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Video laryngoscopy outperforms direct laryngoscopy for successful orotracheal intubation in the emergency department. When performing video laryngoscopy, emergency physicians may use a standard geometry blade or a hyperangulated blade. Hyperangulated video laryngoscopy is easier when using a rigid hyperangulated stylet instead of a standard malleable stylet. The angulation of the hyperangulated blade makes it difficult to use an endotracheal tube (ETT) introducer (bougie). We describe a case report using a DuCanto suction catheter (SSCOR) with a preloaded bougie to perform orotracheal intubation during hyperangulated video laryngoscopy. An adult patient presented to the emergency department in status epilepticus and was intubated for airway protection. Hyperangulated video laryngoscopy was performed with a LoPro S4 (GlideScope) blade; a DuCanto suction catheter was used to deliver a bougie through the vocal cords. The bougie was advanced down the trachea, and the DuCanto suction catheter was removed. The bougie successfully delivered a size 8.0 ETT. Visualization of the larynx with hyperangulated video laryngoscopy is usually easy, but ETT delivery into the trachea can be challenging. Rigid hyperangulated stylets were created to facilitate ETT delivery, but these stylets are expensive and often not available. Traditional teaching says that a bougie cannot be used while intubating with a hyperangulated blade. This case report describes a method to deliver a bougie via a DuCanto suction catheter during hyperangulated video laryngoscopy. It allows for the use of a bougie with a hyperangulated blade and offers a technique to perform hyperangulated video laryngoscopy without a rigid stylet.

BACKGROUND: Double lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced clinicians. We hypothesized that airway anatomy, particularly of the glottis and proximal trachea, significantly impacts the ease or difficulty in placement of these tubes. METHODS: Images from 24 randomly selected Positron Emission Tomography - Computed Tomography (PET-CT) scans were evaluated for several anatomic aspects of the upper airway, including size and angulation of the glottis and proximal tracheal using calibrated CT measurements and an online digital protractor. The anatomic issues identified were confirmed in cadaveric anatomic models. RESULTS: Proximal tracheal diameter measurements in PET-CT scans demonstrated a mean ± standard deviation of 20.4 ± 2.5 mm in 12 males and 15.5 ± 0.98 mm in 12 females (p

The article discusses effective strategies for educating healthcare professionals in critical airway management techniques. Topics include the importance of simulation training to enhance hands-on skills and decision-making in real-time scenarios; the role of evidence-based practices in shaping educational curricula for airway management; and the need for continuous learning and assessment to maintain proficiency in advanced airway techniques.

Summary: Background: The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy‐to‐use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children. Methods: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co‐variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification. Results: We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73–0.87) vs. 0.69 (95%CI 0.62–0.76), respectively, p = 0.018. Eight eligible tracheal intubation‐related factors, that were selected by 100‐times repeated 10‐fold cross‐validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96–0.99) vs. 0.69 (95%CI 0.62–0.76), respectively, p < 0.001. Conclusion: We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification. [ABSTRACT FROM AUTHOR]

Summary: Introduction: There is uncertainty about the optimal videolaryngoscope for awake tracheal intubation in patients with anticipated difficult airway. The use of channelled and unchannelled videolaryngoscopy has been reported, but there is a lack of evidence on which is the best option. Methods: We conducted a randomised clinical trial to compare the efficacy of the C‐MAC D‐Blade® vs. Airtraq® in adult patients (aged ≥ 18 y) scheduled for elective or emergency surgery under general anaesthesia with anticipated difficult airway who required awake tracheal intubation under local anaesthesia and conscious sedation. The primary endpoint was the first‐attempt tracheal intubation success rate. Secondary outcomes included the overall success rate; number of tracheal intubation attempts; Cormack and Lehane glottic view; level of difficulty (visual analogue score); patient discomfort (visual analogue score); and incidence of complications. Results: Ninety patients (70/90 male (78%); mean (SD) age 65 (12) y) with anticipated difficult airways were randomly allocated to C‐MAC D‐Blade or Airtraq videolaryngoscopy. First‐attempt successful tracheal intubation rate was higher in patients allocated to the C‐MAC D‐Blade group compared with those allocated to the Airtraq group (38/45 (84%) vs. 28/45 (62%), respectively; p = 0.006). The proportion of patients' tracheas that were intubated at the second and third attempt was 4/45 (9%) and 3/45 (7%) in those allocated to the C‐MAC D‐Blade group compared with 14/45 (31%) and 1/45 (2%) in those allocated to the Airtraq group (p = 0.006). There was no significant difference in overall tracheal intubation success rate (C‐MAC D‐Blade group 45/45 (100%) vs. Airtraq group 43/45 (96%), p = 0.494). Discussion: In patients with anticipated difficult airway, first‐attempt awake tracheal intubation success rate was higher with the C‐MAC D‐Blade compared with Airtraq laryngoscopy. No difference was found between the two videolaryngoscopes in overall tracheal intubation success rate. [ABSTRACT FROM AUTHOR]

Objectives: While flipped classroom instruction has repeatedly shown efficacy in undergraduate medical education, evidence for its utility in procedural domains remains sparse. This holds particular significance for surgical subspecialties such as otolaryngology, which have limited time in undergraduate medical curricula. We designed a novel airway management skills simulation course with a flipped classroom approach and evaluated its efficacy in a pilot study. Methods: A simulation course was designed to provide instruction in seven airway management skills: bag valve mask ventilation, laryngoscopy, intubation, cricothyroidotomy, tracheotomy, and tracheostomy care. Publicly available YouTube videos were selected as pre-learning materials. Participating students completed surveys before the pre-learning assignment and after completion of the simulation center workshop. Results: Sixteen students participated in the workshop, and data was collected from 14 participants. Learners reported significant improvements in knowledge regarding all covered skills except tracheotomy; mean self-rated knowledge improved from 2.9 to 5.8 (p < 0.001) on a scale from 0 to 10. Significant increases in self-reported confidence in performing all seven skills were also observed, with an overall increase from 1.1 to 5.7 (p < 0.001). Students also rated all elements of the workshop highly, including a prevailing belief that the pre-learning materials markedly enhanced their learning. Conclusion: Our novel framework for skills-based education using a flipped classroom approach demonstrated remarkable efficacy in improving learner knowledge and self-reported confidence regarding airway management skills. This educational design, including the use of high-quality, publicly available pre-learning videos, has significant implications for undergraduate medical education in surgical subspecialties. [ABSTRACT FROM AUTHOR]

