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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)., (© 2024. The Author(s).)

Background: Based on current evidence, there appears to be an association between peri-intubation hypotension and patient morbidity and mortality. Studies have identified shock indices as possible pre-intubation risk factors for peri-intubation hypotension. Thus, we sought to evaluate the association between shock index (SI), modified shock index (MSI), and diastolic shock index (DSI) and peri-intubation hypotension along with other outcomes., Methods: The present study is a sub-study of a randomized controlled trial involving critically ill patients undergoing intubation. We defined peri-intubation hypotension as a decrease in mean arterial pressure <65 mm Hg and/or a reduction of 40% from baseline; or the initiation of, or increase in infusion dosage of, any vasopressor medication (bolus or infusion) during the 30-min period following intubation. SI, MSI, and DSI were analyzed as continuous variables and categorically using pre-established cut-offs. We also explored the effect of age on shock indices., Results: A total of 151 patients were included in the analysis. Mean pre-intubation SI was 1.0  ±  0.3, MSI 1.5  ±  0.5, and DSI 1.9  ±  0.7. Increasing SI, MSI, and DSI were significantly associated with peri-intubation hypotension (OR [95% CI] per 0.1 increase  =  1.16 [1.04, 1.30], P   =  .009 for SI; 1.14 [1.05, 1.24], P   =  .003 for MSI; and 1.11 [1.04, 1.19], P   =  .003 for DSI). The area under the ROC curves did not differ across shock indices (0.66 vs 0.67 vs 0.69 for SI, MSI, and DSI respectively; P   =  .586). Increasing SI, MSI, and DSI were significantly associated with worse sequential organ failure assessment (SOFA) score (spearman rank correlation: r  =  0.30, r  =  0.40, and r  =  0.45 for SI, MSI, and DSI, respectively, all P  < .001) but not with other outcomes. There was no significant impact when incorporating age., Conclusions: Increasing SI, MSI, and DSI were all significantly associated with peri-intubation hypotension and worse SOFA scores but not with other outcomes. Shock indices remain a useful bedside tool to assess the potential likelihood of peri-intubation hypotension., Trial Registration: ClinicalTrials.gov identifier - NCT02105415., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: With its introduction in 1986, the use of metal tracheal stents gained favor due to relative ease of deployment and reduced risk of stent migration and mucus plugging. However, adverse events associated with metal stenting led the FDA to publish a recommendation against its use for benign airway stenosis in 2005. We present a case which illustrates the difficulty in removal of a metal stent from the airway., Case Report: Our patient is a 47-year-old woman with a history of postintubation tracheal stenosis. She underwent multiple interventions with Thoracic Surgery at an outside facility, including stenting with an Ultraflex expandable metal stent. Her course was complicated by recurrent intraluminal granulation tissue, which led to placement of additional metal stents, as well as a tracheostomy due to obstructive proximal granulation tissue. On presentation at our institution, removal of the stents was recommended due to recurrent tracheitis and proximity of stent fragments to the innominate artery on CT imaging. She underwent direct microlaryngoscopy and bronchoscopy, and stent fragments were removed using a hemostat through the trach stoma. Postoperative imaging has confirmed retained stent fragments, and additional procedures have been required for further removal., Discussion/conclusion: Removal of metal stents from the trachea is challenging for several reasons. Neoepithelization of respiratory mucosa makes identification of fragments difficult. Furthermore, growth of granulation tissue through the metal lattice framework, as well as the stents' tendency to fracture, complicates extraction. This case illustrates the dangers of metal stenting for benign airway stenosis. Laryngoscope, 134:3977-3980, 2024., (© 2024 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Post-extubation dysphagia (PED) emerges as a frequent complication following endotracheal intubation within the intensive care unit (ICU). PED has been strongly linked to adverse outcomes, including aspiration, pneumonia, malnutrition, heightened mortality rates, and prolonged hospitalization, resulting in escalated healthcare expenditures. Nevertheless, the reported incidence of PED varies substantially across the existing body of literature. Therefore, the principal objective of this review was to provide a comprehensive estimate of PED incidence in ICU patients undergoing orotracheal intubation., Methods: We searched Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science, Technology Journal Database (VIP), and SinoMed databases from inception to August 2023. Two reviewers independently screened studies and extracted data. Subsequently, a random-effects model was employed for meta-statistical analysis utilizing the "meta prop" command within Stata SE version 15.0 to ascertain the incidence of PED. In addition, we performed subgroup analyses and meta-regression to elucidate potential sources of heterogeneity among the included studies., Results: Of 4144 studies, 30 studies were included in this review. The overall pooled incidence of PED was 36% (95% confidence interval [CI] 29-44%). Subgroup analyses unveiled that the pooled incidence of PED, stratified by assessment time (≤ 3 h, 4-6 h, ≤ 24 h, and ≤ 48 h), was as follows: 31.0% (95% CI 8.0-59.0%), 28% (95% CI 22.0-35.0%), 41% (95% CI 33.0-49.0%), and 49.0% (95% CI 34.0-63.0%), respectively. When sample size was 100 < N ≤ 300, the PED incidence was more close to the overall PED incidence. Meta-regression analysis highlighted that sample size, assessment time and mean intubation time constituted the source of heterogeneity among the included studies., Conclusion: The incidence of PED was high among ICU patients who underwent orotracheal intubation. ICU professionals should raise awareness about PED. In the meantime, it is important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED., (© 2024. The Author(s).)

