 0.0032) and ACT (mean, 3.18, p = 0.0011) scores were observed since the first month’s follow-up after a single lung airway treatment, with similar trends till the end of the 12-month follow-up. Conclusion: This study provides the first clinical evidence of the safety, feasibility, and initial efficacy of BCD in patients with severe asthma.

Single stage pediatric airway reconstruction in solid organ transplant recipients

ObjectivesTo describe results of single stage laryngotracheal reconstruction (ssLTR) in patients with solid organ transplants and to discuss modifications which need to be considered in this subset of patients pre-operatively, intra-operatively and post-operatively. Study designWe performed a retrospective case series review of children undergoing single stage laryngotracheal reconstruction in the context of prior solid organ transplant. SettingA tertiary care academic setting. MethodsPediatric cases undergoing Laryngotracheal reconstruction over a 3-year period. Demographic data including age, sex, presenting symptoms, operative details. ResultsTwo cases of ssLTR in solid organ transplant patients were found, one each with renal and cardiac transplants respectively. Both patients successfully underwent ssLTR for Grade 2 subglottic stenosis. The care of these patients was multidisciplinary and required alterations in their preoperative prophylactic antibiotics. While they did not require changes to the LTR post-operative sedation protocol, their immunosuppressant doses and target ranges were lowered. Special care was taken to avoid nephrotoxic and cardiotoxic medications throughout their hospital stay. ConclusionsAlthough traditionally considered for double stage laryngotracheal reconstruction, single stage laryngotracheal reconstruction is a viable option in patients with solid organ transplant. These patients require a multidisciplinary approach and pharmacological protocol alterations pre-, intra-, and post-operatively.

A single priming event prevents oral tolerance to peanut.

Indoor dust (ID) is a source of peanut proteins and immunostimulatory adjuvants (e.g. LPS) that can promote airway sensitization to peanut. We aimed to determine whether a single airway exposure to peanut plus adjuvant is sufficient to prevent oral tolerance. To determine the effect of a single priming event, C57BL/6J mice were exposed once to peanut plus adjuvant through the airway, followed by either airway or low-dose oral exposure to peanut, and assessed for peanut allergy. Oral tolerance was investigated by feeding high-dose peanut followed by airway sensitization. To determine whether a single priming could prevent oral tolerance, the high-dose peanut regimen was applied after a single airway exposure to peanut plus adjuvant. Peanut-specific IgE and IgG1 were quantified, and mice were challenged to peanut to assess allergy. Peanut-specific CD4+ memory T cells (CD4+ TCRβ+ CD44hi CD154+ ) were quantified in mediastinal lymph nodes following airway priming. Mice co-exposed to peanut with LPS or ID through the airway were primed to develop peanut allergy after subsequent low-dose oral or airway exposures to peanut. Oral tolerance was induced in mice fed high-dose peanut prior to airway sensitization. In contrast, mice fed high-dose peanut following a single airway exposure to peanut plus adjuvant led to allergy. Peanut-specific CD4+ memory T cells were detected as early as 7 days after the single airway priming with peanut plus adjuvant, however, delaying peanut feeding even 1 day following priming led to allergy, whereas peanut feeding the same day as priming led to tolerance. A single airway exposure to peanut plus adjuvant is sufficient to prime the immune system to develop allergy following subsequent high-dose oral exposure. These results highlight the importance of introducing peanut as early as possible to prevent sensitization through a non-oral priming event.

Heart rate responses in critical care trainees during airway intubation: a comparison between the simulated and clinical environments

ObjectiveThis study aimed to compare the heart rate response to stress during airway intubations in clinical practice and a simulated environment.MethodsTwenty-five critical care registrars participated in the study over a 3-month period. Heart rate data during intubations was recorded by a FitBit® Charge 2 worn by each participant during their clinical practice, and during a single simulated airway management scenario. The heart rate range was calculated by subtracting the baseline working heart rate (BWHR) from the maximum functional heart rate (MFHR). For each airway intubation performed participants recorded an airway diary entry. Data from intubations performed in the clinical environment was compared to data from a simulated environment. Heart rate changes were observed in two ways: percentage rise (median) across the 20-min intubation period and; percentage rise at point of intubation (median).ResultsEighteen critical care registrars completed the study, mean age 31.8 years (SD = 2.015, 95% CI = 30.85–32.71). Throughout the 20-min peri-intubation recording period there was no significant difference in the median change in heart rates between the clinical (14.72%) and simulation (15.96%) environment (p = 0.149). At the point of intubation there was no significant difference in the median change in heart rate between the clinical (16.03%) and the simulation (25.65%) environment groups (p = 0.054).ConclusionIn this small population of critical care trainees, a simulation scenario induced a comparable heart rate response to the clinical environment during intubation. This provides evidence that simulation scenarios are able to induce a comparable physiological stress response to the clinical environment and thus facilitates effective teaching of a high-risk procedure in a safe manner.