Background: and Aim of study: Endotracheal intubation in pediatric patients might be challenging due to anatomical variances. One problem is selecting the appropriate size of endotracheal tube for intubation (1). Choosing the right Endotracheal tube size is crucial, especially for young patients. Using an incorrectly sized ETT can have serious consequences, including death. Various methods are used to estimate correct ETT size based on patient demographics, such as age, weight, and height. Some anesthesiologists use the diameter of the little finger for crude estimation. However, these methods have poor agreement with the actual ETT size appropriate for the patient. This study evaluated the efficacy of ultrasonographic assessment of ETT size to the usual age-based calculation. Material and Method: This cross sectional randomised study was done on 72 patients undergoing elective procedures at the Department of Anaesthesiology, Integral Institute of Medical Sciences, Lucknow, between September 2022 and March 2024, after institutional ethics committee permission. Patients were separated into two groups of 36 each. Group A's ETT size was approximated using Pennington's method. Group B where ETT size was assessed by ultrasonography. The results were evaluated using descriptive statistics and compared between groups. Categorical data were summarized as proportions and percentages (%), whereas discrete data were reported as mean ± SD. Results: Insertion of ETT estimated by ultrasound had greater rate of successful insertion in first attempt, easy insertion and less postoperative complications when compared to ETT size estimated by Penlington's formula. [ABSTRACT FROM AUTHOR]

Background: Undesirable injuries during the intraoperative period, such as pressure injuries caused by improper positioning, medical devices, or adhesive tapes, can lead to patient harm and decreased satisfaction. This study aims to identify the risk factors of pressure injuries during the intraoperative period and the characteristics of these injuries. Methods: A retrospective case‑control study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. Data were collected from the hospital incident reporting system and electronic medical records for incidents reported from January 1, 2022 to December 31, 2022. Inclusion criteria consisted of all patients with a reported pressure injury, including pressure ulcers, medical adhesive‑related skin injuries, or medical device‑related pressure injuries, occurring at least once during surgery. Results: Among the 113 patients, 57 (50.44%) had intraoperative pressure injuries (cases), while 56 (49.56%) did not (controls). The most common locations for pressure injuries were the lips (33.33%). Most of these injuries were classified as Medical Adhesive‑Related Skin Injury (61.40%). Stage 1 injuries were observed in 47 cases (82.46%), while Stage 2 injuries were observed in 10 cases (17.54%). Duration of surgery and device tightness were identified as significant risk factors (P < 0.001). Conclusion: This case‑control study identified the duration of surgery and device tightness as significant risk factors for intraoperative pressure injuries. The findings emphasize the importance of implementing evidence‑based prevention strategies. Healthcare professionals should prioritize staff education and training, while future research should focus on conducting prospective, multicenter studies and developing risk assessment tools and innovative medical devices. [ABSTRACT FROM AUTHOR]

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]

Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents—such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine—depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period. [ABSTRACT FROM AUTHOR]

To evaluate effectiveness of using MLT tubes for transoral laser MLS in terms of surgical visualization, complete excision of vocal cord lesions, maintenance of adequate oxygenation and ventilation and the occurrence of any airway related complications. In a retrospective case series study, review of electronic medical records was conducted for 64 patients who underwent transoral laser MLS over an 18-month period. The collected data included vital parameters, mode of ventilation, ET tube details, surgical field of vision, perioperative adverse events and postoperative ventilation requirements. Among the 64 patients, 82.8% of the time, 5 size MLT tubes were used, fixed at mean lengths of 21.6cm in females and 23.07cm in males respectively. A good surgical field of exposure was achieved in 92.2% of patients, with an average FiO2 of 0.29 during laser use and pressure control ventilation mode being the majority choice. 98.4% were extubated on table. The incidence of cuff rupture and bronchospasm was 4.7% and 1.6% respectively with no instances attributable to laser related events. Even though Laser resistant tubes are considered gold standard, MLT tubes can be used by taking adequate precautions to reduce Laser related complications when there is limited availability of laser tubes. Level of evidence Case series. [ABSTRACT FROM AUTHOR]

Purpose: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). Methods: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician–researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Results: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. Conclusion: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties. [ABSTRACT FROM AUTHOR]

Background: The ramped position facilitates mask ventilation and endotracheal intubation in patients with obesity. This study aimed to determine whether the ramped position improves supraglottic airway (SGA) insertion in patients with obesity. Methods: In this prospective, randomized, single-center trial, 48 obese patients undergoing elective surgery were randomized into either ramped or sniffing position groups. The Ambu® AuraGainTM (Ambu A/S), a second-generation SGA, was used. The primary outcome was the time required for the AuraGain insertion. Secondary outcomes included ease and number of insertion attempts, oropharyngeal leak pressure (OLP), and complications. The number needed to treat (NNT) was calculated to ensure ease of insertion. Results: The time required for the AuraGain insertion was significantly shorter in the ramped group than in the sniffing group (13.0 [11.0, 16.0] vs. 24.0 [21.0, 28.0], P < 0.001). The insertion was easier in the ramped group than in the sniffing group (23/24 vs. 13/24, NNT = 2.4 [95% CI, 1.6, 5.0], P = 0.003). The first-attempt success rate was higher in the ramped group than in the sniffing group, although the difference was not statistically significant (22/24 vs. 18/24, P = 0.319). The OLP and postoperative complication rates were not significantly different between the groups. Conclusions: The ramped position reduced the time required for the AuraGain insertion in obese patients while providing comparable airway sealing without increasing adverse events. Therefore, a ramped position may be a more suitable option for SGA insertion in this population. [ABSTRACT FROM AUTHOR]

