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An endoscopic bite block is a device to ensure that the patient’s mouth remains wide open during endoscopic procedures. Wide opening of the mouth may facilitate the efficiency of one-handed mask ventilation. We evaluated the effect of an endoscopic bite block on mask ventilation among three ventilation techniques: one-handed ventilation, one-handed ventilation with an endoscopic bite block, and two-handed ventilation. Fifty-nine anesthetized and paralyzed patients were included. After induction of anesthesia, one-handed ventilation, one-handed ventilation with an endoscopic bite block and two-handed ventilation were performed in a cross-over, randomized order. The primary outcome was the expiratory tidal volume (mL/kg of predicted body weight). Secondary outcomes included minute ventilation (L/min) and the incidence of inadequate mask ventilation or dead space ventilation. The expiratory tidal volume of one-handed ventilation with an endoscopic bite block was significantly improved when compared with that of one-handed ventilation (8.2 [6.8–10.2] mL/kg vs. 7.1 [4.5–9.0] mL/kg, respectively, difference = 1.1 mL/kg; 95% CI 0.8–2.4; P

Introduction: Positive pressure ventilation (PPV) with T-Piece and self-inflating bag (SIB) during neonatal resuscitation after birth is associated with variability in ventilation. The use of a ventilator with respiratory function monitoring (RFM) for PPV, however, has not been evaluated. Objective: To determine if ventilator + RFM can reduce ventilation variability compared to T-Piece and SIB in a preterm manikin at different combinations of target tidal volume (VT) and lung compliance (CL). Methods: Twenty clinicians provided PPV via mask and endotracheal tube (ETT) using SIB, T-Piece, T-Piece + RFM and Ventilator + RFM to a manikin with adjustable lung CL. Three combinations of CL and target VT: Low CL-Low VT, Low CL-High VT and High CL-Low VT were used in a random order. Results: The use of ventilator + RFM for PPV via ETT during High CL-Low VT period reduced the proportion of breaths with expiratory VT above target when compared to the other 3 devices (56 ± 35%, 85 ± 20%, 90 ± 25%, 92 ± 12% for ventilator + RFM, T-Piece + RFM, T-Piece, SIB, respectively; p < 0.05). During PPV via both mask and ETT, ventilator + RFM maintained the set Ti and rate, whereas SIB and T-Piece use resulted in higher rates, and T-Piece in higher proportion of breaths with prolonged Ti. During PPV via mask, ventilator + RFM reduced gas leakage compared to other devices. Conclusion: In this simulation study, use of a mechanical ventilator with RFM led to an overall improvement in volume targeting at different settings of CL and reduced the gas leak during mask ventilation. The efficacy and safety of using this strategy to neonatal resuscitation in the delivery room needs to be evaluated.

Background Operating table height/patient level in relation to anaesthesiologist influences mask ventilation, laryngoscopy, intubation and task performance in terms of physical and mental workload. The same was evaluated in this study. Methods Twenty five specialist anaesthesiologists performed mask ventilation and laryngoscopy thrice and intubation once on six patients each, [n = 150] at three different operating table levels (Level X: patient at level of xiphisternum of anaesthesiologist, level A: 5 cms above; level B: 5 cms below xiphisternum). Primary variable was quality of laryngoscopic view obtained. Secondary variables were anaesthesiologist's comfort, ease of performing these tasks and movements at various joints in anaesthesiologist assessed in subjective and objective ways. Results Laryngoscopic view was best at levels X and A when compared to B (p = 0.0004). Mask ventilation was most comfortable at level B and least at level A (p Conclusion Higher operating table levels are ideal for laryngoscopy and intubation whereas lower levels favour mask ventilation.

Background and objectives: Laryngectomy with extensive extirpational neck dissection is still the treatment of choice for patients with advanced laryngeal cancer. During the initial part of laryngectomy – tracheostomy, there is a significant upper airway obstruction, caused by the cancer process itself and worsened by surgical pressure and manipulation during creation of tracheostomy. This study aims to make comparative assessment of the patient’s hemodynamic parameters, operated using three of the most popular approaches during tracheostomy: local anesthesia with preserved spontaneous ventilation; general anesthesia with ventilation by endotracheal intubation and general anesthesia with ventilation by laryngeal mask airway. Methods: A prospective cohort study was conducted in a tertiary referral center. Sixty patients with advanced laryngeal cancer appointed for total laryngectomy, were enrolled in the study. They were randomly assigned into three groups, according to the ventilation method used during the tracheostomy. Results: Patients who underwent tracheostomy under local anesthesia displayed statistically the highest levels of SAP, DAP, MAP and heart rate intraoperatively. The group of patients who underwent tracheostomy with endotracheal intubation, also displayed significantly higher levels of hemodynamic parameters during the procedure compared with the group with laryngeal mask airway ventilation, despite the fact that both groups were under general anesthesia. Conclusions: To our knowledge, this is the first study to demonstrate that laryngeal mask ventilation during tracheostomy improves intraoperative hemodynamic stability in patients undergoing total laryngectomy compared to endotracheal intubation.

