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Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table's height was adjusted at four points: the operator's umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table's height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures. [ABSTRACT FROM AUTHOR]

Alcohol withdrawal syndrome (AWS) is defined as the cessation or reduction in heavy and prolonged alcohol use within several hours to a few days of cessation. The recommended first-line therapy for AWS ranging from mild to severe or complicated remains benzodiazepines; in cases where benzodiazepines are not adequate in controlling persistent autonomic hyperactivity or anxiety, dexmedetomidine could be utilized. The possible advantage of dexmedetomidine compared to benzodiazepines is that it does not cause respiratory depression, thus reducing the risk of intubation and hospitalization in the ICUs, with the potential reduction in healthcare costs. The purpose of this systematic review and meta-analysis (PROSPERO CRD42018084370) is to evaluate the effectiveness and safety of dexmedetomidine as adjunctive therapy to the standard of care for the treatment of AWS. We retrieved literature from PubMed, EMBASE, and CENTRAL until 10 January 2024. Eligible studies were both randomized trials and nonrandomised studies with a control group, published in the English language and peer-reviewed journals. The primary outcome was tracheal intubation; secondary outcomes were (i) bradycardia and (ii) hypotension. A total of 3585 papers were retrieved: 2635 from EMBASE, 930 from Medline, and 20 from CENTRAL. After eliminating duplicates, 2960 papers were screened by title and abstract; 75 out of the 2960 papers were read in full text. The qualitative synthesis included nine of all manuscripts read in full text. The quantitative synthesis included eight studies for the primary outcome (tracheal intubation), seven for the secondary outcome bradycardia, and six for the secondary outcome hypotension. The meta-analysis showed that Dexmedetomidine, as adjunctive therapy, is not more effective than standard therapy in reducing the risk of tracheal intubation in AWS [RR: 0.57, 95% CI: 0.25–1.3, p = 0.15]. It also appears to be less safe than sedative therapy as it significantly increases the risk of bradycardia [RR: 2.68, 95% CI: 1.79–4.16, p = 0.0016]. Hypotension was not significantly different in patients who received dexmedetomidine [RR: 1.5, 95% CI: 0.69–3.49, p = 0.21]. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation in the Sellick and Trendelenburg position (ST position) can prevent pulmonary aspiration but increase the difficulty of tracheal intubation. We compared tracheal intubation using video and direct laryngoscopy in the ST position with direct laryngoscopy in the supine sniffing position to evaluate the overall intubation performance. Methods: One hundred and twenty patients were randomly assigned to three groups: direct laryngoscope in the supine sniffing position (control), direct laryngoscope in the ST position (ST direct), and video laryngoscope in the ST position (ST video). The primary outcome was the intubation time; secondary outcomes included the first attempt success rate of tracheal intubation, intubation difficulty scale score, operator's subjective assessment of intubation difficulty, and modified Cormack–Lehane grades. Results: The median intubation times were greater in the ST direct (36.0 s) and video (34.5 s) than the control (28.0 s) groups. The first attempt success rate decreased in the ST direct (77.5%) but not the video (95.0%) group compared with the control group (100%). Conclusions: The challenges of tracheal intubation in the ST position, aimed at reducing the risk of pulmonary aspiration, can be mitigated by using a video laryngoscope, despite slightly longer intubation times. [ABSTRACT FROM AUTHOR]

Background and Objective: Obesity is associated with difficult or failed intubation attempts, making general anesthesia challenging for anesthesiologists to perform. The purpose of this study was to evaluate and compare the efficacy of a McCoy laryngoscope and a C-MAC D-blade video laryngoscope for intubation in obese patients with a body mass index (BMI) ≥ 35 kg/m2. Methods: In total, 104 patients were randomly assigned to be intubated with a McCoy (McCoy group) or C-MAC D-blade video laryngoscope (C-MAC group). The primary outcome was intubation time. The secondary outcomes were vocal cord exposure time, vocal cord passage time, proportion of successful intubation, mask ventilation scale, intubation difficulty scale (IDS), percentage of glottis opening (POGO) score, and hemodynamic variables. Results: Although the intubation time did not significantly differ, the C-MAC group showed shorter vocal cord exposure times and a higher rate of successful vocal cord exposure within 5 s. The IDS value was significantly lower in the C-MAC group than in the McCoy group. The proportion of patients who required an increase in lifting force during laryngoscopy was higher in the McCoy group than in the C-MAC group, which may explain the difference in MAP between the groups. Conclusions: Both the McCoy laryngoscope and the C-MAC D-blade video laryngoscope were useful during the intubation of obese patients. The C-MAC D-blade video laryngoscope might be more useful for obese patients in terms of hemodynamic stability. [ABSTRACT FROM AUTHOR]

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery. [ABSTRACT FROM AUTHOR]

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended. [ABSTRACT FROM AUTHOR]

Background: In recent years, videolaryngoscopy has increasingly been utilized as an alternative to fiberoptic bronchoscopy in awake intubation. Nonetheless, it remains uncertain whether videolaryngoscopy represents a viable substitute for fiberoptic bronchoscopy. We conducted this systematic review with a meta-analysis to compare videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. Methods: We systematically searched for all randomized controlled trials (RCTs) comparing videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically queried through August 2023. Our primary outcome measure was the duration of intubation. Secondary outcomes encompassed the rate of successful intubation on the initial attempt, failed intubation, patient-reported satisfaction, and any complications or adverse events potentially stemming from the intubation procedure. The Cochrane Risk of Bias Tool for RCTs was employed to evaluate all studies for evidence of bias. The GRADE approach was utilized to gauge the certainty of the evidence. Results: Eleven trials involving 873 patients were ultimately included in our review for data extraction. Meta-analysis demonstrated that videolaryngoscopy decreased the duration of intubation compared to fiberoptic bronchoscopy (SMD −1.9671 [95% CI: −2.7794 to −1.1548] p < 0.0001), a finding corroborated in subgroup analysis by the type of videolaryngoscope (SMD −2.5027 [95% CI: −4.8733 to −0.1322] p = 0.0385). Additionally, videolaryngoscopy marginally lowered the risk of experiencing a saturation below 90% during the procedure (RR −0.7040 [95% CI: −1.4038 to −0.0043] p = 0.0486). No statistically significant disparities were observed between the two techniques in terms of failed intubation, initial successful intubation attempt, or sore throat/hoarseness. With regard to patient-reported satisfaction, a pooled analysis was precluded due to the variability in evaluation methods employed across the trials to assess this outcome. Lastly, trial sequential analysis (TSA) conducted for intubation time (primary outcome) affirmed the conclusiveness of this evidence; TSA performed for secondary outcomes failed to yield conclusive evidence, indicating the necessity for further trials. Conclusions: Videolaryngoscopy for awake tracheal intubation diminishes intubation time and the risk of experiencing a saturation below 90% compared to fiberoptic bronchoscopy. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the usefulness of an attachable video laryngoscope (AVL) by attaching a camera and a monitor to a conventional Macintosh laryngoscope (CML). Normal and tongue edema airway scenarios were simulated using a manikin. Twenty physicians performed tracheal intubations using CML, AVL, Pentax Airwayscope® (AWS), and McGrath MAC® (MAC) in each scenario. Ten physicians who had clinical experience in using tracheal intubation were designated as the skilled group, and another ten physicians who were affiliated with other departments and had little clinical experience using tracheal intubation were designated as the unskilled group. The time required for intubation and the success rate were recorded. The degree of difficulty of use and glottic view assessment were scored by participants. All 20 participants successfully completed the study. There was no difference in tracheal intubation success rate and intubation time in the normal airway scenario in both skilled and unskilled groups. In the experienced group, AWS had the highest success rate (100%) in the tongue edema airway scenario, followed by AVL (60%), MAC (60%), and CML (10%) (p = 0.001). The time required to intubate using AWS was significantly shorter than that with AVL (10.2 s vs. 19.2 s) or MAC (10.2 s vs. 20.4 s, p = 0.007). The difficulty of using AVL was significantly lower than that of CML (7.8 vs. 2.8; p < 0.001). For the experienced group, AVL was interpreted as being inferior to AWS but better than MAC. Similarly, in the unskilled group, AVL had a similar success rate and tracheal intubation time as MAC in the tongue edema scenario, but this was not statistically significant. The difficulty of using AVL was significantly lower than that of CML (8.8 vs. 3.3; p < 0.001). AVL may be an alternative for VL. [ABSTRACT FROM AUTHOR]