Erratum to: Does the use of supraglottic device in rabbits cause less injury than other airway management devices?

Unfortunately the original version of the article was missing the following statement. This Knowledge Summary has reviewed the available evidence on the use of a SGAD (v-gel®) in rabbit anaesthesia. Since writing a new design of a single use supraglottic airway device (SGAD) has been introduced; currently there is no published evidence on whether this new device has an impact on the risk of injury. This error was in both the HTML and PDF versions. This has now been updated in both the HTML and PDF versions, and can be found in the clinical bottom line and the evidence section.

Single Airway Co-Exposure to Peanut and an Environmental Adjuvant Increases the Risk of Oral Peanut Sensitization

There is increasing evidence that environmental exposures to foods through the skin or respiratory tract cause allergic sensitization, whereas oral exposure results in tolerance. We previously reported that repeated airway co-exposures to peanut and environmental adjuvants could promote systemic allergic sensitization. Here we investigated if a single airway co-exposure to peanut with an environmental adjuvant was a risk factor for oral sensitization to peanut.

Lung-resident CD69+ST2+ TH2 cells mediate long-term type 2 memory to inhaled antigen in mice

Chronic airway diseases such as asthma are characterized by persistent type 2 immunity in the airways. We know little about the mechanisms that explain why type 2 inflammation continues in these diseases. We used mouse models to investigate the mechanisms involved in long-lasting immune memory. Naive mice were exposed intranasally to ovalbumin (OVA) antigen with Alternaria extract as an adjuvant. Type 2 memory was analyzed by parabiosis model, flow cytometry with invivo antibody labeling, and intranasal OVA recall challenge. Gene-deficient mice were used to analyze the mechanisms. In the parabiosis model, mice previously exposed intranasally to OVA with Alternaria showed more robust antigen-specific immune responses and airway inflammation than mice with circulating OVA-specific T cells. After a single airway exposure to OVA with Alternaria, CD69+ST2+ TH2-type T cells, which highly express type 2 cytokine messenger RNA and lack CD62L expression, appeared in lung tissue within 5 days and persisted for at least 84 days. When exposed again to OVA invivo, these cells produced type 2 cytokines quickly without involving circulating T cells. Development of tissue-resident CD69+ST2+ TH2 cells and long-term memory to an inhaled antigen were abrogated in mice deficient in ST2 or IL-33, but not TSLP receptor. CD69+ST2+ TH2 memory cells develop quickly in lung tissue after initial allergen exposure and persist for a prolonged period. The ST2/IL-33 pathway may play a role in the development of immune memory in lung to certain allergens.

Characteristics of the patients with asthmarhinitis multimorbidity.

