Successful Endotracheal Intubation Research Articles

Cadaveric Study on Comparison of Neck Extension Angles for Endotracheal Intubation in Rabbits Using a Rigid and Flexible Endoscope.

Endotracheal intubation in rabbits is always challenging due to the unique anatomical conformation. To improve endotracheal intubation success, this study determined the relationship between head placement angles guided by endoscope-assisted visualization techniques and the endotracheal intubation success rate. Thirty-two rabbit cadavers were used in the study. Six veterinary practitioners who had no experience with rabbit endotracheal intubation were randomly assigned to intubate rabbit cadavers using the guidance of either a rigid endoscope (RE) or flexible endoscope (FE), with the head placement angles with an ascending neck at 90, 100, 110, 120 and 130 degrees. The endotracheal intubation completed in 90 s was determined to be a success. The success rates using RE and FE were 97.2% and 95.9%, respectively. The means and standard error of means (SEM) of endotracheal intubation times guided by RE and FE were 53.7 ± 4.68 and 55.2 ± 4.24 s, respectively. Results from survival time analysis show that the five veterinarians successfully intubated the rabbit within 90 s, regardless of the different types of endoscopes. Angle was the only significant factor that affected the endotracheal intubation success. The head placement angle at 110 and 120 degrees had the highest success rate of endotracheal intubation compared to 90 degrees (p ≤ 0.05). In conclusion, for inexperienced veterinarians, the success of endotracheal intubation in rabbits, guided by endoscope-assisted visualized techniques regardless of rigid endoscope or flexible endoscope guidance, is improved when the head extension is 110 and 120 degrees.

Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials

BackgroundIntubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting.MethodsWe systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively.ResultsFourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = − 6.92, 95% CI [− 12.86, − 0.99], P = 0.02), intubation difficulty score (MD = − 0.62, 95% CI [− 0.86, − 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05).ConclusionIn emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.

Effect of operation table height on ease of mask ventilation, laryngeal view, and endotracheal intubation success

Abstract Background and Aims: Optimal patient positioning and operating table height are essential for an ergonomic posture of an anesthesiologist in which there is minimal or no strain on thewrist during mask ventilation. It also avoids flexion of the neck, lower back, and knee bending at the time of laryngoscopy and intubation. Material and Methods One hundred eighty patients were randomly allocated to three groups based on different table heights. The height of the table is kept at the mid-sternum level of an anesthesiologist in group 1, at the xiphoid process in group 2, and at the level of umbilicus in group 3. Laryngoscopic view with or without postural changes (exertion at wrist joint, flexion of the neck, lower back, or knee bending) was graded as per Cormack Lehane’s (CL) grading. The degree of discomfort experienced by the anesthesiologist during mask ventilation or tracheal intubation was graded subjectively (1 = no discomfort, 2 = mild discomfort, 3 = moderate discomfort, and 4 = severe discomfort) at different table heights. Postural changes required to obtain the best glottic view and quality of endotracheal (ET) intubation (intubation time and attempts required) were also noted. For analysis, quantitative variables were expressed as mean ± SD and compared using unpaired t or analysis of variance test. Qualitative variables were expressed as frequencies/percentages and compared using the Chi-square test. Results with P value &lt;0.05 were considered significant statistically. Results Moderate discomfort (strain at wrist joint) during bag–mask ventilation was experienced by the anesthesiologist in a maximum number of patients in group 1 (81.7%). Significant improvement was seen in CL grade after the use of postural modifications in groups 1 and 2 (P value ≤0.05). Greater postural modifications were required during ET intubation at lower table heights (group 3). Conclusions: It is advisable to adopt higher table positioning in relation to anesthesiologist performing the laryngoscopy for smooth and single-attempt ET intubation since the best laryngoscopic view and intubation with minimal postural modifications was seen at higher table heights (at the mid-sternum level of an anesthesiologist).

A randomized crossover comparison of the bébé VieScope and direct laryngoscope for pediatric airway management by nurses in medical simulation settings

ABSTRACT Background Airway management in life-threatening emergencies is essential for children, and endotracheal intubation is the gold standard. It protects against regurgitation and enables mechanical ventilation. New types of airway management equipment are being developed and implemented to meet the needs of medical personnel. Research design and methods This prospective, randomized, cross-over simulation trial evaluated the success of endotracheal intubation in three scenarios: normal airway (scenario-A), tongue edema (scenario-B), and continuous chest compression (scenario-C), using the bébé Vie Scope™ laryngoscope (VieScope) and the Macintosh blade laryngoscope (MAC) as a comparative tool performed by nurses with limited tracheal intubation experience. Results The results of the study showed that in scenario-A, there were no significant differences in the first attempt success rate or endotracheal intubation time between VieScope and MAC. However, VieScope was associated with better visualization of the glottis. In scenarios B and C, VieScope was significantly more effective than MAC in terms of first-pass success rate, time to intubate, Cormack-Lehane grade, POGO score, and ease of endotracheal intubation. Conclusions Bébé VieScope may be useful for endotracheal intubation in pediatric patients, particularly in cases of tongue edema and ongoing chest compression, providing a higher first-pass success rate than conventional laryngoscopes.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries. Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed. No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05). We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.

Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study.

Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations. Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling. A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.

Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial

To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI). A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests. Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P=.71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P=.035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P=.048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P=.02). There were more mucosal trauma events in the simulation-based JITT group (P=.02). Residents in both groups reported similar confidence level in performing ETI. Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents. ClinicalTrials.gov: NCT02809924.

Lessons from the first two years of a new out-of-hospital airway registry in New South Wales

Background Advanced airway interventions, including endotracheal intubation (ETI) and supraglottic airway devices (iGel®), are used for airway management. Advanced airway proficiency is critical to maintain patient safety. Airway registries are commonly used quality assurance tools that can drive system-level improvement. This study analyses the first two years of data from a new prehospital airway registry. Methods This is a retrospective review of the first two years of an airway registry for Intensive Care Paramedics in New South Wales Ambulance spanning 8 August 2020 to 8 August 2022. Changes in airway management effectiveness were examined as a time series and analysis proceeded regression using Newey–West standard errors. Additionally, a machine learning algorithm (generalised boosted model) was used to predict successful ETI. Results There were 872 unique advanced airway episodes suitable for analysis. Of 705 patients that had received ETI, 655 were successful resulting in an overall success rate of 92.9%. Intubation was achieved on the first attempt in 573 out of 705 (81.3%) patients. Supraglottic airway insertion was successful in 193 of 222 patients (86.9%). The first-pass success for the iGel® supraglottic device was 183 of 222 (82.4%). Considerable increases in ETI and iGel® first-pass success were observed over time. A machine learning analysis demonstrated that factors predicting success for endotracheal intubation included airway-grade, patient age, the use of video laryngoscopy, patient weight and the use of external laryngeal manipulation/bi-manual laryngoscopy. Conclusions This prehospital airway registry analysis demonstrates increasing advanced airway success over the first two years of registry implementation. These increases may be explained in part by the reflective feedback and awareness of airway management that results from the registry, training and the increased use of video laryngoscopy.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates.

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018. To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age). In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www. gov; www.controlled-trials.com), and reference lists of relevant studies. Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy. Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion. We used the GRADE approach to assess the certainty of the evidence. The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification.Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence). For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies. Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

Objective The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic. Methods We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization. Results We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73–3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58–2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001). Conclusions VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

Applications of Airway Ultrasound for Endotracheal Intubation in Pediatric Patients: A Systematic Review

Endotracheal intubation is a challenging procedure for pediatric patients. Airway ultrasound as a new technology is suitable for aiding this process, but its diagnostic value remains unclear. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Chinese biomedical literature database to summarize specific applications of airway ultrasound in each step of endotracheal intubation in pediatric patients. Diagnostic accuracy and 95% confidence interval were used as outcomes. In total, 33 studies (6 randomized controlled trials and 27 diagnostic studies) with 1934 airway ultrasound examinations were included. Population included neonates, infants, and older children. Airway ultrasound could be used to determine the endotracheal tube size and confirm endotracheal intubation and intubation depth; the diagnostic accuracy for all these factors was 23.3-100%, 90.6-100%, and 66.7-100%, respectively. Furthermore, the accuracy of airway ultrasound in predicting endotracheal tube size was consistently higher than traditional methods, such as height formula, age formula, and the width of the little finger. In conclusion, airway ultrasound has unique advantages for confirming successful endotracheal intubation in pediatric patients, and it may become an effective auxiliary tool in this field. There is a need to develop a unified airway ultrasound protocol to conduct clinical trials and practice in the future.