Purpose: Adequate oxygenation and airway management during deep sedation can be challenging. We investigated the effect of high-flow nasal cannula (group HF) and conventional nasal cannula (group CO) during sedation for endoscopic submucosal dissection (ESD). Methods: Patients undergoing ESD with deep sedation were enrolled. The primary outcome was difference in lowest oxygen saturation (SpO2) between the groups. Incidence of hypoxia (SpO2 < 90%), patients with SpO2 < 95%, hypercapnia, and airway interventions; operator satisfaction; and adverse events were recorded. Results: Thirty-two patients in each group completed the study. The mean of minimum SpO2 values was significantly higher in group HF than in group CO (96.8% ± 4.2% vs. 93.3% ± 5.3%, p = 0.005). The incidence of hypoxia was comparable between the groups (4 [12.5%] vs. 6 [18.8%], p = 0.491); however, patients with SpO2 < 95% were significantly less in group HF (5 [15.6%] vs. 18 [56.3%], p = 0.003). Incidence of hypercapnia was higher in group HF than in group CO (14 [46.7%] vs. 5 [16.7%], p = 0.013). Airway rescue interventions were significantly less common in group HF. Satisfaction of operators and post-procedural complications were comparable between the two groups. In multivariable analysis, group CO and higher body mass index were risk factors for airway managements (odds ratio [95% confidence interval]: 6.204 [1.784–21.575], p = 0.004; 1.337 [1.043–1.715], p = 0.022, respectively). Conclusions: Compared to conventional nasal cannula, high-flow nasal cannula maintained higher minimum SpO2 value during deep sedation with propofol–remifentanil for ESD. Trial registration: Clinical Trial Registry of the Republic of Korea (KCT0006618, https://cris.nih.go.kr; registered September 29, 2021; principal investigator: Ji Won Choi). [ABSTRACT FROM AUTHOR]

Summary: Background: Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first‐choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children. Methods: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six‐stage grading system. Results: There were 904 tracheal intubations in 809 children over a 16‐month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway‐related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59–0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73–0.87) for the direct glottic view during laryngoscopy (p = 0.005). Conclusions: Universal, first‐choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children. [ABSTRACT FROM AUTHOR]

This article explores the use of artificial intelligence (AI) in peri-operative prediction model research. It discusses various AI methodologies, including supervised and unsupervised learning, as well as deep learning. The article highlights the importance of methodological considerations when interpreting prediction models, such as sample size, class imbalance, internal and external validation, and evaluation of discrimination and calibration. It also addresses the comparison between traditional statistical methods and machine learning, emphasizing the need for improved reporting and reduction of bias in prediction model research. The article concludes by providing a list of considerations for interpreting prediction model research that utilizes AI. [Extracted from the article]

Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients. [ABSTRACT FROM AUTHOR]

Background Objective Methods Results Conclusions Hospital‐level and international variations exist in the management strategies of bronchopulmonary dysplasia (BPD). However, studies evaluating hospital‐level variations in the respiratory outcomes of pre‐term infants associated with differing management strategies of BPD are lacking.Herein, we aimed to assess inter‐hospital variations in the respiratory outcomes of BPD in very pre‐term and extremely pre‐term infants.In this cohort study, the administrative claims and discharge summary data were extracted from 276 hospitals in Japan between April 2014 and March 2016. This study assessed neonates of a gestational age of 22–31 weeks old, who had been hospitalised for ≥7 days.The primary outcome was a BPD defined using any respiratory support, such as supplemental oxygen, high‐flow nasal cannula, CPAP, or mechanical ventilation at 36 weeks PMA. The median odds ratio (MOR) was calculated using a multilevel logistic regression model, including baseline characteristics, comorbidities, and treatment as covariates, to evaluate the inter‐hospital variation of the outcome.Of the 8143 neonates from across 132 hospitals, 53.7% were male, with a mean gestational age (standard deviation) of 28.0 (2.5)‐weeks‐old and birthweight of 1086 (386) g. Among these patients, BPD occurred in 2737 (33.6%). The MOR was 2.49, representing the median value of odds ratios when comparing two neonates with identical covariates from hospitals with high and low propensity for the outcomes to occur.Outcome variations in the BPD were observed among hospitals in Japan, even after adjusting for individual factors, including gestational age, birthweight, comorbidities, and treatments. Thus, in Japan, developing strategies is essential to decrease the BPD rates, while minimising inter‐hospital heterogeneity, to improve the healthcare quality for pre‐term neonates. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Submental intubation, a technique often considered a good alternative for managing the airway in challenging maxillofacial surgical scenarios, plays a pivotal role in providing accessibility to the surgical site and ensuring airway safety, particularly in cases involving facial fractures. This innovative approach not only grants surgeons adequate access to the operative field but also mitigates potential complications associated with traditional intubation methods, making it a valuable tool in dealing with complex facial trauma cases. Case Report: A 37-year-old man arrived at the Emergency Department (ED) with a severe facial injury caused from a traumatic incident involving a falling concrete wall, resulting in severe facial injuries that included multiple lacerations and abrasions on his face and body. The patient presented with multiple facial and body lacerations and abrasions, necessitating prompt medical intervention. The ED team swiftly treated the facial lacerations, controlled the bleeding, stabilized the patient, and proceeded to secure the airway through orotracheal intubation. Following stabilization, the patient was transferred to the operation theater (OT) for further management of his extensive pan-facial fractures under general anesthesia, utilizing the submental intubation technique for airway management. Conclusions: Despite its limited use, submental intubation is a good option for some maxillofacial surgeries, offering a less intrusive approach to airway management and presenting an alternative pathway to the conventional endotracheal intubation technique. Its ability to streamline procedures, enhance patient outcomes, and reduce complications underscores the importance of considering submental intubation as a valuable tool in dealing with complex maxillofacial cases. [ABSTRACT FROM AUTHOR]