Asthma and allergic rhinitis frequently coexist and have been regarded as a single airway disease. Clinical features of patients with asthmarhinitis multimorbidity may change depending on the allergic sensitization pattern. The aim of our study is to determine the frequency, type, and characteristics of the patients with asthma-rhinitis multimorbidity. Patients who were followed up with a diagnosis of asthma between 2015 and 2020 in our clinic were included in our crosssectional study. Sociodemographic and clinical characteristics of the patients, rhinitis symptoms, and atopy status according to the results of the skin prick test, and sp IgE were recorded from the patient files. Asthma-rhinitis multimorbidity was seen in 138 (113 F/25 M) out of 405 asthmatics and the mean age was 45.51 ± 13.56 years. They were younger and the age of onset of asthma was earlier than asthma patients without rhinitis. The rate of concomitant allergic rhinitis (AR) was 25.9%, and the rate of non-allergic rhinitis (NAR) was 8.1% in the entire group. There was no difference between patients with AR and NAR in terms of comorbidities such as NSAID sensitivity, nasal polyps, chronic rhinosinusitis, and bronchiectasis but, gastroesophageal reflux disease was more common in those with NAR than in those with AR (39.4%, 18.1%, respectively, p= 0.01). Of 105 asthmatic patients accompanied by allergic rhinitis, 41 (39.09%) were monosensitized, and 64 (60.95%) were polysensitized. House dust mites were found to be the most common responsible allergen in monosensitized patients. Sensitization to two allergens was the most common pattern among polysensitized patients, and mites and mold association was the most frequent. Patients with monosensitized allergic rhinitis had more severe asthma and a higher rate of NSAID sensitivity than polysensitized patients (p= 0.03, p= 0.04, respectively). There was no difference in the control level, frequency of eosinophilia, and other comorbidities. Our patients with asthma-rhinitis multimorbidity were mostly polysensitized. The most responsible allergen for the sensitization was house dust mites, regardless of whether the patient was monosensitized or polysensitized.

Spinal cord injury: the cost of mechanical ventilation versus phrenic nerve stimulation

Patients with respiratory insufficiency caused by tetraplegia at or above the level of cervical segment two can be treated with phrenic nerve stimulation instead of mechanical ventilation. An analysis of the annual invoices for single use airway equipment of 20 patients using phrenic nerve stimulation and 20 patients who were mechanically ventilated was conducted. The initial implantation of the phrenic nerve stimulation device costs considerably more than the mechanical ventilation device. However, this analysis found that the cost of running a phrenic nerve stimulator device is lower because of the reduced amount of airway nursing equipment needed. This analysis demonstrates that the cost of implanting a phrenic nerve stimulator device would be repaid within 4 years.

Emergency Subglottic Airway Training and Assessment of Skills Retention of Attending Anesthesiologists With Simulation Mastery-Based Learning.

Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques. Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member. Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results. We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology.

Airway Management During Cardiopulmonary Resuscitation.

Purpose of the reviewThis review summarizes the updated literature on airway management during cardiopulmonary resuscitation (CPR). It provides guidance for clinicians to carefully incorporate the most recent recommendations related to airway management, oxygenation, and ventilation both during CPR and after return of spontaneous circulation.Recent FindingsThe American Heart Association and the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care provide updated recommendations related to airway management during CPR, which focus on advanced airway strategies in out-of-the hospital cardiac arrest and in-hospital cardiac arrest. There is no evidence that any single advanced airway technique is superior to the other in terms of survival and neurological outcomes. There is controversy as to whether early advanced airway management could lead to favorable outcome.SummaryAdvanced airway strategies and alternatives to airway management (including passive oxygenation) can be utilized in different settings while minimizing interruption in chest compressions.

Патоморфологические изменения некоторых органов и тканей в периоде реконвалесценции коронавирусной инфекции COVID-19

New coronavirus infection (COVID-19) is highly contagious viral disease caused by SARS-CoV-2 leading to the pandemic. The autopsy of COVID-19 patients often showed features of previous brain diseases including neurodegeneration, previous strokes, demyelinating diseases and atherosclerosis. Patients with acute cerebrovascular accidents and severe COVID-19 had higher numbers of lethality in comparison to non-severe course of infection without cerebrovascular accidents. A comparative analysis of morphological changes in lungs of deceased patients who died in different periods of first clinical symptoms is to be conducted. Objective. Description of pathomorphological changes in deceased patients during the period of reconvalescence. Patients and methods. The analysis of 15 fatal cases which took place in Botkin Hospital with the diagnosis of ischemic stroke and new coronavirus infection in the previous 2-4 months has been held. Macro and microscope examination of brain, lungs, brachiocephalic arteries, kidneys and liver has been carried out. Results. All patients had morphological features of ischemic damage of grey matter in the brain. Beside necrosis of neurocytes with diffuse infiltration in the grey matter, hematoxylin cycles were found, in some cases they were placed in a perivascular way in choroid plexus. Also 5 patients suffered a myocardial infarction up to 3 days. 10 patients had structures disorganisation in areas of lung parenchyma with hystoacrchitectonic changes because of the fibrosis. Alveoli in some places collaborated mostly with single airway clearance. The fact that most patients had lung hemosiderosis can prove coronavirus infection suffered earlier with microcirculatory bed damage. Conclusion. Thus, morphological changes seen in the period of reconvalescence of COVID-19 is a result of pathomorphosis of changes described earlier for acute period of coronavirus infection and affect not only lungs, but also other organs and tissues. This proves systematic characteristic of the infection. Key words: COVID-19, acute cerebrovascular accidents, stroke, pathomorphological changes in the brain