Association between First-pass Intubation Success and Enhanced PPE Use during the COVID-19 Pandemic

Objectives We evaluated first-pass endotracheal intubation (ETI) success within the critical care transport (CCT) environment using a natural experiment created by the COVID-19 pandemic. Our primary objective was to evaluate if the use of personal protective equipment (PPE) or the COVID-19 time period was associated with differences in first-pass success rates of ETI within a large CCT system with a high baseline ETI first-pass success rate. We hypothesized that pandemic-related challenges would be associated with decreased first-pass success rates. Methods We performed a retrospective before-after cohort study of airway management by CCT personnel relative to the COVID-19 pandemic. We used a mixed effects logistic regression to evaluate the association between enhanced PPE (N95 mask, eye protection) use and the pandemic time period on first-pass intubation success, while controlling for other factors potentially associated with intubation success. Variables in the final model included patient demographics (age, sex, and race), body mass index, medical category (trauma versus non-trauma), interfacility or scene response, blade size (Macintosh 3 versus 4), use of face mask, use of eye protection, and crew member length of service. Results We identified 1279 cases involving intubation attempts on adult patients during the study period. A total of 1133 cases were included in the final analysis, with an overall first-pass success rate of 95.7% (96.4% pre-COVID-19 and 94.8% during COVID-19). In our final mixed effects logistic regression model, enhanced PPE use and the COVID-19 time period were not associated with first-pass intubation success rate. Conclusion In a large regional CCT system with a high ETI first-pass success rate, neither PPE use nor the COVID-19 time period were associated with differences in ETI first-pass success while controlling for relevant patient and operational factors. Other emergency medical services (EMS) systems may have encountered different effects of pandemic-related PPE use on intubation success rates. Further studies are needed to evaluate the influence of sustained use of enhanced PPE or changes in training or procedural experience on post-pandemic ETI first-pass success rates for non-CCT EMS clinicians.

Effect of intravenous fentanyl on cough reflex and quality of endotracheal intubation in cats

ObjectiveTo assess the effects of intravenous (IV) fentanyl on cough reflex and quality of endotracheal intubation (ETI) in cats. Study designRandomized, blinded, negative controlled clinical trial. AnimalsA total of 30 client-owned cats undergoing general anaesthesia for diagnostic or surgical procedures. MethodsCats were sedated with dexmedetomidine (2 μg kg–1 IV), and 5 minutes later either fentanyl (3 μg kg–1, group F) or saline (group C) was administered IV. After alfaxalone (1.5 mg kg–1 IV) administration and 2% lidocaine application to the larynx, ETI was attempted. If unsuccessful, alfaxalone (1 mg kg–1 IV) was administered and ETI re-attempted. This process was repeated until successful ETI. Sedation scores, total number of ETI attempts, cough reflex, laryngeal response and quality of ETI were scored. Postinduction apnoea was recorded. Heart rate (HR) was continuously recorded and oscillometric arterial blood pressure (ABP) was measured every minute. Changes (Δ) in HR and ABP between pre-intubation and intubation were calculated. Groups were compared using univariate analysis. Statistical significance was set as p < 0.05. ResultsThe median and 95% confidence interval of alfaxalone dose was 1.5 (1.5–1.5) and 2.5 (1.5–2.5) mg kg–1 in groups F and C, respectively (p = 0.001). The cough reflex was 2.10 (1.10–4.41) times more likely to occur in group C. The overall quality of ETI was superior in group F (p = 0.001), with lower laryngeal response to ETI (p < 0.0001) and ETI attempts (p = 0.045). No differences in HR, ABP and postinduction apnoea were found. Conclusions and clinical relevanceIn cats sedated with dexmedetomidine, fentanyl could be considered to reduce the alfaxalone induction dose, cough reflex and laryngeal response to ETI and to improve the overall quality of ETI.

Intubation characteristics using modified USB videolaryngoscope: A prospective, randomised study.

Videolaryngoscopes with varying characteristics with regard to angulation of blades and video configurations are now available. However, the contribution of each of these in improving ease of intubation is quite different. We evaluated the role of video camera in the performance of laryngoscopy by using the universal serial bus (USB) videolaryngoscope in patients with predicted difficult airway. Sixty patients in the age group of 25 to 65 years having Mallampati grade III or IV were randomly allocated to two groups. All patients were American Society of Anesthesiologists physical status grade I or II and planned for elective surgical procedure under general anesthesia. USB videolaryngoscope or Macintosh laryngoscope was used for intubation as per group allotted. Comparison of time of endotracheal intubation was our primary outcome measure and it was calculated from the time the laryngoscope tip passes the incisors to the initial appearance of capnography wave. Rate of successful intubation, number of attempts needed for successful tube placement, optimisation manoeuvres used, changes in haemodynamic parameters and airway injuries were evaluated as secondary outcomes. Time for intubation was shorter in the Macintosh group than the USB group (P = 0.024). The incidence of successful intubation was similar in both groups (P = 0.079). USB group required lesser number of attempts for tube placement (P = 0.047). The incidence of airway injuries was similar in both the groups. USB videolaryngoscope reduces the number of attempts required for successful endotracheal intubation compared to Macintosh laryngoscope though it increases the time for intubation in patients with predicted difficult airway.