During induction of general anesthesia, it is common practice to delay neuromuscular blockade until the ability to deliver mask ventilation has been confirmed. However, the benefits of this approach have never been scientifically validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the efficiency of mask ventilation and the time to tracheal intubation in patients with normal airways.Patients (n = 114) were randomized to receive IV rocuronium either before (early rocuronium group, n = 58) or after (late rocuronium group, n = 56) checking mask ventilation. Expiratory tidal volumes (VTs) were measured at 10, 20, 30, 40, 50, and 60 seconds after apnea during mask ventilation. We graded the ease of mask ventilation and measured the time from apnea to tracheal intubation. The primary outcome was the average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea. The main secondary outcome was the time from apnea to tracheal intubation. STATA was used for statistical analysis.The average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea was larger in the early rocuronium group than in the late rocuronium group (552 mL breath [165 mL breath] vs 393 mL breath [165 mL breath], mean difference, 160 mL breath; 95% CI, 98-221 mL breath; P.001, unpaired t test). Because the interaction between time and group was significant in mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea (P.001, linear mixed effects model), pairwise comparisons were performed at the 6 time points. The differences in VTs between the groups were significant at 10, 20, 30, 40, and 50 seconds after apnea (P.001 each, contrast statements in STATA). The time from apnea to tracheal intubation was shorter in the early rocuronium group than in the late rocuronium group (116 seconds [42 seconds] vs 195 seconds [41 seconds]; mean difference, -79 seconds; 95% CI, -96 to -64 seconds, P.001).The early administration of rocuronium before checking mask ventilation resulted in a larger mask VT and earlier tracheal intubation than the late administration of rocuronium after checking mask ventilation in patients with normal airways.

BACKGROUND The value of checking mask ventilation before administering neuromuscular blocking drugs is still debated. METHOD We conducted a survey of the practice of anaesthetists in Sweden, first asking if they use a mask ventilation trial (MVT) as part of routine induction with intubation (not rapid sequence induction or expected difficult airway). We focused on the reasons for or against the MVT, probing the anaesthetists' attitudes in general but also in specific scenarios. RESULTS The response rate was 54%. We found that 65.1% routinely use a MVT, 21.4% sometimes do and 13.5% never do so. There was no effect for years of experience on the distribution. The most common reason for checking mask ventilation was "to gather information about the airway," while the reason for not using the MVT was mostly "that muscle relaxation often improves mask ventilation." CONCLUSION We found several interesting comments about airway management at both practical and theoretical levels. The survey highlights that routinely performing a MVT is a common practice in Sweden in spite of the lack of evidence for increased patient safety. Future airway guidelines may need to address this practice.

Treball Final de Grau en Medicina. Codi: MD1158. Curs acadèmic: 2020/2021 Antecedentes. El manejo de la vía aérea (VA) es una habilidad fundamental en Medicina. La ventilación con mascarilla facial (VMF) es el inicio de toda asistencia respiratoria. En caso de dificultad, se puede recurrir al empleo de dispositivos que facilitan este procedimiento, como la cánula orofaríngea. Nuestro estudio plantea la pregunta ¿por qué no usar este instrumento de manera rutinaria mejorando y facilitando la ventilación de todos los pacientes en general, incluidos los a priori "fáciles" de ventilar? Objetivo. El objetivo principal de nuestro estudio es determinar si el uso de la cánula orofaríngea durante la VMF supone un beneficio para los pacientes sin criterios de ventilación dificultosa, al aumentar el volumen corriente (VC). Como objetivos secundarios, analizamos si existieron o no diferencias en cuanto a la saturación de oxígeno, la facilidad de la ventilación para el anestesista y si hubo alguna complicación. Material y métodos. Se realizó un ensayo clínico aleatorizado controlado que consta de 100 pacientes separados en dos grupos. Las variables recopiladas se dividieron en aquellas previas a la inducción (recogidas en la consulta preanestésica) y las que se valoraron tras la inducción. En ambos grupos, tanto en el de control, como en el de intervención, se evaluó cada parámetro de la misma forma. Todos los datos se analizaron utilizando el programa estadístico IBM SPSS statistics 27. Primero se realizó un estudio descriptivo de las variables y posteriormente un análisis inferencial con el empleo del test t de Student para variables cuantitativas que cumplian la normalidad. En caso de que no la cumplieran, se empleó su alternativa no paramétrica, la prueba de U-Mann Whitney. El test de Chicuadrado se usó para variables categóricas. Resultados. El análisis estadístico mostró que el VC aumentó de 247,5 (141,4) a 428,3 (181,5), lo que corresponde a un incremento del 77,02% de los valores iniciales (p