Background: Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA., Methods: Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. The primary exposure was TI-CA, defined as cardiac arrest occurred during TI procedure or within 20 min after endotracheal tube placement. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged)., Results: Among 315 children with cardiac arrests, 48 (15.2%) met criteria for TI-CA. Pre-existing medical conditions were similar between groups. Pre-arrest non-invasive mechanical ventilation was more common among TI-CA patients (18/48, 37.5%) compared to non-TI-CA patients (35/267, 13.1%). In 48% (23/48), the TI-CA occurred within 20 min after intubation (i.e., not during intubation). Duration of CPR was longer in TI-CA patients (median 11.0 min, interquartile range [IQR]: 2.5, 35.5) than non-TI-CA patients (median 5.0 min, IQR 2.0, 21.0), p = 0.03. Return of spontaneous circulation occurred in 32/48 (66.7%) TI-CA versus 186/267 (69.7%) non-TI-CA, p = 0.73. Survival to hospital discharge with favorable neurological outcome occurred in 29/48 (60.4%) TI-CA versus 146/267 (54.7%) non-TI-CA, p = 0.53., Conclusions: Fifteen percent of these pediatric ICU cardiac arrests were associated with TI. Half of TI-CA occurred after endotracheal tube placement. While duration of CPR was longer in TI-CA patients, there were no differences in unadjusted outcomes following TI-CA versus non-TI-CA., Trial Registration: The ICU-RESUS (ClinicalTrials.gov Identifier: NCT02837497)., (© 2024. The Author(s).)

Rationale: Primary hyperparathyroidism (PHPT), which is characterized by increased parathyroid hormone secretion, typically manifests as hypercalcemia and hypertension. Here, we report a case of severe hypotension following tracheal intubation during anesthesia induction in a patient with PHPT, in contrast to the expected hypertensive response., Patient Concerns: A 52-year-old man presented with nausea after eating, leg pain when walking, and headaches., Diagnosis: Based on the blood test and computed tomography results, he was diagnosed with PHPT., Interventions: The patient underwent parathyroidectomy under general anesthesia. After induction anesthesia and tracheal intubation, severe acute hypotension and tachycardia suddenly developed. To treat hypotensive shock, we immediately administered ephedrine and phenylephrine and infused Ringer solution., Outcomes: The symptoms of hypotensive shock were alleviated by this intervention., Lessons: We speculate that the cause of his severe hypotension was vasodilation due to the transient release of parathyroid hormone from mechanical stimulation by anesthetic procedures, such as tracheal intubation, combined with hypercalcemia-induced severe dehydration. Moreover, we speculate that fluid resuscitation stabilized his condition and helped achieve a successful surgical outcome. The possibility of severe hypotension after anesthesia induction should be anticipated, and management of cases with severe dehydration should be optimized during the anesthetic management of patients with PHPT., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT., (© 2024. The Author(s).)

Background and Purpose: Patients who have been intubated ≥48 hours are at risk of dysphagia. Evaluation of swallowing before starting oral feeding after extubation is necessary to prevent aspiration and the problems caused by aspiration. The Postextubation Dysphagia Screening tool is a validated and reliable tool used to evaluate extubation-induced dysphagia. This study was conducted to evaluate the validity and reliability of the Postextubation Dysphagia Screening Tool for the Turkish population. Methods: The study had a methodological design and was carried out with 50 patients followed in the intensive care unit of a public hospital. The study was carried out in four stages: (1) language validity, (2) content validity, (3) establishing interrater reliability by agreement with two observers (intensive care nurse and intensivist), and (4) establishing sensitivity and specificity with the intensive care nurse and intensivist. Results: The overall content validity index was 0.91, indicating content validity. Interrater reliability was established (Cohen's g = 0.93). The prevalence of postextubation dysphagia was 42%, and the sensitivity of the Postextubation Dysphagia Screening Tool was 82% and the specificity was 64%. Implications for Practice: The Turkish version of the Postextubation Dysphagia Screening Tool exhibited good evidence of validity and reliability and was determined important as it can help nurses evaluate postextubation dysphagia in intensive care patients. The use of this tool by a nurse reduces the risk of unsafe oral intake among patients after prolonged intubation. This tool allows accurate assessment of dysphagia and initiation of early and safe oral feeding in critical care patients., (© 2024 Springer Publishing Company, LLC.)

Purpose: The aim of this study was to identify factors associated with difficult video laryngoscopy in obese patients., Methods: A total of 579 obese patients undergoing elective laparoscopic weight loss surgery were intubated with a single-lumen endotracheal tube using a video laryngoscopy under general anesthesia, and the patients were divided into two groups based on the Cormack-Lehane classification (difficult video laryngoscopy defined as ≥ 3): the easy video laryngoscopy group and the difficult video laryngoscopy group. Record the general condition of the patient, bedside testing indicators related to the airway, Cormack-Lehane classification during intubation, and intubation failure rate., Results: The findings of this study show that the incidence of difficult video laryngoscopy in obese patients is 4.8%. Multivariate logistic regression analysis indicated that body mass index was significantly associated with difficult video laryngoscopy (OR = 1.082, 95% CI [1.033-1.132], P  < 0.001)., Conclusion: For Chinese obese patients without known difficult airways, the incidence of difficult video laryngoscopy is 4.8%. Body mass index is associated factors for the occurrence of difficult video laryngoscopy, with an increased risk observed as body mass index rise., Competing Interests: The authors declare there are no competing interests., (©2024 Li et al.)

Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit., Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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., (© 2024. The Author(s).)

Objective: To compare the frequency of respiratory complications encountered in two different positions used for extubation i.e. conventional recovery position versus the modified recovery position (recovery position with 10-degree left tilt and head-down)., Study Design: Comparative study. Place and Duration of the Study: Department of Anaesthesia, Combine Military Hospital, Kohat, Pakistan, from April 2022 to March 2023., Methodology: Two hundred patients scheduled for elective nose and throat surgeries were equally divided into two groups (Group C and Group M). Patients with history of bronchial asthma, chronic obstructive pulmonary disease (COPD), recent respiratory infection, and gastro-oesophageal reflux disease (GERD) were excluded from this study. Patients with more than two intubation attempts were also excluded. Group C patients were extubated in a conventional left lateral recovery position, whereas Group M patients were extubated in a modified recovery position with patient in a left lateral position with 10-degree head-down and 10-degree left tilt. All patients were observed for persistent coughing (coughing that lasted for at least 2 minutes after extubation), breath holding for 20 seconds or more, desaturation (oxygen saturation less than 90%), laryngospasm, need for reintubation, vomiting, and regurgitation., Results: Frequency of airway complications was significantly higher in Group C as compared to Group M. In Group C, 18 (18%) out of hundred patients had complications compared to 6 (6%) patients only in Group M (p = 0.009)., Conclusion: Extubation in a modified recovery position is associated with reduced frequency of airway complications as compared to the conventional recovery position., Key Words: Airway complications, Extubation, Cough, Laryngospasm, Recovery position.

Purpose: Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity., Methods: We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival., Results: Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m 2 , no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m 2 and BMI < 30 kg/m 2 )., Conclusions: Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Postextubation dysphagia (PED) is a common complication to endotracheal intubation in critically ill patients and may lead to pneumonia, prolonged ventilation, longer hospital stays, and increased mortality. Recognizing dysphagia is paramount to preventing adverse events. The aim of this study was to describe PED management by investigating practice in Danish intensive care units (ICUs) focusing on current practice in 2023 (screening, prevention, and treatment), perceived best practice (barriers and facilitators), and when possible, to compare practice in 2017 and 2023., Methods: Self-reported, cross-sectional survey of dysphagia practice in Danish ICUs administered from April to May 2023. In addition, data were compared with the 2017 Dysphagia in Intensive Care Evaluation study, when possible., Results: Only half of Danish ICUs reported to have a PED protocol, and less than half routinely screen patients for dysphagia after extubation. Most common screening methods were the oral mechanism examination, water test, and Facio-oral tract therapy. Nurses and physicians often relied on an overall physical assessment of the patient. Best treatment methods were uniformly agreed to be patient positioning, modification of food and fluids, use of ergonomic utensils, and compensatory maneuvers. Key barriers to dysphagia management were lack of specialized staff, under-recognition of dysphagia as a health issue, and lack of standardized protocols., Conclusion: Awareness of PED is increasing and identification, prevention, and treatment is slowly improving, but systematic implementation of protocols for dysphagia screening and treatment could enhance dysphagia management in Danish ICUs., (© 2024 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

The use of the laryngeal mask airway (LMA), which offers the benefits of ease in insertion and prevention of tracheal damage, is associated with a risk of flow leakage. This study analyzed our extensive database to compare leakage associated with the use of LMA and endotracheal tube (ETT). Adult patients who underwent chest wall, abdominal wall, inguinal region, limb, transurethral, or transvaginal surgery and received either LMA or ETT between January 2007 and March 2020 were included. The leak fraction was calculated as (inspiratory tidal volume-expiratory tidal volume)/(inspiratory tidal volume) × 100% every minute during intraoperative stable positive pressure ventilation. The median leak fraction was calculated for each case. The leak fraction in the LMA group demonstrated a left-skewed distribution with a larger proportion of excessive leak fraction. The leak fraction in the LMA group (median, 7.9%; interquartile range, 4.8-11.4%) was significantly lower than that in the ETT group (median, 9.1%; interquartile range: 5.5-12.4%; P < 0.001). This tendency was consistent across subgroups divided by sex, age, type of surgery, and ventilation mode. We propose that LMA provides leakage comparable to or less than ETT in most cases if stable positive pressure ventilation is achieved., (© 2024. The Author(s).)

