Comparison of VividTrac, King Vision and Macintosh laryngoscopes in normal and difficult airways during simulated cardiopulmonary resuscitation among novices

Introduction Early endotracheal intubation improves neurological outcomes in cardiopulmonary resuscitation, although cardiopulmonary resuscitation is initially carried out by personnel with limited experience in a significant proportion of cases. Videolaryngoscopes might decrease the number of attempts and time needed, especially among novices. We sought to compare videolaryngoscopes with direct laryngoscopes in simulated cardiopulmonary resuscitation scenarios. Materials and methods Forty-four medical students were recruited to serve as novice users. Following brief, standardized training, students executed endotracheal intubation with the King Vision®, Macintosh and VividTrac® laryngoscopes, on a cardiopulmonary resuscitation trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction. Results In the normal airway scenario, significantly shorter intubation times were achieved using the King Vision® than the Macintosh laryngoscope. In the difficult airway scenario, we found that the VividTrac® was superior to the King Vision® and Macintosh laryngoscopes in the laryngoscopy time. In both scenarios, we noted no difference in the first-attempt success rate, but the best view of the glottis and dental trauma, esophageal intubation and bougie use were more frequent with the Macintosh laryngoscope than with the videolaryngoscopes. The shortest tube insertion times were achieved using the King Vision® in both scenarios. Conclusion All providers achieved successful intubation within three attempts, but we found no device superior in any of our scenarios regarding the first-attempt success rate. The King Vision® was superior to the Macintosh laryngoscope in the intubation time in the normal airway scenario and noninferior in the difficult airway scenario for novice users. We noted significantly less esophageal intubation using the videolaryngoscopes than using the Macintosh laryngoscope in both scenarios. Based on our results, the KingVision® might be recommended over the VividTrac® and Macintosh laryngoscopes for further evaluation.

Neonatal Respiratory Distress and Airway Emergency: Report of Two Cases

We discuss two cases of congenital airway malformations seen in our neonatal intensive care unit (NICU). The aim is to report extremely rare events characterized by immediate respiratory distress after delivery and the impossibility to ventilate and intubate the airway. The first case is a male twin born at 34 weeks by emergency caesarean section. Immediately after delivery, the newborn was cyanotic and showed severe respiratory distress. Bag-valve-mask ventilation did not relieve the respiratory distress but allowed for temporary oxygenation during subsequent unsuccessful oral-tracheal intubation (OTI) attempts. Flexible laryngoscopy revealed complete subglottic obstruction. Postmortem analysis revealed a poly-malformative syndrome, unilateral multicystic renal dysplasia with a complete subglottic diaphragm, and a tracheo-esophageal fistula (TEF). The second case is a male patient that was vaginally born at 35 weeks. Antenatally, an ultrasound (US) arose suspicion for a VACTERL association (vertebral defects, anal atresia, TEF with esophageal atresia and radial or renal dysplasia, plus cardiovascular and limb defects) and a TEF, and thus, fetal magnetic resonance (MRI) was scheduled. Spontaneous labor started shortly thereafter, before imaging could be performed. Respiratory distress, cyanosis, and absence of an audible cry was observed immediately at delivery. Attempts at OTI were unsuccessful, whereas bag-valve-mask ventilation and esophageal intubation allowed for sufficient oxygenation. An emergency tracheostomy was attempted, although no trachea could be found on cervical exploration. Postmortem analysis revealed tracheal agenesis (TA), renal dysplasia, anal atresia, and a single umbilical artery. Clinicians need to be aware of congenital airway malformations and subsequent difficulties upon endotracheal intubation and must plan for multidisciplinary management of the airway at delivery, including emergency esophageal intubation and tracheostomy.