Laryngoscopy for tracheal intubation has been developed for many decades. Among various conventional laryngoscopes, videolaryngoscopes (VLs) have been applied in different patient populations, including difficult airways. The safety and effectiveness of VLs have been repeatedly studied in both normal and difficult airways. The superiority of VLs then has been observed and is advocated as the standard of care. In contrast to laryngoscopy, the development of video-assisted intubating stylet (VS, also named as styletubation) was noticed two decades ago. Since then, sporadic clinical experiences of use have appeared in the literature. In this review article, we presented our vast use experiences of the styletubation (more than 55,000 patients since 2016). We found this technique to be swift (the time to intubate from 3 s to 10 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction and fast learning curve for the novice trainees) in both normal and difficult airway scenarios. We, therefore, propose that the styletubation technique can be feasibly applied as universal routine use for tracheal intubation. [ABSTRACT FROM AUTHOR]

Objective: This retrospective cohort study was performed to clarify the association between intubation in the delivery room and the mortality after pulmonary hemorrhage in very low birth weight infants (VLBWIs) during hospitalization. Methods: The study participants were screened from the VLBWIs admitted to the neonatal intensive care unit (NICU) of the Children's Hospital Affiliated to Nanjing Medical University from 31 July 2019 to 31 July 2022. The newborns who ultimately were included were those infants who survived until pulmonary hemorrhage was diagnosed. These subjects were divided into the intubation-at-birth group (n = 29) and the non-intubation-at-birth group (n = 35), retrospectively. Results: Univariate analysis found that the intubation group had a higher mortality and shorter hospital stay than the non-intubation group (p < 0.05) (for mortality: 25/29 (86.21%) in intubation group versus 14/35 (40.00%) in non-intubation group). By multivariate analysis, the result further showed that intubation in the delivery room was related to shorter survival time and higher risk of death (adjusted hazard ratio: 2.341, 95% confidence interval: 1.094–5.009). Conclusions: Intubation at birth suggested a higher mortality in the VLBWIs when pulmonary hemorrhage occurred in the NICU. [ABSTRACT FROM AUTHOR]

Simple Summary: Rabbit endotracheal intubation is often challenging for anesthetists. Employing an endoscope guided by adjusting the angle of head extension can significantly aid anesthetists in accurately locating and executing rabbit endotracheal intubation, reducing the risk of breathing difficulties during the process. This study explores how specific head extension angles impact endotracheal intubation success rates and time taken. The findings recommend utilizing angles of 110 and 120 degrees for optimal rabbit head extension during endotracheal intubation to enhance success rates and efficiency. 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. [ABSTRACT FROM AUTHOR]

We report the case of a 61-year-old woman who was referred to the Oral Surgery and Implantology Unit of the University Hospitals of Geneva to take care of edentulous sites after the dental avulsions of teeth 11 and 21 following traumatic shock due to endotracheal intubation under general anesthesia. The dental history revealed that the patient had a history of generalized chronic periodontitis that had been treated several years earlier. The treatment consisted, for the first time to our knowledge, of the immediate insertion of implants at sites 11 and 21 with simultaneous bone augmentation in a single surgical procedure and immediate restorations. [ABSTRACT FROM AUTHOR]

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788–54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815–0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837–0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak. [ABSTRACT FROM AUTHOR]

Background: The use of laryngeal masks in the surgical treatment of infantile lacrimal duct stenosis is controversial due to the potential risk of aspiration. Aims: This study investigates airway procedures in children aged <6 years for surgery of lacrimal duct stenosis in a tertiary care university hospital. Methods: After institutional approval, airway procedures, duration of anesthesiological measures, and airway-related complications were retrospectively analyzed. Patients were divided into two groups according to the airway procedures used (endotracheal tube [ET] vs. laryngeal mask [LMA] airway). Associations were calculated using the Chi-square test or Mann-Whitney U-test. Results: Clinical data of 84 patients (ET n = 36 [42.9%] vs. LMA n = 48 [57.1%]) were analyzed. There were no significant differences in surgical treatment, age distribution, and pre-existing conditions between the groups. None of the patients showed evidence of tracheal aspiration or changes in measured oxygen saturation. LMA airway shortened time for anesthesia induction (p = 0.006) and time for recovery/emergence period (p = 0.03). In contrast, the time to discharge from the recovery room was significantly prolonged using LMA (p = 0.001). A total of 7 adverse events were recorded. Five of these were directly or indirectly related to ET (laryngo-/bronchospasm; muscle relaxant residual). Conclusions: LMA airway for infantile lacrimal duct stenosis seems to be a safe procedure and should be used in appropriate pediatric patients due to its lower invasiveness, low complication rate, and time savings. [ABSTRACT FROM AUTHOR]