Demographic disparities in tracheal intubation success rates during infant out-of-hospital cardiac arrest

ObjectivesTracheal intubation is a skill performed by qualified emergency medical services (EMS) providers during out-of-hospital cardiac arrest (OHCA) in adult and pediatric patients. Unsuccessful intubation can negatively impact a patient's likelihood of survival. Thus, intubation success rates are an important quality improvement benchmark. Given other demographic disparities that have been reported in adults and children, we hypothesize there might be disparities in intubation success across infant race/ethnicity and/or sex. MethodsWe examined a national-level registry of EMS activations in the United States (NEMSIS). Inclusion criteria were OHCA calls involving infant patients (under 1 years of age) between January 2017 and May 2022 where EMS attempted tracheal intubation, documented whether the procedure was successful, and documented information about the patient's demographics (eg. race/ethnicity and sex). Intubation success rates across patient sex and racial/ethnic categories with more than one-hundred cardiac arrests with intubation attempts were compared. ResultsA total of 3663 infant cardiac arrests where tracheal intubation was attempted met inclusion criteria. White infants were associated with significantly higher rates of intubation success (62.2%) when compared with Black or African American infants (58.1%) and Hispanic/Latino infants (56.2%) (p < .01). Female infants were associated with slightly higher rates of intubation success than male infants, but this difference was not significant (p > .2). ConclusionSignificant demographic disparities in endotracheal intubation success rates exist among infants who experience OHCA. Future studies should continue to examine these disparities with the goal of identifying why these differences occur and concrete mechanisms for eliminating such disparities.

A comparison of face-to-face endotracheal intubation and standard intubation using Airtraq video laryngoscope in morbidly obese patients: A randomized controlled trial

Routine endotracheal intubation requires a patient in supine position with an operator standing behind the patient's head. In case of a morbidly obese patient positioned in the recommended semi-recumbent position, an alternative method can be considered. Face-to-face intubation can be used both in patients in sitting as well as in prone position and when there is difficult access to the head. Evaluation of effectiveness and safety of face-to-face intubation in morbidly obese adult patients with body mass index over 40 kg m-2. The study was approved by the Local Ethics Committee and written informed consent from patients was obtained. We conducted a parallel randomized controlled trial with patients scheduled for elective sleeve gastrectomy. The trial was registered in ClinicalTrials with a number NCT04959149. Randomization and allocation to trial groups were carried out using the envelope method. The primary outcomes were the time of intubation and the first pass success of endotracheal intubation. 76 patients (routine intubation n = 36, face-to-face intubation n = 40) were included in the study with no dropouts. The intubation success rates were 82.5% versus 100%, mean intubation time was 17.1 ± 18 seconds versus 29 ± 11 seconds and the need for additional maneuvers (backward, upward, rightward pressure or flexing the neck) was 15% versus 19.5%, in face-to-face and routine intubation, respectively. No injuries to teeth or mucosa have been reported. There were no incidents of desaturation below 92% or other complications associated with intubation. Face-to-face intubation is shorter than the routine intubation in obese patients. This method may be an alternative to standard intubation in case of airway management in morbidly obese patients in semi-erect position; however, it requires both training and practice.

Comparison of the ‘D blade’ with the conventional blade of C-MAC® for endotracheal intubation in patients with simulated limitation of cervical movements

Background: The C-MAC® videolaryngoscope enables better visualisation of glottis for rapid and successful endotracheal intubation. Aim: The present study is aimed at comparing the conventional C-MAC® blade with new ‘D’ blade in patients with simulated cervical spine immobilisation. Methods: This was a prospective, randomised and crossover study. Eighty patients were randomised to one of two groups: Group CD or Group DC (CD - Conventional blade first, DC-D blade first). Patients in each group had laryngoscopy performed with both the blades in random order following which the patient’s trachea was intubated using the blade used for second laryngoscopy. Results: The mean (± SD) age was 39.4 (± 12.4) years. There were 33 male and 47 female patients. The average weight was 57.2 kg. No patient had a grade 3 or 4 view at initial laryngoscopy (without cervical spine immobilisation) with Macintosh blade and hence not excluded. 75 patients had a grade 1 view and 5 patients with grade 2 view with D blade whereas 63 patients had a grade 1 view and 17 patients had a grade 2 view with the conventional blade. The difference was clinically and statistically very significant. The time taken for laryngoscopy and intubation, and the overall satisfaction score did not differ between the groups. Conclusions: The D blade of C-MAC® videolaryngoscope enables better visualisation of glottis as compared to the conventional blade, for endotracheal intubation in patients with simulated limitation of cervical movements. The time taken for laryngoscopy, endotracheal intubation and the overall satisfaction score did not differ between the two blades. Keywords: C-MAC®, D blade, videolaryngoscope, cervical immobilisation

Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting.