Study Objective: Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery., Design: Single-center, prospective, randomized, double-blind, placebo-controlled trial., Setting: Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome)., Patients: Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass., Intervention: Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal., Measurements: The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes., Main Results: We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects., Conclusions: Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI., Methods: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel., Results: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture., Conclusions: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia., Materials and Methods: Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation., Results: Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003)., Conclusions: In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required., Competing Interests: Declaration of competing interest RD is a current member of the clinical advisory board of Phagenesis. All other authors declare not conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: Prolonged mechanical ventilation (PMV) and reintubation are among the most serious postoperative adverse events associated with malignant cervical tumors. In this study, we aimed to clarify the incidence, characteristics, and risk factors for PMV and reintubation in target patients., Methods: This retrospective nested case-control study was performed between January 2014 and January 2020 at a large spinal tumor center in China. Univariate analysis was used to identify the possible risk factors associated with PMV and reintubation. Logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) with covariates of a probability < 0.05 in univariate analysis., Results: From a cohort of 560 patients with primary malignant (n = 352) and metastatic (n = 208) cervical tumors, 27 patients required PMV and 20 patients underwent reintubation. The incidence rates of PMV and reintubation were 4.82% and 3.57%, respectively. Three variables (all p < 0.05) were independently associated with an increased risk of PMV: Karnofsky Performance Status < 50 compared to ≥ 80, operation duration ≥ 8 h compared to < 6 h, and C4 nerve root encased by the tumor. Longer operative duration and preoperative hypercapnia (all p < 0.05) were independent risk factors for postoperative reintubation, both of which led to longer length of stay (32.6 ± 30.8 vs. 10.7 ± 5.95 days, p < 0.001), with an in-hospital mortality of 17.0%., Conclusion: Our results demonstrate the risk factors for PMV or reintubation after surgery for malignant cervical tumors. Adequate assessment, early detection, and prevention are necessary for this high-risk population., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring., Methods: In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg -1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg -1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects., Results: The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group., Conclusions: Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023. Published by Elsevier Inc.)

Background: This prospective study aimed to explore the effectiveness of an oral care intervention with Tegaderm on the oral mucosal health of intubated patients., Methods: A total of 70 intubated patients were included and randomly assigned to 1 of 3 groups, clean water brushing teeth (n = 23), brushing teeth combined with mouthwash (BTM) (n = 23), and brushing teeth combined with mouthwash and Tegaderm (BTMT) (n = 24). The Oral Mucositis Assessment Scale (OMAS) was applied to evaluate the patient's oral mucosal health before and after oral care intervention., Results: The BTMT group had lower OMAS scores in almost all regions of the oral cavity, compared to the brushing teeth and BTM groups. The general linear model for repeated measurement indicated the BTMT group had the lowest total OMAS scores from Day 2 to Day 4 after the initiation of baseline OMAS evaluation. Of the 3 intervention groups, the BTMT group had the shortest length of endotracheal intubation. The BTMT group had the lowest incidence rate of ventilator-associated pneumonia; however, no significant between-group differences were found., Conclusions: BTMT effectively reduced the decline in oral mucosal health that was caused by endotracheal intubation and shortened the length of endotracheal intubation., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Double-lumen tubes (DLTs) are commonly used for one-lung ventilation (OLV) in thoracic surgery and the selection of an optimal size of DLTs is still a humongous task. The purpose of this study was to assess the feasibility and accuracy of the method for selecting an optimal size of DLTs in thoracic surgery. Sixty adult patients requiring a left side double-lumen tube (LDLT) for elective thoracoscopic surgery were included in this study. All patients were randomly allocated to the following two groups: Cuffs Collapsed group (CC group, n = 30) and Cuffs Inflated group (CI group, n = 30). In the Cuffs Collapsed group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were collapsed as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice; In the Cuffs Inflated group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were inflated as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice. The primary outcomes were the incidences of airway complications postoperative such as hoarseness and sore throat. The time of intubation and alignment, the incidences of LDLT displacement and adjustment, the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide were also recorded. The incidences of airway complications postoperative such as sore throat and hoarseness were lower in the CI group than the CC group (P < 0.05), the intubation times was shorter in the CI group than the CC group (P < 0.05), while the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide during two-lung ventilation and one-lung ventilation were no significant difference between two groups (P > 0.05). The method which matched the inner diameter of the trachea and bronchus measured on chest CT slice with the outer diameter of the tracheal and bronchial cuffs when they were inflated to select an appropriate size of LDLT can reduce the incidence of airway complications.Trials registration: Clinical Trials: gov. no. NCT05739318. Registered at https://classic.clinicaltrials.gov 22/02/2023., (© 2024. The Author(s).)

Background: In this study, we observed the frequency of side effects encountered when the neural integrity monitor electromyogram endotracheal tube (NIM-EMG-ETT) was used in thyroidectomy and parathyroidectomy surgeries., Methods: After obtaining hospital ethics committee approval, 239 cases affiliated with the American Society of Anesthesiologists (ASA II-IV) who used NIM EMG tubes in thyroid and parathyroid surgery were included in the prospective observational study. Tube and patient-related complications encountered with two different NIM EMG-ETT (silicone and polyvinyl chloride-PVC) were recorded., Results: The average age of the patients is 49.50 ± 13.44 years, the average BMI is 28.25 ± 4.91 kg/m 2 , the median surgery time is 115 (32-475) minutes, 75.7% are women, 97.5% are ASA II. Additional diseases other than thyroid and parathyroid problems were present in 77.3%. Thyroidectomy was performed in 73.2% of the patients. In our study, only 0.8% of patients with transient recurrent laryngeal nerve RLN paralysis were observed in thyroid and parathyroid surgeries performed using NIM-EMG tubes, 3 patient already had nerve involvement in the preoperative period. The most common complication was loss of stimulation response related to tubes and patient-related ventilation failure. There was no difference between the complications of silicone and PVC tubes except for irregular EMG response., Conclusions: There was no significant difference in side effects other than irregular EMG response in the two different tubes we used in our study. It was observed that prolonging the surgical time increased the risk of irregular EMG response. It should not be forgotten that no matter which NIM-EMG tube is used, additional risks are encountered during the intubation and extubation process. In order to avoid negative consequences, it is necessary to follow the usage rules recommended by the manufacturer when using NIM-EMG tubes., (© 2024. The Author(s).)