The aim of the study was to test the hypothesis that the results obtained with three different types of video laryngoscopes (UESCOPE VL-400, I-View, Non-Channeled Aitraq) with and without an endotracheal stylet should be better than the results obtained with a Macintosh laryngoscope in a simulated out-of-hospital scenario by a person without clinical experience. Primary outcome measures were the time taken to successfully achieve tracheal intubation (TI). Secondary outcomes included the grade of glottic view (Cormack and Lehane grades 1–4), the incidence of successful TI, the number of audible dental clicks indicating potential dental damage, the level of effort required to perform TI, and the operator's comfort during the procedure. The time required to achieve tracheal intubation successfully was significantly longer with the Macintosh laryngoscope and Airtraq than with the other video laryngoscopes. The use of the stylet significantly reduced the time required for tracheal intubation with the Macintosh laryngoscope (21.8 sec. vs. 24.0 sec., p = 0.026), UESCOPE VL 400 (18.1 sec. vs. 23.4 sec., p = 0.013), and Airtraq (22.7 sec. vs. 34.5 sec., p < 0.001). There were no significant differences in intubation time when using the I-View with or without stylets. No differences were observed in the Cormack–Lehane grading. The success rate of intubation was 100% for the Macintosh and I-View laryngoscopes used with or without stylets and for the UESCOPE VL 400 and Airtraq laryngoscopes used with stylets. Without stylets, the success rate of intubation was 96.6% for the UESCOPE VL 400 and 86.6% for the Airtraq. There were no significant differences in the risk of dental damage between the Macintosh, UESCOPE VL 400, I-View, and Airtraq laryngoscopes, regardless of the use of stylets (without and with stylets). The use of stylets significantly reduced dental damage only for the Airtraq laryngoscope: 8 (26.6%) vs. 2 (6.6%). Statistically significant differences in perceived exertion were observed between the mentioned laryngoscopes, both with and without stylets. However, there were no differences in the comfort of use between the laryngoscopes, regardless of the use of stylets (without and with stylets. The use of stylets led to better comfort in the case of the Macintosh (2.5 vs. 3, p = 0.043) and UESCOPE VL 400 (2 vs. 3, p = 0.008) laryngoscopes. In our study, the I-View and UESCOPE VL-400 video laryngoscopes provided better intubation results than the Macintosh laryngoscope in terms of time needed to intubate, glottis visibility, and reduction in dental damage. The use of the stylet did not significantly improve the intubation results compared to the results obtained in direct laryngoscopy. Due to the small study group and the manikin model, additional studies should be performed on a larger study group. [ABSTRACT FROM AUTHOR]

Simulation for airway management allows for acquaintance with new devices and techniques. Endotracheal intubation (ETI), most commonly performed with direct laryngoscopy (DL) or video laryngoscopy (VLS), can be achieved also with combined laryngo-bronchoscopy intubation (CLBI). Finally, an articulating video stylet (ProVu) has been recently introduced. A single-center observational cross-sectional study was performed in a normal simulated airway scenario comparing DL, VLS-Glidescope, VLS-McGrath, CLBI and ProVu regarding the success rate (SR) and corrected time-to-intubation (cTTI, which accounts for the SR). Up to three attempts/device were allowed (maximum of 60 s each). Forty-two consultants with no experience with ProVu participated (15 ± 9 years after training completion). The DL was significantly faster (cTTI) than all other devices (p = 0.033 vs. VLSs, and p < 0.001 for CLBI and Provu), no differences were seen between the two VLSs (p = 0.775), and the VLSs were faster than CLBI and ProVu. Provu had a faster cTTI than CLBI (p = 0.004). The DL and VLSs showed similar SRs, and all the laryngoscopes had a higher SR than CLBI and ProVu at the first attempt. However, by the third attempt, the SR was not different between the DL/VLSs and ProVu (p = 0.241/p = 0.616); ProVu was superior to CLBI (p = 0.038). In consultants with no prior experience, ProVu shows encouraging results compared to DL/VLSs under simulated normal airway circumstances and further studies are warranted. [ABSTRACT FROM AUTHOR]

Background: Patients under cardiopulmonary resuscitation (CPR) are at high risk of aspirating gastric contents. Nasogastric tube insertion (NGTI) after tracheal intubation is usually performed blindly. This sometimes causes laryngopharyngeal mucosal injury (LPMI), leading to severe bleeding. This study clarified the incidence of LPMI due to blind NGTI during CPR. Methods: We retrospectively analyzed 84 patients presenting with cardiopulmonary arrest on arrival, categorized them into a Smooth group (Smooth; blind NGTI was possible within 2 min), and Difficult group (blind NGTI was not possible), and consequently performed video laryngoscope-assisted NGTI. The laryngopharyngeal mucosal condition was recorded using video laryngoscope. Success rates and insertion time for the Smooth group were calculated. Insertion number and LPMI scores were compared between the groups. Each regression line of outcome measurements was obtained using simple regression analysis. We also analyzed the causes of the Difficult group, using recorded video laryngoscope-assisted videos. Results: The success rate was 78.6% (66/84). NGTI time was 48.8 ± 4.0 s in the Smooth group. Insertion number and injury scores in the Smooth group were significantly lower than those in the Difficult group. The severity of LPMI increased with NGT insertion time and insertion number. Conclusions: Whenever blind NGTI is difficult, switching to other methods is essential to prevent unnecessary persistence. [ABSTRACT FROM AUTHOR]

Background: The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios. Methods: After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min. Results: In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02). Conclusion: The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial. [ABSTRACT FROM AUTHOR]

This meta-analysis was performed to determine whether an indirect laryngoscope is more advantageous than a direct laryngoscope for tracheal intubation in the setting of a difficult pediatric airway. Data on the intubation failure and intubation time during tracheal intubation were extracted from prospective and retrospective studies identified through a comprehensive literature search. Data from 10 individual articles (11 trials) were combined, and a DerSimonian and Laird random-effects model was used to calculate either the pooled relative risk (RR) or the weighted mean difference (WMD) and the corresponding 95% confidence interval (CI). Meta-analysis of the 10 articles indicated that the intubation failure of tracheal intubation with an indirect laryngoscope was not significantly different from that of a direct laryngoscope in patients with a difficult airway (RR 0.86, 95% CI 0.51–1.46; p = 0.59; Cochrane's Q = 50.5; I2 = 82%). Intubation time with an indirect laryngoscope was also similar to that with a direct laryngoscope (WMD 4.06 s; 95% CI −1.18–9.30; p = 0.13; Cochrane's Q 39.8; I2 = 85%). In conclusion, indirect laryngoscopes had the same intubation failure and intubation time as direct laryngoscopes in pediatric patients with a difficult airway. Currently, the benefits of indirect laryngoscopes have not been observed in the setting of a difficult pediatric airway. [ABSTRACT FROM AUTHOR]