A single baroreceptor unit consists of multiple sensors

Arterial baroreceptors (BRs) play a vital role in the regulation of the cardiopulmonary system. What is known about how these sensors operate at the subcellular level is limited, however. Until recently, one afferent axon was considered to be connected to a single baroreceptor (one-sensor theory). However, in the lung, a single airway mechanosensory unit is now known to house many sensors (multiple-sensor theory). Here we tested the hypothesis that multiple-sensor theory also operates in BR units, using both morphological and electrophysiological approaches in rabbit aortic arch (in whole mount) labeled with Na+/K+-ATPase, as well as myelin basic protein antibodies, and examined microscopically. Sensory structures presented in compact clusters, similar to bunches of grapes. Sensory terminals, like those in the airways, formed leaf-like or knob-like expansions. That is, a single myelinated axon connected with multiple sensors forming a network. We also recorded single-unit activities from aortic baroreceptors in the depressor nerve in anesthetized rabbits and examined the unit response to a bolus intravenous injection of phenylephrine. Unit activity increased progressively as blood pressure (BP) increased. Five of eleven units abruptly changed their discharge pattern to a lower activity level after BP attained a plateau for a minute or two (when BP was maintained at the high level). These findings clearly show that the high discharge baroreceptor deactivates after over-excitation and unit activity falls to a low discharge sensor. In conclusion, our morphological and physiological data support the hypothesis that multiple-sensory theory can be applied to BR units.

Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome.

Purpose of reviewTo summarize the current knowledge about the application of advanced monitoring techniques in coronavirus disease 2019 (COVID-19).Recent findingsDue to the heterogeneity between patients, management of COVID-19 requires daily monitoring of and/or aeration and inspiratory effort. Electrical impedance tomography can be used to optimize positive end-expiratory pressure, monitor the response to changes in treatment or body position and assess pulmonary perfusion and ventilation/perfusion matching. Lung ultrasound is more readily available and can be used to measure and monitor recruitment, provide an indication of diaphragm function and pulmonary perfusion disturbances. Esophageal pressure measurements enable the calculation of the transpulmonary pressure and inspiratory effort in order to prevent excessive stress on the lung. While esophageal pressure measurements are the golden standard in determining inspiratory effort, alternatives like P0.1, negative pressure swing during a single airway occlusion and change in central venous pressure are more readily available and capable of diagnosing extreme inspiratory efforts.SummaryAlthough there is little data on the effectiveness of advanced monitoring techniques in COVID-19, regular monitoring should be a central part of the management of COVID-19-related acute respiratory distress syndrome (C-ARDS).

Base of Tongue Non-Hodgkin’s Lymphoma: Difficult Intubation

Primary Non-Hodgkin’s Lymphoma (NHL) of the tongue is a very rare tumor most commonly affecting elderly patients causing upper airway obstruction and anticipated difficult intubations with space occupying lesions that prevent tongue displacement and hence, scarce space for laryngoscopy. A 78-year-old man presented with progressive stridor and dyspnea. Oral examinations revealed tongue asymmetry and friable ulcerative lesions. During induction of anaesthesia in a scheduled partial glossectomy, difficult nasotracheal intubation was encountered despite using the Glidescope. Laryngeal landmarks could not be identified but successful nasotracheal intubation by hand-assisted and magill forceps manipulation of the endotracheal tube direction under video laryngoscopy. Failed intubation should always be considered in the management of base of tongue tumors. Pre-operative assessment and planning to secure the airway in patients presenting with base of tongue tumors decreases morbidity and mortality, especially when an emergency plan is prepared. No single airway management technique can be used for every patient. Further research is required for guiding the choice of airway management in such patients.