Background: A difficult airway is anticipated with cervical spine injuries (CSIs) as immobilization techniques such as manual in-line stabilization (MILS) are used, which distort the oro-pharyngeal-laryngeal axis. Video laryngoscopes (VLs) make difficult airway management easy, as they do not require axis alignment. The present study aimed to compare the total time taken by Macintosh laryngoscope (ML), conventional blade, and D-blade ™ of C-MAC ® VL in simulated CSI scenarios using MILS., Methods: Ninety patients were randomly allocated into three groups: Group M (ML), Group C (conventional blade of C-MAC ® ), and Group D (D-blade ™ of C-MAC ® ) with MILS applied before intubation. Primary outcome was the total time taken for successful intubation, while secondary outcomes were to assess Cormack-Lehane (CL) grade, number of attempts, hemodynamic response, and associated complications., Results: Total time for intubation in Group C was 23.40 ± 7.06 sec compared to 35.27 ± 6.53 and 47.27 ± 2.53 sec in groups D and M, respectively ( P < 0.001). CL-grade I was observed in 15/30 (50%) in Group M, 25/30 (83.3%) in Group C, and 29/30 (96.7%) in Group D. Group M reported 7/30 (23.3%) failed intubations, while none were observed in other groups. Hemodynamic parameters were significantly higher at 3 and 5 min in Group M. Postoperative sore throat was recorded in 12/30 (40%) in Group M compared to 3/30 (10%) in groups C and D each ( P value 0.037)., Conclusion: C-MAC ® VL requires less time for intubation, provides better glottic view, and has higher success, with better attenuation of hemodynamic response and fewer complications compared to ML., (Copyright © 2024 Copyright: © 2024 Journal of Postgraduate Medicine.)

Background and Aims: In cervical spine injuries, there is an impairment in positioning of the patient to maintain the airway axis during endotracheal intubation (ETI). Literature shows video laryngoscope (VLS) facilitating the intubation in these patients with cervical immobilization. VL3 VLS (HugeMed Medical Technical Development, Shenzhen, China) is a newer VLS with limited studies. The primary aim of this study is to compare the efficacy of ETI using VL3 VLS with Macintosh and McCoy (MC) blades for simulated difficult airway with rigid cervical collar (RCC). The secondary aim was to compare the oral insertion of laryngoscope and intraoral bleeding., Methods: One hundred and fifty patients were randomly divided into three groups depending on laryngoscope used for ETI. Group M, Group V, and Group MC used Macintosh, VL3, and MC laryngoscopic blades, respectively, for ETI. During ETI, the Intubation Difficulty Scale (IDS), intubation time (IT), ease of laryngoscope insertion, and any bleeding intraorally were noted. The data collected were further analyzed., Results: IDS was statistically significantly least (0.9 ± 1.5) with VL3 VLS compared to direct laryngoscopy with Macintosh and MC blades. There was significantly no difference in IT among the three groups. Insertion of blade of VL3 was significantly more difficult than Macintosh or MC. Intraoral bleeding was present in 8% of patients with VL3., Conclusion: VL3 VLS can be used for ETI during cervical immobilization using RCC. More studies are needed to define its efficacy in different difficult airway situations compared with different VLS., (Copyright © 2024 Copyright: © 2024 Annals of African Medicine.)

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different., Case Description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax., Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.

Objective: To assess whether the respiratory oxygenation index (ROX index) measured after the start of high-flow nasal cannula oxygen therapy can help identify the need for intubation in patients with acute respiratory failure due to coronavirus disease 2019., Methods: This retrospective, observational, multicenter study was conducted at the intensive care units of six Brazilian hospitals from March to December 2020. The primary outcome was the need for intubation up to 7 days after starting the high-flow nasal cannula., Results: A total of 444 patients were included in the study, and 261 (58.7%) were subjected to intubation. An analysis of the area under the receiver operating characteristic curve (AUROC) showed that the ability to discriminate between successful and failed high-flow nasal cannula oxygen therapy within 7 days was greater for the ROX index measured at 24 hours (AUROC 0.80; 95%CI 0.76 - 0.84). The median interval between high-flow nasal cannula initiation and intubation was 24 hours (24 - 72), and the most accurate predictor of intubation obtained before 24 hours was the ROX index measured at 12 hours (AUROC 0.75; 95%CI 0.70 - 0.79). Kaplan-Meier curves revealed a greater probability of intubation within 7 days in patients with a ROX index ≤ 5.54 at 12 hours (hazard ratio 3.07; 95%CI 2.24 - 4.20) and ≤ 5.96 at 24 hours (hazard ratio 5.15; 95%CI 3.65 - 7.27)., Conclusion: The ROX index can aid in the early identification of patients with acute respiratory failure due to COVID-19 who will progress to the failure of high-flow nasal cannula supportive therapy and the need for intubation.