Background: During endotracheal intubation, there is a 10% incidence of difficult laryngoscopy, which may result in serious complications. It is important to obtain as much information about the visibility of laryngeal structures before the patient is anaesthetised. Performing awake (video-) laryngoscopy on a patient is uncomfortable and can trigger gagging and coughing reflexes, making visualisation nearly impossible. The objective of this study is to evaluate the effectiveness of a soft mist spray device for airway anaesthesia during awake (video-) laryngoscopy. Methods: Twenty healthy volunteers inhaled through the Trachospray device, which was placed in their mouths. Two 2 mL syringes containing lidocaine at 4% were sprayed into the airway during inspiration. After several minutes, the subjects were asked to perform a videolaryngoscopy on themselves until the glottic structures and the vocal cords were visible. Upon completion of the procedure, all participants were asked to fill out a feedback form. Results: The duration of the videolaryngoscopy to visualisation of the vocal cords averaged 17 ± 13 s. After analysing the data, three distinct groups emerged as follows: Group 1 (70% of participants) showed no response, allowing for easy insertion of the videolaryngoscope. Group 2 (25% of participants) exhibited a light response but still permitted easy insertion and visualisation. One patient demonstrated a clear response with noticeable laryngeal contraction, requiring slightly more effort and discomfort for insertion. In 80% of the participants, the laryngeal structures were visualised according to Cormack–Lehane grade 1. All participants reported a high level of comfort, with an average rating of NRS 8. The anaesthesiologist assessed the level of anaesthesia as good to very good. No adverse events were observed. Conclusions: The Trachospray provided good, reliable, comfortable, and safe topical anaesthesia for awake videolaryngoscopy. This enables a direct visual assessment of the airway and may assist in making decisions regarding airway management for tracheal intubation. [ABSTRACT FROM AUTHOR]

Background and Objective: Placing the laryngoscope blade directly under the epiglottis (known as the direct view (DV) method) during videolaryngoscopy offers a superior view of the glottis when compared to the indirect method of lifting the epiglottis by positioning the Macintosh blade tip over the vallecula. While there are few studies comparing glottic views using Miller and Macintosh blades in pediatric patients, we have not come across such a study in adults. In this study, we aimed to compare the effectiveness and hemodynamic responses of the Miller laryngoscope and the McGrath-MAC videolaryngoscope (VL) in visualizing the glottic opening using the DV method. Material and Methods: A prospective study was conducted between August and December 2022 at XXX Hospital on 85 patients scheduled for surgical procedures involving endotracheal intubation. Patients were divided into two groups: Miller laryngoscope (Group M) and McGrath-MAC videolaryngoscope (Group VL) and intubated using the direct lifting method of the epiglottis. Hemodynamic responses before and after induction, as well as during laryngoscopy, intubation time, number of attempts, Cormack and Lehane (C&L) score, percentage of glottic opening (POGO), duration of the view of the opening, and need for external laryngeal pressure during intubation were recorded. Results: Both laryngoscopes showed similar effectiveness in terms of POGO and C&L score when used with the direct lifting method of the epiglottis. The median POGO values according to the DV method were 80% in Group M and 70% in Group VL (p = 0.099). Hemodynamic responses, intubation time, number of attempts, duration of view of the glottis opening, and the need for external laryngeal pressure were similar between the groups. Conclusions: Due to its ability to provide effective intubation conditions, we believe that the McGrath-MAC VL, when used with the indirect view method, can also be utilized in anesthesia practices alongside the DV method. [ABSTRACT FROM AUTHOR]

Simple Summary: This report describes three successful cases of gastrointestinal foreign body removal from psittacine birds via endoscopy. Our findings suggest that a potentially effective endoscopic removal approach may involve ventral recumbency with anesthesia via a mask or endotracheal intubation when dealing with a limited number of blunt foreign bodies within a short operation time. This case report offers valuable insights and practical guidance for the efficient and safe removal of foreign bodies in avian patients. Although the use of incision-free endoscopy for foreign body (FB) removal in dogs and cats has been extensively documented, its application in birds remains limited. Thus, we present the endoscopic removal of gastrointestinal (GI) FBs from psittacine birds, employing different patient positioning and anesthesia methods. Two blue-and-yellow macaws (Ara ararauna) and a Triton cockatoo (Cacatua galerita triton) were examined. X-ray imaging revealed FBs situated in the proventriculus in each case. The FBs, all identified as feeding tubes, were safely removed using grasping forceps during the endoscopic procedure, and no severe complications occurred. Based on the outcomes of each operation, the most suitable patient position may be ventral recumbency rather than dorsal recumbency, with the use of a mask or endotracheal intubation, depending on the anticipated operation time. However, a larger number of cases would be necessary to confirm the optimal patient positioning and anesthesia method. [ABSTRACT FROM AUTHOR]

We sought to determine whether blade size influences the first-pass success (FPS) rate when performing endotracheal intubation (ETI) with a C-MAC video laryngoscope (VL) in emergency department (ED) patients. This single-center, retrospective, observational study was conducted between August 2016 and July 2022. A total of 1467 patients was divided into two categories based on the blade size used during the first ETI attempt: blade-3 (n = 365) and blade-4 groups (n = 1102). The primary outcome was the FPS rate. The secondary outcomes included the glottic view, multiple attempt rate, and ETI-related complications. We used propensity score matching to reduce the potential confounders between the two groups. Among these, 363 pairs of matched propensity scores were generated. The FPS rate did not differ between the blade-3 (84.8%) and blade-4 groups (87.3%) in the matched cohort (p = 0.335). The multiple attempt rate did not differ significantly between groups (p = 0.289) and was 3.9% and 2.5% in the blade-3 and blade-4 groups, respectively. The difficult glottic view (11.3 vs. 6.9%, p = 0.039) and complication rates (15.4% vs. 10.5%, p = 0.047) were significantly higher in the blade-3 group than in the blade-4 group. The FPS rates of ETI with the blade-3 and blade-4 groups in adult patients in the ED did not differ significantly. [ABSTRACT FROM AUTHOR]

Bronchopulmonary dysplasia (BPD) is a major respiratory condition mainly affecting premature infants. Although its occurrence is global, risk factors may differ regionally. This study, involving 3111 infants with birth weight ≤ 1500 gm or gestational age (GA) < 30 weeks, aimed to identify risk factors for BPD and BPD/mortality in Taiwan using data from the Taiwan Neonatal Network. The BPD criteria were based on the National Institute of Child Health and Human Development standards. Average GA was 27.5 weeks, with 23.7% classified as small for GA (SGA). Multivariate analysis highlighted low GA, low birth weight, and other perinatal factors as significant risk indicators for BPD. For moderate-to-severe BPD, additional risk factors included male gender and SGA, endotracheal intubation (ETT) or cardiopulmonary cerebral resuscitation (CPCR) in initial resuscitation. In the moderate-to-severe BPD/death group, SGA and ETT or CPCR in initial resuscitation remained the only additional risk factors. The study pinpoints male gender, SGA and ETT or CPCR as key risk factors for moderate-to-severe BPD/death in low-birth-weight infants in Taiwan, offering a basis for focused interventions and further research. [ABSTRACT FROM AUTHOR]