Background: Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. Methods: This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. Results: Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). Conclusions: Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. Trial registration: The study was registered in the German Register for Clinical Studies (number DRKS00028068). [ABSTRACT FROM AUTHOR]

Background: The timing of tracheostomy for intensive care unit patients is controversial, with conflicting findings on early versus late tracheostomy. Methods: Patients undergoing tracheostomy from 2001through 2012 were identified from the Medical Information Mart for Intensive Care-III database. Early tracheostomy was defined as less than the 25th percentile of time from intensive care unit admission to tracheostomy (time to tracheostomy). Statistical analysis for tracheostomy timing on intensive care unit length of stay and mortality were conducted. Results: Of the 1,566 patients that were included, patients with early tracheostomy had shorter intensive care unit length of stay (27.32 vs 12.55 days, p < 0.001) and lower mortality (12.9 per cent vs 9.0 per cent, p = 0.039). Multivariate logistic regression analysis found an association between increasing time to tracheostomy and mortality (odds ratio: 1.029, 95 per cent confidence interval 1.007–1.051, p = 0.009). Conclusion: Our analysis revealed that patients with early tracheostomy were more likely to have shorter intensive care unit lengths of stay and lower mortality. Our data suggest that early tracheostomy should be given strong consideration in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well. [ABSTRACT FROM AUTHOR]

Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented. [ABSTRACT FROM AUTHOR]

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o'clock direction) while maintaining the bronchial lumen towards the left (9 o'clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3–11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique. [ABSTRACT FROM AUTHOR]

Background: Supraglottic airways (SGAs) like the laryngeal mask airway (LMA) provide advantages such as faster placement and better haemodynamic stability. LMAs, whether singleuse or reusable, can be crucial in managing difficult airways or maintaining airway patency. This study compares the ProSeal LMA and endotracheal tube (ETT) in patients undergoing laparoscopic surgeries. Methods: A prospective observational study was conducted on 60 participants over one year, with ethical clearance and informed consent. Participants were divided into two groups: 30 received the ProSeal LMA and 30 received the ETT. Data were analyzed using SPSS version 24 with descriptive and inferential statistics, including independent t-tests and Chi-square tests. Results: The ProSeal LMA group had a mean age of 35.73 years, and the ETT group had a mean age of 40.30 years (p > 0.05). ProSeal LMA had faster intubation (13.30 seconds vs. 16.17 seconds) and Ryle's tube insertion (11.30 seconds vs. 13.12 seconds) compared to ETT (p < 0.05). Sore throat incidence was lower in the ProSeal LMA group. Conclusion: The ProSeal LMA offers better stability and similar airway maintenance compared to ETT, suggesting it may be a superior intubation device. [ABSTRACT FROM AUTHOR]

Background: Difficult intubation poses a significant challenge in anesthesia practice, potentially leading to severe complications. Traditional predictors of difficult intubation, such as the Mallampati score and thyromental distance, have limitations. This study evaluates the neck-circumference-thyromental-distance (NC/TMD) ratio as a novel predictor of difficult intubation in adult patients. Materials and Methods: This observational study was conducted on 200 adult patients scheduled for elective surgery requiring general anesthesia with endotracheal intubation. Patients were assessed preoperatively for neck circumference, thyromental distance, and NC/TMD ratio. The difficulty of intubation was determined using the Cormack-Lehane grading system. Statistical analysis was performed to evaluate the predictive value of the NC/TMD ratio, with a threshold ratio determined for predicting difficult intubation. Results: Out of 200 patients, 30 (15%) experienced difficult intubation. The mean NC/TMD ratio was significantly higher in the difficult intubation group (3.5 ± 0.6) compared to the easy intubation group (2.7 ± 0.4) (p < 0.01). Receiver Operating Characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.82, indicating good predictive value. A NC/TMD ratio threshold of 3.0 yielded a sensitivity of 80% and specificity of 75% for predicting difficult intubation. Conclusion: The NC/TMD ratio is a valuable predictor of difficult intubation, offering a simple and reliable assessment tool that could be integrated into preoperative evaluations. Further studies are recommended to validate these findings across diverse populations and clinical settings. [ABSTRACT FROM AUTHOR]