Background: Music therapy has been used as a complementary intervention to provide synergistic analgesia for various procedures., Objective: To evaluate the effects of natural sound therapy on pain intensity and agitation scores in intubated adult Chinese patients who received endotracheal suctioning in a critical care unit., Methods: A prospective, real-world, randomized, double-blind, controlled study was conducted from July 2021 through February 2022 among intubated surgical intensive care unit patients in a Chinese hospital. Patients were randomly assigned to a control group receiving conventional treatment or an intervention group receiving natural sound therapy plus conventional treatment (50 patients in each group). Patients' pain intensity and agitation levels were analyzed before, during, immediately after, 5 minutes after, and 15 minutes after completion of endotracheal suctioning. Pain intensity was assessed with the Critical-Care Pain Observation Tool (CPOT); agitation was assessed with the Richmond Agitation-Sedation Scale (RASS)., Results: According to CPOT scores, patients in the intervention group had significant relief of pain intensity during, immediately after, and 5 minutes after endotracheal suctioning compared with patients in the control group (all P < .001). The RASS scores showed that agitation levels were significant lower in the intervention group than in the control group during (P = .002) and immediately after (P < .001) endotracheal suctioning., Conclusions: In this real-world study, natural sound therapy was part of a holistic bundle of interventions used to reduce pain and agitation in surgical intensive care unit patients during endotracheal suctioning., (©2024 American Association of Critical-Care Nurses.)

Background: Tracheal intubation sometimes causes postoperative sore throat (POST) due to laryngeal damage. However, clinical observations suggest that the environment of the oral cavity may also affect POST., Objective: The purpose of this study was to investigate whether salivary pH in the oral cavity affects POST., Methods: After obtaining ethical approval, informed consent was obtained from all patients. Patients who underwent surgery in the supine position were enrolled as the control group. Patients who underwent laparoscopic surgery in the head-down position were enrolled as the intervention group. Immediately before both groups of patients were anaesthetised, expelled saliva was collected, and salivary pH was measured. Immediately postoperatively, the same measurement was carried out before the patient regained consciousness. The primary outcome was the change in salivary pH. The secondary outcome was POST. In our study, POST was defined as pharyngeal and swallowing pain in the glossopharyngeal and superior laryngeal nerves. The normal distribution of pH was tested using the Shapiro-Wilk test followed by analysis using repeated-measurements and one-way analysis of variance. Statistical significance was set at p < .05., Results: A total of 62 patients were enrolled, of whom two were excluded based on the exclusion criteria. Salivary pH in the intervention group was significantly lower than that in the control group. Five patients had POST in the intervention group, whereas none had POST in the control group had POST., Conclusion: Acidotic-shifted saliva is considered one of the causes of POST., (© 2024 John Wiley & Sons Ltd.)

Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population., Methods: This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence., Results: Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively., Conclusion: Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the effectiveness of peri-intubation non-pharmacological interventions in reducing postoperative sore throat (POST), cough (PEC), and hoarseness in surgical patients., Design: A systematic review with meta-analysis and meta-regression., Setting: Elective surgery under general anesthesia in operating rooms., Main Outcome Measures: Evaluate the impact of non-pharmacological interventions, including pre-intubation (gargling with Sodium Azulene Sulfonate, licorice, or using Strepsils tablets of honey and lemon lozenge), during-intubation (inflating the TT cuff with normal saline and softening the ETT cuff with warm normal saline), and post-intubation (cold vapor therapy, gargling with honey lemon water, and using green tea gargle), on the occurrence of POST, PEC, and hoarseness., Results: Nineteen trials with 2,136 participants were included. Pre-intubation intervention significantly reduced POST immediately after extubation (n = 861; OR: 0.28, 95 % CI: 0.20-0.38, P < 0.001), and 24 h post-extubation (n = 1006; OR: 0.21, 95 % CI: 0.16-0.28, P < 0.001). During-intubation intervention did not show significant effects on POST. Pre-intubation intervention also reduced POST-associated pain score at 24 h post-extubation (n = 440; MD: -0.50, 95 % CI: -0.81 to -0.18, P < 0.001). Post-intubation interventions were effective in reducing POST-associated pain scores at different time points post-extubation (P < 0.05). Pre-intubation intervention significantly reduced PEC (OR: 0.13, 95 % CI: 0.02-0.70, P = 0.02) and hoarseness (OR: 0.36, 95 %CI: 0.15-0.86, P = 0.02) at 24 h post-extubation. However, during-intubation interventions did not reduce hoarseness at 24 h post-extubation., Conclusion: Pre-intubation non-pharmacological interventions were found to be the most effective in reducing the incidence and severity of POST, PEC, and hoarseness., Implications for Clinical Practice: Implementing pre-intubation non-pharmacological interventions can be beneficial for bedside nurses and healthcare professionals in reducing postoperative complications and nurses can contribute to improving patient comfort and recovery outcomes following surgery., Systematic Review Protocol: The protocol was registered in the PROSPERO international prospective register of systematic reviews on 2 January 2024 (CRD42023492813)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This case report describes laryngeal oedema occurring in a 35-year-old woman with chronic bowel-associated dermatosis-arthritis syndrome, and stenosis of the left main bronchus. The oedema was attributed to persistent cough exacerbated by delayed treatment and intubation-related irritation. Evaluations ruled out inflammatory, autoimmune, and malignant causes. Literature lacks on specific descriptions of cough-induced laryngeal oedema, emphasizing the need for a multidisciplinary approach and early intervention in complex cases to prevent severe hospitalizations in patients with known serious conditions and symptom exacerbation., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Background: Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS)., Methods: The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results., Results: Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001)., Conclusion: Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future., (© 2024. The Author(s).)