Background: Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position. Methods: This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients. Results: Sixty patients with a median age of 37 [inter-quartile range (IQR): 29–44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5–50.8] kg/m2. The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8–228.8] seconds (s) in the lateral position, compared to 214.5 [181.8–280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045). Conclusions: In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway. [ABSTRACT FROM AUTHOR]

(1) Background: In the last few years, many randomized controlled trials (RCTs) have compared direct Macintosh laryngoscopy with McGrath videolaryngoscopy in order to assess the potential benefits of the latter; the results were sometimes controversial. (2) Methods: We conducted a comprehensive literature search to identify our articles according to inclusion and exclusion criteria: to be included, each study had to be a prospective randomized trial or comparison between the McGrath videolaryngoscope and the Macintosh laryngoscope in an adult population. We did not include manikin trials or studies involving double-lumen tubes. (3) Results: 10 studies met the inclusion criteria necessary. In total, 655 patients were intubated with the McGrath and 629 with the Macintosh. In total, 1268 of 1284 patients were successfully intubated, showing equivalent results for the two devices: 648 of 655 patients with the McGrath videolaryngoscope and 620 of 629 patients with the Macintosh laryngoscope. No differences were noted in terms of hemodynamic changes or the incidence of adverse events. (4) Conclusions: We can assert that the McGrath videolaryngoscope and Macintosh laryngoscope, even if with equivalent tracheal intubation results, supplement each other. [ABSTRACT FROM AUTHOR]

Aim: To explore what factors determine communication with awake intubated critically ill patients from the point of view of critical care nursing professionals. Background: Impaired communication frequently affects mechanically ventilated patients with artificial airways in the intensive care unit. Consequences of communication breaches comprise emotional and ethical aspects as well as clinical safety, affecting both patients and their conversation partners. Identification of determining factors in communication with awake intubated patients is needed to design effective action strategies. Design: A qualitative phenomenological approach was used. Methods: Semi-structured interviews were used as the data collection method. A total of 11 participants from three intensive care units of three Majorcan public hospitals, selected by purposive sampling, were interviewed. Findings: Three major themes regarding the communication determinants of the awake intubated critically ill patients were identified from the interviewees' statements: factors related to the patient (physical and cognitive functionality to communicate, their relational and communicative style and their personal circumstances), to the context (family presence, ICU characteristics, workload, availability/adequacy of communication aids, features of the messages and communication situations) and, finally, those related to the professionals themselves (professional experience and person-centredness). Conclusions: The present study reveals determinants that influence communication with the awake intubated patient, as there are attitudes and professional beliefs. Relevance to clinical practice: The discovery of relations between different kinds of determinants (of patient, context or professionals) provides a multi-factor perspective on the communicative problem which should be considered in the design of new approaches to improve communicative effectiveness. This study is reported according to the COREQ checklist. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation in critical care is a high-risk procedure requiring significant expertise and airway strategy modification. We hypothesise that awake tracheal intubation is associated with a lower incidence of severe adverse events compared to standard tracheal intubation in critical care patients. Methods: Records were acquired for all tracheal intubations performed from 2020 to 2022 for critical care patients at a tertiary hospital. Each awake tracheal intubation case, using a videolaryngoscope with a hyperangulated blade (McGrath® MAC X-Blade), was propensity matched with two controls (1:2 ratio; standard intubation videolaryngoscopy (VL) and direct laryngoscopy (DL) undergoing general anaesthesia). The primary endpoint was the incidence of adverse events, defined as a mean arterial pressure of <55 mmHg (hypotension), SpO2 < 80% (desaturation) after sufficient preoxygenation, or peri-interventional cardiac arrest. Results: Of the 135 tracheal intubations included for analysis, 45 involved the use of an awake tracheal intubation. At least one adverse event occurred after tracheal intubation in 36/135 (27%) of patients, including awake 1/45 (2.2%; 1/1 hypotension), VL 10/45 (22%; 6/10 hypotension and 4/10 desaturation), and DL 25/45 (47%; 10/25 hypotension, 12/25 desaturation, and 3/25 cardiac arrest; p < 0.0001). Conclusions: In this retrospective observational study of intubation practices in critical care patients, awake tracheal intubation was associated with a lower incidence of severe adverse events than anaesthetised tracheal intubation. [ABSTRACT FROM AUTHOR]

A wide range of airway devices and techniques have been created to enhance the safety of airway management. However, airway management remains a challenge. All techniques are susceptible to failure. Therefore, it is necessary to have and know the greatest number of alternatives to treat even the most challenging airway successfully. The aim of this narrative review is to describe some new devices, such as video laryngeal masks, articulated stylets, and non-standard techniques, for laryngeal mask insertion and endotracheal intubation that are not applied in daily practice, but that could be highly effective in overcoming a difficulty related to airway management. Artificial intelligence and 3D technology for airway management are also discussed. [ABSTRACT FROM AUTHOR]

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research. [ABSTRACT FROM AUTHOR]

Here, we report the perioperative management of a clinical case of a 6 year, 5 month old girl suffering from Beckwith–Wiedemann syndrome undergoing a partial glossectomy procedure in a patient with surgical indication for obstructive sleep apnea syndrome (OSAS), difficulty swallowing, feeding, and speech. On surgery day, Clonidine (4 µg/kg) was administered. Following this, a general anesthesia induction was performed by administering Sevoflurane, Fentanyl, continuous intravenous Remifentanil, and lidocaine to the vocal cords, and a rhinotracheal intubation with a size 4.5 tube was carried out. Before starting the procedure, a block of the Lingual Nerve was performed with Levobupivacaine. Analgosedation was maintained with 3% Sevoflurane in air and oxygen (FiO2 of 40%) and Remifentanil in continuous intravenous infusion at a rate of 0.08–0.15 µg/kg/min. The surgical procedure lasted 2 h and 32 min. At the end of the surgery, the patient was under close observation during the first 72 h. In the pediatric patient with Beckwith–Wiedemann syndrome submitted to major maxillofacial surgery, the difficulty in managing the airways in the preoperative phase during intubation and in the post-operative phase during extubation should be considered. [ABSTRACT FROM AUTHOR]

Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results. [ABSTRACT FROM AUTHOR]