Summary: Background: It is not certain whether the blade geometry of videolaryngoscopes, either a hyperangulated or Macintosh shape, affects glottic view, success rate and/or tracheal intubation time in patients with expected difficult airways. We hypothesised that using a hyperangulated videolaryngoscope blade would visualise a higher percentage of glottic opening compared with a Macintosh videolaryngoscope blade in patients with expected difficult airways. Methods: We conducted an open‐label, patient‐blinded, randomised controlled trial in adult patients scheduled to undergo elective ear, nose and throat or oral and maxillofacial surgery, who were anticipated to have a difficult airway. All airway operators were consultant anaesthetists. Patients were allocated randomly to tracheal intubation with either hyperangulated (C‐MAC D‐BLADE™) or Macintosh videolaryngoscope blades (C‐MAC™). The primary outcome was the percentage of glottic opening. First attempt success was designated a key secondary outcome. Results: We assessed 2540 adults scheduled for elective head and neck surgery for eligibility and included 182 patients with expected difficult airways undergoing orotracheal intubation. The percentage of glottic opening visualised, expressed as median (IQR [range]), was 89 (69–99 [0–100])% with hyperangulated videolaryngoscope blades and 54 (9–90 [0–100])% with Macintosh videolaryngoscope blades (p < 0.001). First‐line hyperangulated videolaryngoscopy failed in one patient and Macintosh videolaryngoscopy in 12 patients (13%, p = 0.002). First attempt success rate was 97% with hyperangulated videolaryngoscope blades and 67% with Macintosh videolaryngoscope blades (p < 0.001). Conclusions: Glottic view and first attempt success rate were superior with hyperangulated videolaryngoscope blades compared with Macintosh videolaryngoscope blades when used by experienced anaesthetists in patients with difficult airways. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population. DESIGN: 1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages. SETTING: Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting. SUBJECTS: Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention. CONCLUSIONS: This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity. [ABSTRACT FROM AUTHOR]

Background: Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS). Methods: We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015–2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1‐ and 30‐day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression. Results: A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1‐day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37–0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68–1.04), but no difference in 30‐day mortality (OR after implementation 1.10, 95% CI 0.92–1.30). Implementation of an SOP improved first‐pass success rate from 87.3% to 96.5%, p < 0.001. Conclusion: Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1‐day mortality and an improved first‐pass success but did not affect 30‐day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly. [ABSTRACT FROM AUTHOR]

Endotracheal intubation is a common lifesaving procedure that often is performed outside the operating room in a variety of clinical scenarios. Providers who perform intubation outside the operating room have variable degrees of training, skill development, and experience. A large number of studies were published in 2023 on the topic of intubations outside the operating room across a wide variety of settings and patient populations. Here, we review relevant papers on this topic published in 2023. [ABSTRACT FROM AUTHOR]

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Background: Endotracheal intubations (EIs) in the intensive care unit are high-risk procedures often performed by pulmonary and critical care medicine (PCCM) providers. The Accreditation Council for Graduate Medical Education mandates PCCM fellows' competency in this procedure; however, the learning experiences vary across programs. After conducting a needs assessment, we developed a curriculum unique to our institution to supplement our fellows' existing EI experiences in the operating room and the intensive care unit. Objective: To assess the curriculum's short-term objectives: knowledge acquisition, maintenance, and practical skills 1 year after participation. Methods: We administered a survey to the graduating PCCM fellows for two consecutive years. We designed the comprehensive airway curriculum to include didactic lectures and simulation-based education. The knowledge acquisition and maintenance were measured by administering a 26-question knowledge survey before and after curriculum participation and after 1 year. The fellows also received a practical examination 1 year after participation. To compare knowledge survey scores, we used paired t tests and permutation tests. Results: In the needs assessment, 56% of graduating fellows believed they were proficient in performing EI, whereas 33% were undecided and 11% believed they were unprepared. Most believed they would need more than two courses after graduation to be confident in independently performing EIs. Most will only occasionally have backup for EI from anesthesiology or emergency medicine in their future jobs. One identified barrier to learning EI was the lack of a formal curriculum. In the knowledge assessment, nine first-year fellows participated in the curriculum. The cohort's mean presurvey score was 13.0 (standard deviation [SD], 4.5) versus 18.6 (SD, 3.6) mean postsurvey score. One year after participation, the mean survey score was 17 (SD, 1.2). The postsurvey and 1-year postparticipation survey scores were significantly higher than the presurvey scores (P < 0.05). One year after participation, the practical examination showed most fellows retained skills in EI using ramped position, video and direct laryngoscopy, bag-mask ventilation, and oropharyngeal airway placement. Conclusion: The airway curriculum enhances fellows' knowledge acquisition and maintenance 1 year after participation. The practical examination 1 year after participation highlighted the skills retained and those still needing improvement. [ABSTRACT FROM AUTHOR]

Pfeiffer syndrome (PS) is a rare inherited disorder that affects the craniofacial and extremity bones but can also include anomalies of the upper and lower airways. Among the 3 subtypes, PS types 2 and 3 are the most severe. We describe the anesthetic management of a 10-year-old boy with PS type 2 scheduled for dental treatment under general anesthesia. Because of his history of Chiari malformation, avoiding neck hyperextension was recommended to prevent worsening of his neurologic function. Preoperative computed tomography revealed significant nasal stenosis but no tracheal anomalies. Considering the difficulty of nasotracheal intubation, we planned for an oral intubation. General anesthesia was induced using sevoflurane, nitrous oxide, and oxygen along with an oropharyngeal airway. After lidocaine was topically applied to the oropharynx, fiber-optic orotracheal intubation was performed under spontaneous ventilation to minimize head and neck movement. Anesthesia was maintained using desflurane and remifentanil, and no postoperative complications were observed. General anesthesia for patients with PS requires careful planning, which should include preoperative assessment of the airway to determine the feasibility of nasotracheal intubation and identify airway irregularities. [ABSTRACT FROM AUTHOR]

Nasotracheal intubation can reveal unexpected findings like a foreign body in the airway. In such instances, expeditious decision-making is crucial to achieve ideal outcomes. This case report describes a petroleum jelly–based foreign body discovered in the nasopharynx during nasotracheal intubation and the subsequent airway management. A 64-year-old man with no prior history of adverse anesthetic events presented to an oral surgery office for extraction of teeth and placement of implants. While video laryngoscopy for nasotracheal intubation was performed, a blue foreign body was discovered inside the tip of the nasal endotracheal tube. Subsequent attempts to locate the source of the foreign body revealed in the nasopharynx a strip of blue gelatinous foreign body which was removed with suction. Due to the persistent presence of foreign body residues in the nasopharynx, orotracheal intubation was performed. Nasopharyngeal foreign bodies may elude even the most thorough preoperative medical history review and airway assessment. Therefore, it is reasonable for practitioners to ask explicitly about any foreign bodies in the nasal passages. Practitioners should become familiar with cognitive aids for relevant airway emergency management techniques and equipment for expeditious decision-making when unexpected foreign bodies are found. [ABSTRACT FROM AUTHOR]