Background Unanticipated difficult airway is a potentially life-threatening event during elective surgery or management of critical conditions. Nevertheless, predicting difficult mask ventilation currently remains a challenge due to the poor sensitivity of available clinical tests. Our primary goal was to verify whether preoperative upper airway ultrasound measurements were useful to predict difficult face mask ventilation. Our secondary goal was to evaluate clinical characteristics and differences between patients who are difficult to ventilate and patients who are not. Methods We performed a prospective observational study, enrolling 250 adult patients selected for colorectal, gastric, bariatric and pancreatic elective surgery between September 2017 and October 2018. We performed a preoperative US assessment of the airways, following a standardized protocol. We measured the hyomental distance (DIM), the thickness of the base of the tongue (SBL), the thickness of the soft tissues anterior to the hyoid bone (STTi), thyro-hyoid distance (DTI), the thickness of soft tissue anterior to the epiglottis (STTe), to the arytenoid (STTa) and to the commissure of the vocal cords (STTcv). Results SBL had a predictive role of difficult mask ventilation in curarized and noncurarized patients for values higher than 50mm. Hyomental distance with hyperextension of the head and subluxation of the mandible (DIMs) had a predictive role in the curarized patient (protective parameter). Conclusions Airways ultrasound evaluation could be an important tool to predict difficult mask ventilation. Further studies are necessary to validate the parameters found and correlate them to the preoperative clinical evaluation.

The basic skills required for competence in pediatric airway management include mask ventilation, supraglottic airway placement, direct laryngoscopy, and intubation. Although techniques used for children are similar to those used for adults, there are some nuances that pertain only to the pediatric patient. This chapter describes and illustrates these basic airway management procedures for pediatric patients. Bag mask ventilation is used extensively in the operating room, emergency department, and intensive care unit. Effective bag mask ventilation can save a child’s life in emergent situations.1 Respiratory assistance is provided to the patient through a mask on the patient’s face, held in a specialized way to maximize airway patency (described later), that is attached to a device capable of delivering positive pressure manually or automatically. Oxygenation is achieved by compressing air/oxygen through the delivery device into the lungs, and ventilation is ensured by maintaining airway patency as the patient exhales with chest wall recoil. Intubation is indicated in any patient who is unable to maintain adequate spontaneous respiration or who is at risk for aspiration. Examples are patients in respiratory arrest, those in cardiac arrest, or sometimes those experiencing neurologic issues such as seizures. Patients undergoing surgical procedures will often require intubation because of the apnea and risk for aspiration caused by the anesthetics and the surgical procedure itself.

Nasotracheal intubation (NTI) is generally preferred for maxillofacial surgery to provide a more suitable and wide surgery area for the surgeons. The purpose of the study was to evaluate whether using a nasal airway just before the NTI may facilitate NTI or not.This prospective, randomized, and controlled study was performed on patients who were admitted to our hospital for maxillofacial surgery. In group 1, a nasal airway was used just before the NTI during mask ventilation, and patients in the group were ventilated without nasal airway. Airway group was the primary predictor of the study. The NTI duration was the primary outcome variable, and the number of attempts was the secondary outcome variable. Difficulty of ventilation and complications were the other variables that were recorded.A total of 70 patients were included in the study and divided into 2 groups. There was no statistically significant relationship between the duration of NTI and other variables, but the significance value for sternomental distance, ventilation difficulty, and epistaxis was P .10. The NTI duration (the primary outcome variable) and the number of attempts (the secondary outcome variable) are statistically lower in the nasal airway group (group 1) than the control group (group 2). Ventilation difficulty was significantly higher in group 2 when compared with group 1 (P = .04). The model and regression coefficients for both variables are statistically significant in terms of duration of NTI and number of attempt values that they were lower in nasal airway group than the control group. There were no statistically significant differences between the groups in terms of complications (P .05).The present study has shown that inserting a nasal airway into the nostril just before the NTI may facilitate the intubation process by preparing the nasal passage.