Introduction: Dental injuries during anesthesia, especially when advanced airway management is required, represent a legal problem. Factors such as poor dental condition and excessive pressure during intubation contribute to dental damage. The maxillary central incisors are commonly affected. Objective: The objective of this review is to know the incidence of dental injuries in adults undergoing anesthesia that requires airway management. Materials and Methods: The search was performed in MEDLINE (through Pubmed), ClinicalTrials.gov, Scopus, LILACS (through the Virtual Health Library Regional Portal), and SciELO for all available literature on the subject up to December 2022. Inclusion criteria involved articles that studied patients aged 18 years or older who underwent general anesthesia requiring airway management with tracheal intubation or insertion of a laryngeal mask airway. Results: Of all the articles, nine report dental injury associated with the type of airway management. Only one article does not have dental injury. Discussion: This study addresses dental injuries related to tracheal intubation during general anesthesia. Although techniques are used to prevent them, these injuries still occur. Laryngoscopy, especially with support on the upper central incisors, can cause damage to the teeth. Conclusions: It is important that the anesthesiologist is aware of dental trauma and that orotracheal intubation or the placement of the laryngeal mask airway is performed systematically and rigorously, always considering the patient's dentition to choose the best approach in each specific situation. [ABSTRACT FROM AUTHOR]

Supraglottic airway devices are currently widely used for airway management both for anaesthesia and emergency medicine. First-generation SADs only had a ventilation channel and did not provide protection from possible aspiration of gastric content if regurgitation occurred. Second-generation SADs are equipped with a gastric channel to allow the insertion of a gastric catheter and suctioning of gastric content. Additionally, the seal was improved by a change in the shape of the cuff. Some second-generation SADs were also designed to allow for intubation through the lumen using fiberscopes. Although the safety and efficacy of use of SADs are very high, there are still some issues in terms of providing an adequate seal and protection from possible complications related to misplacement of SAD. New SADs which allow users to choose the insertion scope and control the position of SAD can overcome those problems. Additionally, the Video Laryngeal Mask Airway may serve as an endotracheal intubation device, offering a good alternative to fibre-optic intubation through second-generation SADs. In this narrative review, we provide knowledge of the use of video laryngeal mask airways and the possible advantages of introducing them into daily clinical practice. [ABSTRACT FROM AUTHOR]

Background: The appropriate management of a "difficult airway" remains a challenge for novices and experienced anaesthetists. With the current available airway technologies, e.g., video laryngoscopy, flexible bronchoscopy (fibreoptic intubation (FOI)) for endotracheal intubation is decreasing, likely diminishing caregiver skills. We investigated whether bronchoscopy simulator training improved FOI skills. Methods: 72 volunteers, consisting of anaesthetists, anaesthesia residents, and nurses, performed six exercises on a bronchoscopy simulator. At baseline and after 12 months, the six exercises included one serious game (to train agility), two basic airways, and three difficult airways. After a baseline assessment, subjects were randomly allocated to the intervention group (with) or control group without bronchoscopy simulator training every six weeks for 10 min using a preloaded serious game. The primary outcome was the difference in the time to reach the carina after 12 months, as measured objectively by the simulator. The level of stress and FOI confidence after 12 months were secondary outcomes. Results: The control and intervention groups had a similar time to reach the carina in difficult airway cases and the reported stress levels, at baseline and 12 months, showed no difference. In contrast, the intervention group's self-reported confidence in FOI skills improved more. Conclusions: Although participants rated higher in confidence, practicing FOI skills on an airway simulator with an agility game did not increase their performance in simulated challenging airway instances. [ABSTRACT FROM AUTHOR]

Direct laryngoscopes and videolaryngoscopes are the dominant endotracheal intubation tools. The styletubation technique (using a video-assisted intubating stylet) has shown its advantages in terms of short intubation time, high success rate, less required stimulation, and operator satisfaction. The learning curve can be steep but is easily overcome if technical pitfalls are avoided. Conditions that make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, obesity, etc. In this clinical report, we present the effectiveness and efficiency of the routine use of the styletubation for tracheal intubation in a super-super-obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy. [ABSTRACT FROM AUTHOR]

Background: An inter-incisor gap <3 cm is considered critical for videolaryngoscopy. It is unknown if new generation GlideScope Spectrum™ videolaryngoscopes with low-profile hyperangulated blades might facilitate safe tracheal intubation in these patients. This prospective pilot study aims to evaluate feasibility and safety of GlideScopeTM videolaryngoscopes in severely restricted mouth opening. Methods: Feasibility study in 30 adults with inter-incisor gaps between 1.0 and 3.0 cm scheduled for ENT or maxillofacial surgery. Individuals at risk for aspiration or rapid desaturation were excluded. Results: The mean mouth opening was 2.2 ± 0.5 cm (range 1.1–3.0 cm). First attempt success rate was 90% and overall success was 100%. A glottis view grade 1 or 2a was achieved in all patients. Nasotracheal intubation was particularly difficult if Magill forceps were required (n = 4). Intubation time differed between orotracheal (n = 9; 33 (25; 39) s) and nasotracheal (n = 21; 55 (38; 94) s); p = 0.049 intubations. The airway operator's subjective ratings on visual analogue scales (0–100) revealed that tube placement was more difficult in individuals with an inter-incisor gap <2.0 cm (n = 10; 35 (29; 54)) versus ≥2.0 cm (n = 20; 20 (10; 30)), p = 0.007, while quality of glottis exposure did not differ. Conclusions: GlidescopeTM videolaryngoscopy is feasible and safe in patients with severely restricted mouth opening if given limitations are respected. [ABSTRACT FROM AUTHOR]

Airway management procedures, such as endotracheal intubation (ETI), pose a significant risk of aerosol generation, requiring robust personal protective equipment (PPE) against aerosol-generating procedures (AGP). This study aimed to assess the impact of PPE-AGP on intubation success rates, time to intubation, and glottic visualization using ETView and a standard Macintosh laryngoscope (MAC). A total of 52 physicians participated in this prospective, observational, randomized crossover study conducted in a medical simulation setting. Participants included COVID-19 patients with cardiac arrest scenarios with and without PPE-AGP who were intubated with ETView and MAC. During intubation without PPE-AGP, ETView showed a similar first-pass success rate (FPS) but had a shorter intubation time and better glottal hydration compared to MAC. In scenario B (with PPE-AGP), ETView outperformed MAC in FPS, initiation time, and glottic visualization. The use of PPE-AGP had little impact on ETView's performance. However, it negatively affected the Macintosh laryngoscope, reducing FPS and glottic visibility. Participants found intubation with ETView easier in both scenarios. In conclusion, as compared to the Macintosh laryngoscope, ETView demonstrated higher performance under the circumstances of the simulation, especially when PPE-AGP was used. [ABSTRACT FROM AUTHOR]