Background In patients with out-of-hospital cardiac arrest (OHCA), guidelines recommend advanced airway (AA) management at the advanced cardiovascular life support stage; however, the ideal timing remains controversial. Therefore, we evaluated the prognosis according to the timing of AA in patients with OHCA. Methods We conducted a retrospective observational study of patients with OHCA at six major hospitals in Daegu Metropolitan City, South Korea, from August 2019 to June 2022. We compared groups with early and late AA and evaluated prognosis, including recovery of spontaneous circulation (ROSC), survival to discharge, and neurological evaluation, according to AA timing. Results Of 2,087 patients with OHCA, 945 underwent early AA management and 1,142 underwent late AA management. The timing of AA management did not influence ROSC in the emergency department (5–6 minutes: adjusted odds ratio [aOR], 0.97; p=0.914; 7–9 minutes: aOR, 1.37; p=0.223; ≥10 minutes: aOR, 1.32; p=0.345). The timing of AA management also did not influence survival to discharge (5–6 minutes: aOR, 0.79; p=0.680; 7–9 minutes: aOR, 1.04; p=0.944; ≥10 minutes: aOR, 1.86; p=0.320) or good neurological outcomes (5–6 minutes: aOR, 1.72; p=0.512; 7–9 minutes: aOR, 0.48; p=0.471; ≥10 minutes: aOR, 0.96; p=0.892). Conclusion AA timing in patients with OHCA was not associated with ROSC, survival to hospital discharge, or neurological outcomes.

Abstract Objectives While flipped classroom instruction has repeatedly shown efficacy in undergraduate medical education, evidence for its utility in procedural domains remains sparse. This holds particular significance for surgical subspecialties such as otolaryngology, which have limited time in undergraduate medical curricula. We designed a novel airway management skills simulation course with a flipped classroom approach and evaluated its efficacy in a pilot study. Methods A simulation course was designed to provide instruction in seven airway management skills: bag valve mask ventilation, laryngoscopy, intubation, cricothyroidotomy, tracheotomy, and tracheostomy care. Publicly available YouTube videos were selected as pre-learning materials. Participating students completed surveys before the pre-learning assignment and after completion of the simulation center workshop. Results Sixteen students participated in the workshop, and data was collected from 14 participants. Learners reported significant improvements in knowledge regarding all covered skills except tracheotomy; mean self-rated knowledge improved from 2.9 to 5.8 (p

Background and Aims: Precise airway management is vital in thoracic surgeries to ensure patient safety and optimal outcomes. Choosing the correct double-lumen tube (DLT) size is challenging, as it typically relies on height, gender and subjective experience. This study investigates using ultrasonography (USG) and computed tomography (CT) to measure cricoid cartilage diameter for objective DLT sizing. Methods: In a randomised study, 120 adult patients undergoing elective thoracic surgery were randomised to three groups: Group A (DLT size determined by USG), Group B (DLT size determined by CT) and Group C (DLT size determined by conventional methods based on height and gender). The primary outcome variable was the appropriateness of DLT size. Secondary outcome variables were the degree of lung collapse and sore throat. Student’s t-test and ꭓ2 test were used to analyse continuous and dichotomous variables, respectively. Results: DLT sizing based on cricoid cartilage diameter improved the accuracy, with inappropriate sizes found in 25% in the conventional group, 5% in the USG group and 2.5% in the CT group (P < 0.05). Lung collapse was better in the USG (excellent in 92.5%) and CT (95%) groups compared to the conventional group (70%) (P < 0.05). Moderate sore throat was higher in the conventional group (37.5%) compared to the USG (5%) and CT groups (7.5%). Conclusion: The study demonstrates that USG- and CT-guided measurements of cricoid cartilage diameter are reliable and effective methods for determining DLT size in thoracic surgery compared to conventional methods.

Pediatric patients are more susceptible to critical events, the management of their airway necessitates skilled and meticulous interventions. Thus, it is essential to be well versed with the knowledge that can aid in our understanding of the pediatric airway. We conducted a narrative review of the current understanding of pediatric airway assessment techniques, various airway adjuncts and devices, the use of video laryngoscopes for endotracheal intubation and future trends. The databases Ovid, Medline, PubMed, Web of Science, and Google Scholar were searched regarding various aspects of pediatric airway management from 2005 to 2024. The search terms were pediatric or infant difficult airway, pediatric difficult airway, apneic oxygenation, and pediatric airway assessment. One hundred articles were deemed relevant by abstract, and their full text was obtained and examined further for compliance, and finally, 40 full-text articles were included in the study. This article discusses the various challenges of pediatric anesthesia related to airway management, emphasizing the need for individualized perioperative methods due to children’s unique anatomical and physiological features.

Abstract Background Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. Methods This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. Results Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). Conclusions Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. Trial registration The study was registered in the German Register for Clinical Studies (number DRKS00028068).

Abstract Simulation is a cornerstone of medical education for difficult airway management. The lack of standards regarding the frequency of retraining that would ensure the maintenance of skills and competencies over time still needs to be solved.