Titration studies overestimate continuous positive airway pressure requirements in uncomplicated obstructive sleep apnea.

Attended manual continuous positive airway pressure (CPAP) titration is the standard practice for determining optimal positive airway pressures for obstructive sleep apnea (OSA) treatment. However, an unattended single night auto-titrating positive airway pressure (APAP) titration is an alternative. The goal of this study was to determine whether therapeutic CPAP pressures determined during manual titrations are higher than APAP-generated surrogate pressures. We conducted a retrospective review of 165 adults with uncomplicated OSA who had full/split-night manual CPAP titrations prior to commencing treatment with APAP. Demographic and clinical data including 30-day APAP compliance data were obtained. We compared the recommended CPAP pressure from manual titrations with the 90th/95th percentile pressure generated from APAP usage over 30 days. The recommended CPAP pressures during the manual titrations were higher than the 90th/95th percentile pressures generated from APAP (11.4 ± 3.4 vs 10.3 ± 2.4 cmH2O; P = .000). Almost half the group (41.9%) had their manually derived titration pressure at least 1.5 cm above the 90th/95th percentile pressure. In multivariate analyses, body mass index was the only variable that predicted higher manual titration pressures. Notably, the average residual apnea-hypopnea index on 30-day APAP data was less than the average residual apnea-hypopnea index observed at the recommended pressure during the manual titration (5.0 ± 4.3 vs 7.2 ± 8.5; P = .006). Manual CPAP titrations may overestimate pressure requirements, particularly in patients with higher body mass index, and may not be necessary in managing patients with uncomplicated OSA. APAP appears to be at least as effective as single-pressure CPAP, while delivering lower positive airway pressure. Fashanu OS, Budhiraja R, Batool-Anwar S, Quan SF. Titration studies overestimate continuous positive airway pressure requirements in uncomplicated obstructive sleep apnea. J Clin Sleep Med. 2021;17(9):1859-1863.

A Consecutive Case Series of Rescue Intubations With the Articulating Total Control Introducer for Precision Tracheal Access

Effective rescue after failed intubation is important to limit the number of attempts and patient risk. Nothing is known about the Total Control Introducer's (TCI) effectiveness as an intubation rescue device. A single system's airway management database was studied. The TCI was used for rescue in 34 cases. Overall success was 33 of 34 (97%). First-pass success was 32 of 33 (97%). First-pass rescue was successful in 12 of 12 (100%) after video and direct laryngoscopy had failed. In this case series, the TCI was found to be a highly effective rescue technique after failed direct and video laryngoscopy.

Anesthesia airway management for tracheal resection and reconstruction: a single-center case series.

Anesthesia airway management is challenging during tracheal resection and reconstruction as these surgical procedures involve the airway. This case series describes four approaches to airway management in patients undergoing tracheal resection and reconstruction and discusses their advantages and disadvantages. Thirteen patients underwent 1 of the following 4 kinds of airway management techniques during tracheal resection and reconstruction between 2013 and 2019: intubation, intubation with high frequency jet ventilation (HFJV), non-intubation, and venovenous extracorporeal membrane oxygenation (VV-ECMO). Intraoperative variables and postoperative outcomes were compared for the techniques based on our institution's medical electronic database. Intraoperative oxygenation management involved VV-ECMO in 8 patients, intubation in 2 patients, intubation with HFJV in 2 patients, or non-intubation in 1 patient. The lowest peripheral oxygen saturation (SpO2) in 4 patients was below 90%. Three patients were extubated in the operation room after complete recovery of spontaneous respiration. Most patients were admitted to the intensive care unit for further postoperative treatment, except 1 patient who received laryngeal mask airway management without tracheal intubation during surgery. Two patients died, 1 due to severe anastomotic leakage and the other from acute respiratory distress syndrome. In addition, another patient showed complications with oozing from the wound. Our clinical experience suggests that there is no single airway strategy universally suitable for all tracheal surgeries. The choice of airway management strategy is best determined by multifactorial assessment of advantages and disadvantages according to preoperative comorbidities, unique features of the obstructive mass, surgical experience, and patient preference.

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial

BackgroundChest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART). MethodsWe analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT. ResultsOf 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs. ConclusionIn the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.