Maintaining the airway patency and ensuring a proper gas exchange is a fundamental role when managing the airway; failure to do so would result in catastrophic complications. Difficult airway management should be addressed with the exact stage of difficulty, such as mask ventilation, supraglottic airway device insertion, laryngoscopy and endotracheal tube insertion, or extubation. Physicians should be aware of the pathologies that might impact the management of the airway, and the conditions that might lead to difficult airway management, including congenital and acquired disorders. As well as be able to perform a thorough assessment of the airway including history relevant to airway management, performing a physical exam, and interpreting required investigations. In this chapter, we will also shine a light on new and evolving techniques for assessing and managing the airway, including virtual endoscopy, preoperative endoscopic airway examination, airway ventilation through a straw or a small lumen tube, and on the use of alternative oxygenation techniques like the use of high-flow nasal cannula and apneic oxygenation. Although we have a massive arsenal of equipment to manage the difficult airway, it is still a situation that is best managed when anticipated and meticulously planned.

Patients with Pierre Robin sequence present with numerous anatomical abnormalities that make mask ventilation and tracheal intubation challenging. In this case series, we describe a unique way to overcome upper airway obstruction with the placement of a supraglottic airway in 4 children with Pierre Robin sequence followed by flexible bronchoscopic nasotracheal intubation. This new approach is proven to be a successful method to overcome severe upper airway obstruction, provide continuous oxygenation, and allows nasotracheal intubation for intraoral procedures.

Correction: Volume: 156 Pages: 194-195 DOI: 10.1016/j.resuscitation.2020.05.028 Published: NOV 2020 Aim: To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts. Methods: International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis. Results: The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8). Conclusion: There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.

Background Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization. Methods Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view. Results Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position. Conclusion Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position. Clinical trial registration Identifier: NCT03640442. Date: August 2018.

EDITOR’S PERSPECTIVE What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Background and objectives: Nerve injury following mask ventilation is a rare but serious anesthetic complication. The majority of reported cases are associated with excessive pressure applied to the face mask, long duration of mask ventilation, excessive digital pressure behind the mandible to relieve airway obstruction and pressure exerted by the plastic oropharyngeal airway. Case report: We present a case of bilateral mandibular nerve injury following mask ventilation with short duration, most likely due to a semi-silicone facemask with an over-inflated cushion. Conclusion: An over-inflated sealing cushion of a facemask may trigger difficult mask ventilation leading to mandibular nerve injury following mask ventilation. Alternative airway management techniques such as laryngeal mask airway should be considered when airway maintenance can only be achieved with strong pressure applied to the facemask and/or mandible. Resumo: Justificativa e objetivos: A lesão nervosa após ventilação com máscara é uma complicação anestésica rara, mas grave. A maioria dos casos relatados está associada à pressão excessiva aplicada à máscara facial, ao tempo prolongado de ventilação, à pressão digital excessiva atrás da mandíbula para aliviar a obstrução das vias aéreas e à pressão exercida pela cânula orofaríngea. Relato de caso: Apresentamos um caso de lesão do nervo mandibular bilateral após uma ventilação de curta duração via máscara, provavelmente devido ao uso de uma máscara facial (de semissilicone) com insuflação excessiva da almofada. Conclusão: A insuflação excessiva da almofada de uma máscara facial pode desencadear uma ventilação com máscara difícil, levando à lesão do nervo mandibular após a ventilação. Técnicas alternativas de manejo das vias aéreas, como o uso de máscara laríngea, devem ser consideradas quando a manutenção das vias aéreas só pode ser obtida com forte pressão aplicada à máscara facial e/ou mandíbula. Keywords: Mandibular nerve injury, Mask ventilation, Anesthesia, Palavras-chave: Lesão do nervo mandibular, Ventilação com máscara, Anestesia