This study sought to determine the perception of healthcare workers (HCWs) about pre-hospital airway management and their experiences. Methods: This cross-sectional study was conducted among health workers at the emergency department of King Fahad Medical City in the capital of Saudi Arabia, Riyadh City. This study targeted physicians, nurses, paramedics, and respiratory therapists. Data were collected using an online questionnaire. The questionnaire included demographic characteristics, training, and experiences in airway management and a 5-item questionnaire to measure the perception of HCWs about airway management. Results: Of the 100 HCWs, 39% were doctors, and 37% were nurses. Approximately 23% had a poor experience with intubation. Traumatic injuries were the major difficulties involving airway management (44%). The overall perception of HCWs about prehospital airway management was good (68%), 31% were moderate, and only 1% were considered poor perception levels. No significant differences were observed between perception scores in relation to the demographic characteristics and experiences of HCWs in airway management (all p>0.05). Conclusion: Despite HCWs' good perception of prehospital airway management, some gaps have been identified mainly through intubation skills and experiences. This study provided evidence that perception towards prehospital airway management was not affected by profession, years of experience, regular practice of intubation, and airway management. Regular training should be implemented, with equipment and resources should be available to improve airway management and patient quality of care. [SJEMed 2024; 5(2.000): 128-133]

Background and Aims: None of the clinical difficult airway predictors are 100% sensitive and specific. Ultrasound is being used for airway assessment, but there is still no established parameters or model to predict difficult laryngoscopy. This observational study was planned to determine the predictive ability of clinical and sonography-based airway assessment parameters for difficult laryngoscopy and intubation. Material and Methods: A total of 130 patients of 18–60 years of age undergoing elective intubation were included. The distribution of Cormack–Lehane (CL) grade and intubation difficulty scale (IDS) was correlated with the clinical and sonographic screening parameters for difficult airways. Results: The prevalence of difficult laryngoscopy and difficult intubation in our study was 17.6% and 11.5%, respectively. Mallampati grade (MMG), upper lip bite test (ULBT), neck circumference, hyomental distance ratio (HMDR), tongue thickness (TT), skin to epiglottis/epiglottis to vocal cord distance (SED/E-VC), and mandibular condylar mobility (MCM) had significant association with the difficult laryngoscopy and MMG, neck circumference, SED, SED/E-VC; MCM had significant association with the difficult intubation. The combination of these predictors showed better diagnostic ability for difficult airways. Model 1 based on ultrasound parameters showed an area under the curve (AUC) of 0.848 (CI- 0.748-0.947, P value < 0.0001) and model 2 based on combined clinical and ultrasound parameters showed an AUC of 0.755 (95% CI- 0.631-0.879, P value < 0.0001). Conclusions: Ultrasound-based airway predictors can help in predicting difficult laryngoscopy and intubation along with the clinical parameters. Individual sonographic predictors have moderately satisfactory diagnostic profiles. The models based on combined tests have better diagnostic value.

Objective: Air-Q intubating laryngeal airway (ILA) is associated with a 58-77% success rate in blind intubation. The newer laryngeal mask airway (LMA) blockbuster is specially designed to facilitate easier endotracheal intubation and may have a higher success rate. The current study aimed to compare the success rate of endotracheal intubation using the Air-Q ILA and LMA blockbuster. Methods: After ethics committee approval and informed written consent, 140 adult patients with normal airways who were scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were recruited for this randomized controlled trial. Blind endotracheal intubation was performed using the Air-Q ILA in group A and the LMA blockbuster in group B with special maneuvers and/or tubes in the second attempt. Fibreoptic bronchoscope (FOB) guidance was used in the third attempt if required. The primary outcome was the success rate of intubation without FOB assistance. The number of attempts for supraglottic airway (SGA) insertion, the time taken for SGA insertion, and the overall intubation time was also noted. Results: The success rate of intubation without FOB guidance was significantly higher in group B than in group A [91.4% vs 55.7%; relative risk (RR) 1.68; (95% confidence interval (CI) 1.34, 2.11); p

Abstract Introduction Self-directed learning (SDL) stands as a contemporary approach to learning, offering efficient and sustainable strategies for enhancing knowledge and practices. Given the pivotal role of nurses in ensuring patient safety and care effectiveness, this study aims to assess the impact of the SDL model compared to the traditional learning model (TLM) on elevating nurses’ airway management (AM) competencies and minimizing airway-related incidents. Methodology The study employed an experimental research design using a posttest-only control group structure within a two-group comparison framework. Seventy-two nurses participated, with 35 in the study group and 37 in the control group at the Obstetrics and Gynecology Hospital affiliated with Cairo University, Egypt. The trial was carried out between February 2020 and July 2021. Following an assessment of SDL readiness for the intervention group, they received SDL model training based on Knowles’ SDL principles, while the control group received TLM. The primary endpoint was a significant elevation in nurses’ airway management competency, with the secondary outcome being a significant decrease in airway-related incidents reported by nurses. Competency assessments occurred immediately after completion of the intervention and again three months later. Results A statistically significant difference was observed between the control and intervention groups regarding their practice and knowledge scores, with p-values of 0.02 and 0.05). Conclusion The SDL model significantly enhanced nurses’ competencies in AM compared to the TLM. However, the efficacy of both learning models diminishes over time. Although nurses who underwent SDL model reported fewer airway incidents compared to those who received TLM approach of learning, no statistically significant difference was detected. Trial registration The study has been registered with Clinical Trials.gov under the registration number (NCT04244565) on 28/01/2020.

Abstract For many years, ventilation has been an essential part of advanced life support (ALS) in cardiopulmonary resuscitation (CPR). Nevertheless, there is little evidence about the best method of ventilation during resuscitation for both out-of-hospital cardiac arrest (OHCA) and inhospital cardiac arrest (IHCA) patients. Effective ventilation is one of the two main keys to successful resuscitation. In this context, the question always arises as to which airway management, along with which ventilation mode, constitutes the best strategy. Conventional ventilation modes are not designed for cardiac arrest and show important limitations that must be considered when used in CPR. Manual ventilation without the use of an automated transport ventilator (ATV) could be shown to be uncontrolled in applied volumes and pressures and should be avoided. Mechanical ventilation with an ATV is therefore superior to manual ventilation, but both volume- and pressure-controlled ventilation modes are significantly influenced by chest compressions. With the newly designed chest compression synchronized ventilation (CCSV), a special ventilation mode for resuscitation is available. Further research should be conducted to obtain more evidence of the effect of ventilation during CPR on outcomes following OHCA and not only about how to secure the airway for ventilation during CPR.