Simple Summary: Cancer patients appear to be more vulnerable to COVID-19. This vulnerability can be explained by an immune-compromised status inherent to oncological disease and antitumoral treatments. Additionally, nosocomial exposure associated with regular medical visits and oncological treatments in the hospital context also contribute to the frailty of this group. Previously published studies have reported a superior mortality in COVID-19 oncological patients as well as more severe clinical evolution, with higher rates of admission to the intensive care unit (ICU) and intubation. However, there are few studies only involving cancer patients with COVID-19 admitted to the ICU. Therefore, this analysis is important from an epidemiological and clinical point of view. Furthermore, the comparison of COVID-19 cancer patients admitted to the ICU with a control group (non-cancer patients) limits the confounding factors and helps to determine whether cancer is a risk factor for adverse outcomes in the intensive care setting. Cancer patients appear to be a vulnerable group in the COVID-19 pandemic. This study aims to compare clinical characteristics and outcomes of cancer and non-cancer patients with COVID-19 admitted to the ICU. All COVID-19 cancer patients (cases) admitted to a Portuguese ICU between March 2020 and January 2021 were included and matched on age, sex and comorbidities with COVID-19 non-cancer patients (controls); 29 cases and 29 controls were enrolled. Initial symptoms were similar between the two groups. Anemia was significantly superior among cases (76% vs. 45%; p = 0.031). Invasive mechanical ventilation (IMV) need at ICU admission was significantly higher among cases (48% vs. 7%; odds ratio (OR) = 12.600, 95% CI: 2.517–63.063, p = 0.002), but there were no differences for global need for IMV during all-length of ICU stay and mortality rates. In a multivariate model of logistic regression, the risk of IMV need at ICU admission among cases remained statistically significant (adjusted OR = 14.036, 95% CI: 1.337–153.111, p = 0.028). Therefore, compared to critical non-cancer patients, critical cancer patients with COVID-19 had an increased risk for IMV need at the moment of ICU admission, however, not for IMV need during all-length of ICU stay or death. [ABSTRACT FROM AUTHOR]

Aerosols and droplets have put healthcare workers performing airway management at high risk of contracting coronavirus disease 2019 (COVID-19). Experts have developed endotracheal intubation (ETI) guidelines and protocols to protect intubators from infection. We aimed to determine whether changes in the emergency department (ED) intubation protocol to prevent COVID-19 infection were associated with first-pass success (FPS) rates in ETI. We used data from the airway management registries in two academic EDs. The study was divided into pre-pandemic (January 2018 to January 2020) and pandemic (February 2020 to February 2022) periods. We selected 2476 intubation cases, including 1151 and 1325 cases recorded before and during the pandemic, respectively. During the pandemic, the FPS rate was 92.2%, which did not change significantly, and major complications increased slightly but not significantly compared with the pre-pandemic period. The OR for the FPS of applying infection prevention intubation protocols was 0.72 (p = 0.069) in a subgroup analysis, junior emergency physicians (PGY1 residents) had an FPS of less than 80% regardless of pandemic protocol implementation. The FPS rate of senior emergency physicians in physiologically difficult airways decreased significantly during the pandemic (98.0% to 88.5%). In conclusion, the FPS rate and complications for adult ETI performed by emergency physicians using COVID-19 infection prevention intubation protocols were similar to pre-pandemic conditions. [ABSTRACT FROM AUTHOR]

Given the limited availability of evidence-based methods for assessing the timing of extubation in intubated preterm infants, we aimed to standardize the extubation protocol in this single-center, retrospective study. To accomplish this, we established an extubation evaluation form to assess the suitability of extubation in preterm infants. The form comprises six indicators: improved clinical condition, spontaneous breath rate ≥ 30 breaths per minute, peak inspiratory pressure (PIP) ≤ 15 cmH2O, fraction of inspired oxygen (FiO2) ≤ 30%, blood pH ≥ 7.2, and mixed venous carbon dioxide tension (PvCO2) < 70 mmHg. Each positive answer is given one point, indicating a maximum of six points. We enrolled 41 intubated preterm infants (gestational age < 32 weeks, birth weight < 1500 g) who were receiving mechanical ventilation support for over 24 h. Among them, 35 were successfully extubated, and 6 were not. After completing the extubation evaluation form and adjusting for birth weight and postextubation device, we observed that the total score of the form was significantly associated with successful extubation; the higher the score, the greater the chance of successful extubation. Thus, we infer that the extubation evaluation form may provide a more objective standard for extubation assessment in preterm infants. [ABSTRACT FROM AUTHOR]

Many of the patients with COVID-19 have suffered respiratory distress requiring prolonged endotracheal intubation (ETI) resulting in laryngotracheal complication with an impact on breathing, phonation, and swallowing. Our aim is to describe laryngeal injuries diagnosed after ETI in patients with COVID-19 in a multicentre study. Methods: A prospective descriptive observational study was conducted from January 2021 to December 2021, including COVID-19 patients with laryngeal complications due to ETI diagnosed in several Spanish hospitals. We analyzed the epidemiological data, previous comorbidities, mean time to ICU admission and ETI, need for tracheostomy, mean time on invasive mechanical ventilation until tracheostomy or weaning, mean time in ICU, type of residual lesions, and their treatment. Results: We obtained the collaboration of nine hospitals during the months of January 2021 to December 2021. A total of 49 patients were referred. Tracheostomy was performed in 44.9%, being late in most cases (more than 7–10 days). The mean number of days of ETI until extubation was 17.63 days, and the main post-intubation symptoms were dysphonia, dyspnea, and dysphagia, in 87.8%, 34.7%, and 42.9%, respectively. The most frequent injury was altered laryngeal mobility, present in 79.6%. Statistically, there is a greater amount of stenosis after late ETI and after delayed tracheostomy, not observing the data with the immobility alterations. Conclusion: The mean number of days of ETI was long, according to the latest guidelines, with the need for several cycles of pronation. This long ETI may have had an impact on the increase of subsequent laryngeal sequelae, such as altered laryngeal mobility or stenosis. [ABSTRACT FROM AUTHOR]

Airway management is a common and critical procedure in acute settings, such as the Emergency Department (ED) or Intensive Care Unit (ICU) of hospitals. Many of the traditional physical examination methods have limitations in airway assessment. Point-of-care ultrasound (POCUS) has emerged as a promising tool for airway management due to its familiarity, accessibility, safety, and non-invasive nature. It can assist physicians in identifying relevant anatomy of the upper airway with objective measurements of airway parameters, and it can guide airway interventions with dynamic real-time images. To date, ultrasound has been considered highly accurate for assessment of the difficult airway, confirmation of proper endotracheal intubation, prediction of post-extubation laryngeal edema, and preparation for cricothyrotomy by identifying the cricothyroid membrane. This review aims to provide a comprehensive overview of the key evidence on the use of ultrasound in airway management. Databases including PubMed and Embase were systematically searched. A search strategy using a combination of the term "ultrasound" combined with several search terms, i.e., "probe", "anatomy", "difficult airway", "endotracheal intubation", "laryngeal edema", and "cricothyrotomy" was performed. In conclusion, POCUS is a valuable tool with multiple applications ranging from pre- and post-intubation management. Clinicians should consider using POCUS in conjunction with traditional exam techniques to manage the airway more efficiently in the acute setting. [ABSTRACT FROM AUTHOR]