Background: Among critically ill adults undergoing tracheal intubation, hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain., Methods: In a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults (age, ≥18 years) undergoing tracheal intubation to receive preoxygenation with either noninvasive ventilation or an oxygen mask. The primary outcome was hypoxemia during intubation, defined by an oxygen saturation of less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation., Results: Among the 1301 patients enrolled, hypoxemia occurred in 57 of 624 patients (9.1%) in the noninvasive-ventilation group and in 118 of 637 patients (18.5%) in the oxygen-mask group (difference, -9.4 percentage points; 95% confidence interval [CI], -13.2 to -5.6; P<0.001). Cardiac arrest occurred in 1 patient (0.2%) in the noninvasive-ventilation group and in 7 patients (1.1%) in the oxygen-mask group (difference, -0.9 percentage points; 95% CI, -1.8 to -0.1). Aspiration occurred in 6 patients (0.9%) in the noninvasive-ventilation group and in 9 patients (1.4%) in the oxygen-mask group (difference, -0.4 percentage points; 95% CI, -1.6 to 0.7)., Conclusions: Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask. (Funded by the U.S. Department of Defense; PREOXI ClinicalTrials.gov number, NCT05267652.)., (Copyright © 2024 Massachusetts Medical Society.)

Background: The present study aims to determine the impact of different cuff diameters on the cuff pressure of endotracheal tubes (ETTs) when the trachea is adequately sealed., Methods: In the present single-center clinical trial, adult patients who underwent cardiothoracic surgery were assigned to use ETTs from 2 brands (GME and GZW). The primary endpoint comprised of the following: cuff diameter, inner diameter of the ETT, manufacturer, and the number of subjects with tracheal leakage when the cuff pressure was 30 cm H2O., Results: A total of 298 patients were assigned into 2 groups, based on the 2 distinct brands of ETTs: experimental group (n = 122, GME brand) and control group (n = 176, GZW brand). There were no significant differences in baseline characteristics. However, the cuff diameter was significantly smaller in the control group, when compared to the experimental group (P = .001), and the incidence of tracheal leakage was significantly higher in the control group (P = .001). Furthermore, the GME brand ETT had a significantly larger cuff diameter, when compared to the GZW brand ETT., Conclusion: The cuff size would mismatch the tracheal area in clinical practice. Therefore, chest computed tomography is recommended to routinely evaluate the tracheal cross-sectional area during anesthesia, in order to ensure the appropriate cuff size selection., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

BACKGROUND We present an exceptional case of asystole and tracheal diverticulum rupture as a result of cardiopulmonary resuscitation (CPR) immediately following laparoscopic cholecystectomy performed at Riga 1st Hospital. Tracheal rupture after tracheal intubation is a severe but very rare complication that can be fatal. We present an incidental finding of the tracheal diverticulum and its rupture during CPR. CASE REPORT A 71-year-old woman (American Society of Anesthesiologists class II, body mass index 28.58) underwent a planned laparoscopic cholecystectomy. Preoperative chest X-ray showed no abnormalities. Endotracheal intubation was performed, with the first attempt with a 7-mm inner diameter cuffed endotracheal tube without an introducer. Five minutes after rapid desufflation of the pneumoperitoneum, severe bradycardia and hypotension occurred, followed by asystole. CPR was performed for a total of 2 min, until spontaneous circulation returned. Twenty hours after surgery, subcutaneous emphysema appeared on the chest. Computed tomography scan of the chest revealed subcutaneous neck emphysema, bilateral pneumothorax, extensive pneumomediastinitis, and a pocket-like, air-filled tissue defect measuring 10×32 mm in the distal third of the trachea, with suspected rupture. Two hours after the diagnosis was established, the emergent surgery was performed. The patient was completely recovered after 15 days. CONCLUSIONS Our case illustrates that tracheal diverticula is sometimes diagnosed by accident and too late, which then can lead to life-threatening situations. Tracheal rupture can be made not only by mechanical piercing by an endotracheal tube but also during interventions, such as CPR. Rapid desufflation of the pneumoperitoneum can lead to asystole, induced by the Bezold-Jarisch reflex.

Background: This scoping review was conducted to summarise and map studies on pain resulting from endotracheal suctioning in paediatric intensive care patients., Method: This scoping review conducted in June 2022 was performed by screening articles published in English. Scopus, PubMed, Cochrane, Web of Science, MedLine and Ovid databases were used for screening. The keywords 'endotracheal suctioning', 'pain', 'paediatric intensive care' and their synonyms were used in the search., Results: During the review, 280 articles were accessed, and the full texts of 14 articles were evaluated for suitability. After some of the articles were excluded from the study, abstracts of nine articles were given below., Conclusion: It is recommended that a greater number of randomised controlled studies should be conducted, because the number of studies with a high level of evidence on the effect of endotracheal suctioning on the pain levels of patients in the paediatric intensive care unit is very few.