Abstract Background Double-lumen tubes (DLTs) and bronchial blockers (BBs) can be used to establish one-lung ventilation (OLV) for thoracic surgery. BBs are a good alternative when DLTs are not suitable or patients have difficult airways. However, BBs are more prone to malposition, leading to adverse events. Case presentation We present a 68-year-old male patient who was scheduled for thoracoscopic left lower lobectomy. The patient was not expected to have airway malformation preoperatively. When the DLT could not be inserted into the bronchus after general anesthesia induction, we used a BB to perform OLV. During surgery, malposition of the BB resulted in the development of an “incomplete balloon valve”, leading to a cardiopulmonary crisis. Conclusions Previewing chest computed tomography scans to assess the airway anatomy before thoracic surgery is essential. Three-dimensional reconstruction of the airway can provide a more intuitive assessment of airway anatomy. During OLV with BBs, we should pay attention to balloon malposition to prevent cardiopulmonary crises.

Abstract Pulmonary benign metastasizing leiomyoma is an uncommon condition, predominantly affecting women of childbearing age with a history of uterine smooth muscle tumors and uterine leiomyoma surgery for uterine leiomyoma. The progression of PBML is often unpredictable and depends on the extent of lung involvement. Generally, most patients remain asymptomatic, but a minority may experience coughing, wheezing, or shortness of breath, which are frequently misdiagnosed as pneumonia. consequently, this presents significant challenges in both treatment and nursing care before diagnosis. This paper reports the case of a 35-year-old woman primarily diagnosed with acute hypoxic respiratory failure who was transferred from the emergency room to the intensive care unit. The initial computed tomography scan of the patient’s lungs indicated diffuse interstitial pneumonia, but the sequencing of the alveolar lavage fluid pathogen macro did not detect any bacteria, fungi, or viruses. Moreover, the patient remained in a persistent hypoxic state before the definitive diagnosis. Therefore, our focus was on maintaining the airway patency of the patient, using prone ventilation, inhaling nitric oxide, monitoring electrical impedance tomography, and preventing ventilator-associated pneumonia to improve oxygenation, while awaiting immunohistochemical staining of the patient’s biopsied lung tissue. This would help us clarify the diagnosis and treat it based on etiology. After meticulous treatment and nursing care, the patient was weaned off the ventilator after 26 days and transferred to the respiratory ward after 40 days. This case study may serve as a reference for clinical practice and assist patients suffering from PBML.

Tracheobronchopathia osteoplastica is a rare condition involving large airways with multiple bone and cartilage nodules in the tracheobronchial submucosa. This can cause tracheal stenosis, leading to difficulty in endotracheal intubation. A 79-year-old female patient, who had a history of successful endotracheal intubation for general anesthesia 8 years prior, was scheduled for abdominal surgery. Preoperative chest computed tomography and bronchoscopy revealed slight progression of tracheobronchopathia osteoplastica. Attempts to intubate with a smaller endotracheal tube failed; even the smaller endotracheal tube could barely pass. Mechanical ventilation was successfully administered and the surgery was completed without complications. The use of a smaller endotracheal tube may be beneficial for managing difficult airways in patients with tracheobronchopathia osteoplastica. Chest CT and bronchoscopic examination may be beneficial for evaluating the airway and determining the most appropriate airway management strategy. However, relying solely on these measures may lead to unexpected challenges because there is no established method to evaluate airway in patient with tracheobronchopathia osteoplastica. It is crucial for anesthesiologists to be aware of the potential existence of rare conditions such as tracheobronchopathia osteoplastica and be prepared to handle anticipated or unanticipated difficult airway management.

OBJECTIVES: This study aimed to compare the effects of Macintosh-type and hyperangulated video laryngoscopy (VL) blades on dental force during endotracheal intubation (ETI) using Glidescope and McGrath VL devices. METHODS: In this randomized, crossover, manikin study conducted at a university emergency medicine (EM) program, 65 EM trainees included interns and residents performed 520 intubations using four different VL blades (GlideScope VL with Macintosh-type Mac T3 and hyperangular Lo Pro T3 blades and McGrath VL Macintosh-type MAC 4 and hyperangular McGrath X3 blades) in normal and difficult airway scenarios. The primary outcome of this study was the dental pressure (Newton) exerted during ETI. The secondary outcomes included c-spine motion (degree), intubation success (%), duration (seconds), successful glottic view (%), and intubator comfort (7-point Likert). RESULTS: Significant differences were observed in dental force (H(3) = 11.7, P = 0.008), c-spine motion (H(3) = 8.34, P = 0.039), duration (H(3) = 16.56, P = 0.001), and comfort (H(3) = 174.96, P < 0.001) across blade types. Glidescope LoPro T3 provided a significant lower dental force (adjusted P = 0.01), less c-spine motion (adjusted P = 0.031), and shorter intubation duration (adj P < 0.01) than the McGrath Mac 4. First attempt success and intubator comfort were significantly better with all Glidescope blades (z score of 3.7 and 4.7) than with McGrath blades (z score of-4.1 and-4.4). CONCLUSION: The Glidescope LoPro T3 blade demonstrated advantages in dental force, c-spine motion, and intubation duration compared with McGrath Mac 4. Overall, the Glidescope blades provided superior comfort and higher first attempt success rates.