BACKGROUND: Manual positive pressure ventilation is an essential skill in a variety of clinical situations. The C&E technique is commonly used with standard facemasks to provide effective ventilation. The Tao mask is a novel design that allows a more ergonomic grip. A seal between the mask and face is made with downward pressure of the palm, centered on the mask, and jaw lift is achieved with 4 fingers centered under the mandible. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to a standard mask before and after the administration of neuromuscular blockade (NMB) using 2 previously established ventilation scales. METHODS: One hundred fifty-two patients >18 years of age who were scheduled for general anesthesia were recruited. All care team members were shown a brief instructional video on the use of the Tao mask. After induction of general anesthesia with a standardized protocol, each patient was ventilated with both the standard (Vital Signs #082510) and Tao masks and effectiveness was measured using the Han and Warters scales. This process was repeated after NMB. The sequence of masks was determined with a random-number generator. RESULTS: Tao mask ventilation scores were significantly better than standard mask scores on both the Han scale and the Warters scale before the administration of NMB (P < .001 for both). Tao mask scores were also significantly better than standard mask scores on the Warters scale after the administration of NMB (P < .001). However, there was no significant difference on the Han scale between the 2 mask types after NMB (P = .180). On the Warters scale, there were significantly fewer patients who were difficult to ventilate with the Tao mask than the standard mask before NMB (18 vs 40; P < .001) and after NMB (8 vs 17; P = .005). No adverse events were reported with either mask. CONCLUSIONS: Our results indicate that the Tao mask demonstrated equivalent safety and superior effectiveness compared to a standard mask. The study design favored the standard mask because all participating practitioners had multiple years of experience with the standard mask and no prior experience with the Tao mask. Since the incidence of inadequate mask ventilation goes up significantly with inexperienced operators, the improved effectiveness of the Tao mask could be even more profound with novice operators. (Anesth Analg 2018;127:151–6)

Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU.A retrospective cohort study of a multicenter pediatric airway quality improvement registry.Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand).Children (18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015.None.Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036).Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Paediatric airway tumours can prove to be quite challenging for anaesthesiologists. We attempted to secure airway in a toddler with a large tongue haemangioma using total intravenous anaesthesia (TIVA) with dexmedetomidine and propofol while preserving spontaneous ventilation.

Bronchoscopy is a procedure for diagnosis and treatment decision-making in patients with lung disease, especially those with acute respiratory failure. However, the optimal bronchoscopic method for patients with acute respiratory failure is not known. Therefore, in the real world, we sometimes hesitate to perform bronchoscopy in such patients because of safety and have experienced treating patients without bronchoscopy. To address this problem, we evaluated the usefulness and safety of Jackson mask ventilation, a novel noninvasive method of bronchoscopy performed under mask ventilation using the Jackson Rees circuit, in patients with acute respiratory failure.We retrospectively reviewed patients with acute respiratory failure who underwent bronchoscopy at our institution between January 2015 and May 2018. We compared patients who received Jackson mask ventilation (Jackson group) and those who received conventional oxygen administration (conventional group). Mean percutaneous oxygen saturation (SpO2) and mean oxygen flow rate were compared between the groups by the Wilcoxon signed-rank test. We excluded patients who were intubated and those without acute respiratory failure who received Jackson mask ventilation preventively.Of 1262 patients who underwent bronchoscopy, 12 were classified into the Jackson group and 13 into the conventional group. Proper oxygenation was maintained in the Jackson group, with SpO2 increasing after Jackson mask ventilation (89.4% to 96.8%, P = .03). Mean SpO2 was significantly higher in the Jackson group than in the conventional group (96.8% vs 95.2%, P = .03). Mean oxygen flow rate was significantly lower in the Jackson group (4.0 L/min vs 7.9 L/min, P

Background and Aims: The palatal defect and abnormal dentition in cleft palate make mask ventilation and laryngoscopy difficult. This study aimed to assess the effect of feeding obturator on laryngeal view in unilateral complete cleft palate. Methods: Ninety non-syndromic infants scheduled for the first stage correction of complete unilateral cleft palate were randomised to Group A (no feeding obturator) or Group B (obturator used for induction and intubation). The primary objective was to assess effect of the feeding obturator on the Cormack–Lehane grade on laryngoscopy. Effects on face mask ventilation, easiness of laryngoscopy and intubation and the side effects were also measured. Results: Ninety patients completed the study. There was no statistically significant difference between the two groups regarding the CL grade (P < 0.1). However duration for intubation was significantly longer in Group A than Group B (31.4 ± 12.8 vs. 23.4 ± 40.7 sec, P < 0.001). The degree of difficulty of face mask ventilation was significantly greater in Group A than Group B (P < 0.008). Attempts for successful intubation and manoeuvres for successful intubation were significantly more in Group A than B (P < 0.05). Trauma occurred in ten patients in Group A relative to no patients in Group B. Conclusion: Use of a pre-sized obturator in infants with complete unilateral cleft palate does not improve the laryngoscopic view. However, it results in better face mask ventilation and easier and faster laryngoscopy and intubation.