Aim: The commonly recommended endotracheal tube cuff pressure is 20-30 cmH 2 O. However, some patients require a cuff pressure of >30 cmH 2 O to prevent air leakage. The study aims to determine the risk factors that contribute to the endotracheal tube cuff pressure of >30 cmH 2 O to prevent air leakage., Design: A multi-centre prospective observational study., Methods: Eligible patients undergoing mechanical ventilation in the intensive care unit of three hospitals between March 2020 and July 2022 were included. The endotracheal tube cuff pressure to prevent air leakage was determined using the minimal occlusive volume technique. The patient demographics and clinical information were collected., Results: A total of 284 patients were included. Among these patients, 55 (19.37%) patients required a cuff pressure of >30 cmH 2 O to prevent air leakage. The multivariate logistic regression results revealed that the surgical operation (odds ratio [OR]: 8.485, 95% confidence interval [CI]: 1.066-67.525, p = 0.043) was inversely associated with the endotracheal tube cuff pressure of >30 cmH 2 O, while the oral intubation route (OR: 0.127, 95% CI: 0.022-0.750, p = 0.023) and cuff inner diameter minus tracheal area (OR: 0.949, 95% CI: 0.933-0.966, p < 0.001) were negatively associated with the endotracheal tube cuff pressure of >30 cmH 2 O. Therefore, a significant number of patients require an endotracheal tube cuff pressure of ＞30 cmH 2 O to prevent air leakage. Several factors, including the surgical operation, intubation route, and difference between the cuff inner diameter and tracheal area at the T3 vertebra, should be considered when determining the appropriate cuff pressure during mechanical ventilation., (© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.)

Purpose: We aimed to determine the tongue edema that may develop due to the pressure exerted by the endotracheal intubation (ETI) tube on the tongue during the follow-up period of mechanical ventilation in patients intubated in the intensive care unit (ICU) by submental ultrasonography (USG). Also, we aimed to investigate the effect of tongue edema on the oxygen saturation values (SpO 2 ) measured two h after extubation., Methods: One hundred patients aged 18-65 years, who were followed up with mechanical ventilation in the ICU from the 0th day of intubation, were included. Patients (n = 57) who were followed up on mechanical ventilation for four days or longer after ETI were included in the study group. Those who were followed up on mechanical ventilation for three days or less after endotracheal intubation and were extubated during this period were included in the control group (n = 43). The tongue cross-sectional areas (TSAs) of patients in both groups were measured twice with submental USG. The first measurement (TSA 1 ) was performed on the 0th day of ETI in all patients in both groups. The second measurement (TSA 2 ) was performed on the 4th day of ETI in the study group and just before extubation in the control group. The difference between TSA 2 and TSA 1 was defined as tongue edema. Also, the effect of tongue edema on the oxygen saturation levels measured at the 2nd h after extubation of the patients in the control group was investigated., Results: The tongue edema was more prevalent in the study group (p < 0.01). A significant negative correlation was found between the SpO 2 levels two hours after extubation and the increase in the mean TSA values indicating tongue edema (p < 0.01). The oxygen saturations of the patients with tongue edema were 4% lower than those without tongue edema., Conclusions: Tongue edema may develop due to the long-term application of pressure of the ETI tube on the tongue and may impair oxygenation after extubation., Gov Identifier: NCT05249738., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Expiratory central airway collapse (ECAC) following postintubation airway stenosis (PITS) is a rare phenomenon. The impact of airway malacia and collapse on the prognosis and the success rate of bronchoscopic interventional therapy in patients with PITS had been inadequately investigated., Objective: The aim of this research was to assess the influence of airway malacia and collapse on the efficacy of bronchoscopic interventional therapy in patients with PITS., Design: This retrospective analysis examined the medical documentation of individuals diagnosed with PITS who underwent bronchoscopic intervention at the tertiary interventional pulmonology center of Emergency General Hospital from 2014 to 2021., Main Outcome Measures: Data pertaining to preoperative, perioperative, and postoperative stages were documented and subjected to analysis., Results: The patients in malacia and collapse group (MC group) exhibited a higher frequency of perioperative complications, including intraoperative hypoxemia, need for reoperation within 24 h, and postoperative intensive care unit admission rate (P < 0.05, respectively). Meanwhile, patients in group MC demonstrated significantly worse postoperative scores (higher mMRC score and lower KPS score) compared to those in pure stenosis group (P < 0.05, respectively), along with higher degrees of stenosis after treatment and a lower success rate of bronchoscopic intervention therapy cured (P < 0.05, respectively). Pearson analysis results showed that these terms were all significantly correlated with the occurrence of airway malacia and collapse in the airway (P < 0.05, respectively)., Conclusion: The presence of malacia or collapse in patients with PITS was associated with increased perioperative complications following bronchoscopic interventional therapy, and significantly reduced the long-term cure rate compared to patients with pure tracheal stenosis. Trial registration Chinese Clinical Trial Registry on 06/12/2021., Registration Number: ChiCTR2100053991., (© 2024. The Author(s).)