Airway device-associated infections resulting from the cross-contamination of reusable laryngoscopes are one of the main causes of healthcare-associated infections. Laryngoscope blades are highly contaminated with various pathogens, including Gram-negative bacilli, which can cause prolonged hospitalization, high morbidity and mortality risks, the development of antibiotic-resistant microorganisms, and significant costs. Despite the Centers for Disease Control and Prevention and the American Society of Anesthesiologists' recommendations, this national survey of 248 Spanish anesthesiologists showed that there is great variability in the processing of reusable laryngoscopes in Spain. Nearly a third of the respondents did not have an institutional disinfection protocol, and 45% of them did not know the disinfection procedure used. Good practices for the prevention and control of cross-contamination can be ensured through compliance with evidence-based guidelines, education of healthcare providers, and audits of clinical practices. [ABSTRACT FROM AUTHOR]

Although experiments on intratracheal intubation for animals are essential for research, it remains challenging. This study aimed to validate an animal model using a flexible imaging guide system that can be conveniently and safely used as a new method to provide easy access to organs in small animals. PBS (Phosphate Buffered Saline) and PHMG (Polyhexamethylene guanidine) were administered by intratracheal intubation to 20 rodents (10 mice and 10 rats), and the changes in the lungs were observed. Results were verified using lung tissue histopathologic staining through the intratracheally administered material, which confirmed that 100% of changes in lung tissue occurred in the PHMG-injected group, where intubation was facilitated using the flexible imaging guide. The drug was conveniently and safely administered. The flexible-imaging-fiber-guide-based intratracheal drug injectable system may be conveniently used by researchers. It allows drugs to be administered quantitatively, suggesting its potential wide use in drug development and toxicity evaluation. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has necessitated changes in the safety protocols of endotracheal intubation at every level of care. This study aimed to compare the first-pass success rates (FPS) and intubation times (IT) of three video laryngoscopes (VL) and direct laryngoscopy (DL) for simulated COVID-19 patient emergency intubation (EI). Methods: The study was a prospective, randomized, crossover trial. Fifty-three active paramedics performed endotracheal intubation with the I-viewTM VL, UESCOPE® VL, ProVu® VL and Macintosh direct laryngoscope (MAC) wearing personal protective equipment for aerosol-generating procedures (PPE-AGP) on a manikin with normal airway conditions. Results: The longest IT was noted when the UESCOPE® (29.4 s) and ProVu® (27.7 s) VL were used. The median IT for I-view was 17.4 s and for MAC DL 17.9 s. The FPS rates were 88.6%, 81.1%, 83.0% and 84.9%, respectively, for I-view, ProVu®, UESCOPE® and MAC DL. The difficulty of EI attempts showed a statistically significant difference between UESCOPE® and ProVu®. Conclusions: The intubation times performed by paramedics in PPE-AGP using UESCOPE® and ProVu® were significantly longer than those with the I-view and Macintosh laryngoscopes. The use of VL by prehospital providers in PPE did not result in more effective EI than the use of a Macintosh laryngoscope. [ABSTRACT FROM AUTHOR]

Direct laryngoscopy and videolaryngoscopy are currently the dominant tools for endotracheal intubation. However, the video-assisted intubating stylet, a type of videolaryngoscopy, has been shown to offer some advantages over these tools, such as rapid intubation time, high first-attempt success rates, less airway stimulation, and high subjective satisfaction. On the other hand, this optical intubating technique also has some technical limitations that need to be addressed, including camera lens fogging, airway path disorientation, and obscured visibility due to secretions. In this clinical report, we describe an approach that improves the visibility of the glottis by introducing a suctioning catheter into the nasopharyngeal airway to enhance the efficiency and accuracy of using the intubating stylet technique for tracheal intubation. [ABSTRACT FROM AUTHOR]

Tension pneumothorax is a relatively rare complication after anesthetic induction that requires prompt diagnosis and treatment. Several handling errors related to intubation procedures or equipment and vigorous positive pressure ventilation are potentially important etiologies of tension pneumothorax in patients with underlying lung disease or in mechanically ventilated patients. We describe a case of tension pneumothorax observed after double-lumen tube (DLT) insertion followed by single-lumen tube replacement using an airway exchanger catheter in a mechanically ventilated patient. An 84-year-old female on mechanical ventilation underwent minimally invasive cardiac surgery under general anesthesia. Immediately after left-sided DLT insertion using an airway exchanger catheter, oxygen saturation decreased to 89%, peak airway pressure increased to 35 cm H2O with inadequate tidal volume, and blood pressure gradually dropped to 69/41 mmHg. Breath sounds from the right hemithorax were significantly reduced. Severe collapse of the right lung, a flattened diaphragm, and compressed abdominal organs were identified on chest radiography. Therefore, a tube thoracotomy was performed based on the findings of a tension pneumothorax. Then, oxygen saturation, peak airway pressure with adequate tidal volume, and blood pressure improved, and the distended abdomen normalized. After the pneumothorax resolved, a bronchoscopy was performed. Slight redness was noted in the right bronchus, indicating that the DLT was incorrectly inserted into the right side. In conclusion, the possibility of a tension pneumothorax should be considered during DLT intubation or endotracheal tube replacement with an airway exchange catheter. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the laryngoscopes Macintosh, Miller, McCoy, Intubrite, VieScope and I-View in simulated out-of-hospital conditions when used by people without clinical experience, and to choose the one that, in the case of failure of the first intubation (FI), gives the highest probability of successful second (SI) or third (TI). For FI, the highest success rate (HSR) was observed for I-View and the lowest (LSR) for Macintosh (90% vs. 60%; p < 0.001); for SI, HSR was observed for I-View and LSR for Miller (95% vs. 66,7%; p < 0001); and for TI, HSR was observed for I-View and LSR for Miller, McCoy and VieScope (98.33% vs. 70%; p < 0.001). A significant shortening of intubation time between FI and TI was observed for Macintosh (38.95 (IQR: 30.1–47.025) vs. 32.4 (IQR: 29–39.175), p = 0.0132), McCoy (39.3 (IQR: 31.1–48.15) vs. 28.75 (IQR: 26.475–35.7), p < 0.001), Intubrite (26.4 (IQR: 21.4–32.3) vs. 20.7 (IQR: 18.3–24.45), p < 0.001), and I-View (21 (IQR: 17.375–25.1) vs. 18 (IQR: 15.95–20.5), p < 0.001). According to the respondents, the easiest laryngo- scopes to use were I-View and Intubrite, while the most difficult was Miller. The study shows that I-View and Intubrite are the most useful devices, combining high efficiency with a statistically significant reduction in time between successive attempts. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]