Endotracheal intubation of very low birth weight infants (VLBWI) is an essential procedure in NICUs, but intubation experience is often limited. Video laryngoscopy (VL) has been described as a tool to improve intubation skills, but studies in high-risk neonatal populations are limited. The aim of this study was to investigate whether VL is a useful tool to support airway management in high-risk premature infants with inexperienced operators. In this crossover study predominantly inexperienced participants were exposed in random sequence to VL and conventional direct laryngoscopy (DL) for endotracheal intubation of a VLBWI simulation manikin to measure total time, number of attempts, success rate on first attempt, view of the vocal cords and perceived subjective safety until successful intubation. In our study group of 94 participants there was no significant difference in the total time (mean VL: 34 s (±24 s); DL: 37 s (±28 s), p = 0.246), while the number of intubation attempts using VL was significantly lower (mean VL: 1.22 (±0.53); DL: 1.37 (±0.60), p = 0.023). Success rate of VL during the first attempt was significantly higher (VL: 84%; DL 69%, p = 0.016), view of the vocal cords was significantly better and perceived subjective safety was increased using VL. Our study results suggest that with rather inexperienced operators, VL can be a useful tool to increase rate of successful endotracheal intubation of VLBWI and to improve their perceived safety during the procedure, which may have an impact on mortality and/or morbidity.

Anesthesia in a Patient with Stiff Person Syndrome: About A Case

Stiff person syndrome, characterized by stiffness in the muscles of the torso and extremities and painful episodic spasms, is a rare autoimmune neurological disease. Here we present successful endotracheal intubation. A 46- year-old man underwent surgery with ASA-III classification due to necrosectomy following fasciitis necrotizing. After induction of anesthesia using fentanil propofol and rocuronium, tracheal intubation proceeded easily without neuromuscular blockade. Anesthesia was maintained with isoflurane and an O 2 /air mixture. After an uneventful intraoperative period, the patient was extubated. The evolution was marked by death following a septic shock. Although the mechanism is unclear, neuromuscular blockers and volatile anesthetics can cause prolonged hypotonia in patients with stiff-man syndrome.

Borescope assisted intubation through Fekry intubating airway; a prospective observational study

Objectives: Airway management starts from the use of a nasal prong for oxygenation to successful endotracheal intubation for the ventilation. Intubation has been one of the most studied subject in anesthesiology. Various methods and gadgets have been advocated for its success. We aimed to evaluate the rate of successful intubations using the ordinary borescope and a stylet through Fekry Oral Intubating Airway (FOIA) in a manikin.&#x0D; Methodology: This manikin-based study enrolled 35 trainees, who performed endotracheal intubation guided by the borescope and used FOIA as a conduit. Every trainee was allowed two attempts. The primary outcome was to assess the success rate of intubation. Secondary outcomes included the precise time to intubate, number of attempts, and the need for external manipulations.&#x0D; Results: Our results revealed that 62.9% of the participants performed the intubation successfully (success rate) and 51.43% succeeded to intubate the manikin in the first attempt. External manipulation was needed by 71.4% of the participants in the form of cricoid pressure or laryngeal movement to visualize the glottic view. The time needed for a successful intubation ranged from 16 to 120 sec with a median of 50 sec and a mean of 69.37 ± 42.26 sec.&#x0D; Conclusion: A combination of Fekry Oral Intubating Airway, a borescope and an intubating stylet can be used for endotracheal intubation in remote areas, where advanced airway management aids are not available.. Future studies are warranted to optimize this technique.&#x0D; Trial registration: The ethical approval was obtained from the Research Ethics Committee of Cairo University (Code: MD-79-2019), and registration of the trial was performed on www.clinicaltrials.gov with a registration number (NCT05094453).&#x0D; Key words: Visually assisted intubation, Borescope, Fekry Oral Intubating Airway.&#x0D; Citation: Youssef MMI, Kamel OY, Asswa AR, Kassem SM, Abdelhalim RA, Inas Farouk I. Borescope assisted intubation through Fekry intubating airway; a prospective observational study. Anaesth. pain intensive care 2022;26(6):799−802.&#x0D; DOI: 10.35975/apic.v26i6.2050