Comparison of VividTrac®, King Vision® and Macintosh laryngoscopy for normal and difficult airways during simulated cardiopulmonary resuscitation among novices

Background: Successful early endotracheal intubation improves neurological outcomes in cardiopulmonary resuscitation. However, endotracheal intubation should not compromise cardiopulmonary resuscitation effectiveness and thus requires experience. The use of videolaryngoscopes might decrease the number of attempts as well as the time needed for intubation, especially among novice users. We sought to compare videolaryngoscopes with direct laryngoscopy in simulated cardiopulmonary resuscitation scenarios in mannequins by novices.Methods: Forty-four medical students were recruited to serve as novice users. Following brief, standardized training, students were asked to execute endotracheal intubation with each of the devices, including the King Vision®, the Macintosh laryngoscope and the VividTrac®, on acardiopulmonary resuscitation trainer (Ambu Man Advanced®) in normal and difficult airway scenarios. We evaluated the time to and the proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction.Results: In the normal airway scenario, significantly shorter intubation times (P < 0.05) were measured by King Vision®than by Macintosh laryngoscope. However, VividTrac® was proven to be similar (P > 0.05) to Macintosh laryngoscope in this regard in the normal airway scenario. In the difficult airway scenarios, we found VividTrac® superior (P < 0.05) to King Vision® and Macintosh laryngoscope regarding laryngoscopy times, but there were no significant differences between devices in intubation times. In both normal and difficult airway cardiopulmonary resuscitation scenarios, we noted no difference (P > 0.05) in first attempt success rates, the best view of the glottis and dental trauma, but esophageal intubation and the use of bougie were more frequent (P < 0.05) withMacintosh laryngoscopethan with videolaryngoscopes. The shortest tube insertion times were related to King Vision® in both scenarios.Conclusion: Based upon our results, King Vision®was superior to Macintosh laryngoscoperegarding intubation time in the normal airway cardiopulmonary resuscitation scenario for novice users. We noted significantly less esophageal intubationwhen using videolaryngoscopes compared to Macintosh laryngoscope in both scenarios; thus,videolaryngoscopes might be recommended for novice users for both cardiopulmonary resuscitation scenarios.

Teaching Review on Approach of Esophageal Intubation as Complications in Emergency Airway Management

Background: Intubation is daily process in hospitals, it’s insertion of tube to secure an airway, nonemergent intubation is done in well controlled circumstances, while emergent intubation is not. Most emergency intubated are cardiac or respiratory arrest patients. Intubation helps to secure airway for patient breathing, also could protect from aspiration. Most common complications are: esophagus intubation and hypotension. This research will be divided into two main topics, emergency intubation as a whole, and unrecognized esophagus intubation as a complication. Emergency intubation discuss: knowledge about the procedure, equipment needed, airway assessment, preoxygenation, difficulties and risks, outcomes. While Unrecognized esophagus intubation will be discussed as complication in ER settings, point to clear: Epidemiology, tools of detection, equipment, human and environmental bias and consideration for cardiac arrest patients. Finishing with a conclusion and recommendation. Therefore, we aim to look into the common pitfalls that both medical students and new physicians face in the recognition, diagnosis, and Emergency Airway Management. Targeted Population: Airway cardiorespiratory arrest patients who are requiring urgent management in the ED, with emergency physicians for teaching approach protocol. Aim of the Study: Appropriate for assessment and priorities for Airway cardiorespiratory arrest patients by training protocol to emergency physicians. Based on patients’ causes of Airway injuries. Methods: Collection of all possible available data about the Esophageal Intubation as Complications in the Emergency department. By many research questions to achieve these aims so a midline literature search was performed with the keywords “critical care”, “emergency medicine”, “principals of airway management”, “Esophageal Intubation as Complications”. Literature search included an overview of recent definition, causes and recent therapeutic strategies. Results: All studies introduced that the initial diagnosis of Esophageal Intubation as Complications is a lifesaving conditions that face patients of the emergency and critical care departments. Conclusion: Intubation in emergency settings require a good preparation, available equipment (e.g. ready cart for all time), and supportive anatomical airway of the patient. Following a checklist will improve outcomes, prevent malpractice and complications. Preoxygenation and RSI play major roles for successful intubations with decrease risk of complications. Follow procedure steps, and expect difficult intubation for any patient, so consider LEMON mnemonic to evaluate risk of difficulty, and after 3 attempts try a different technique or equipment. More training and education are essential to decrease congenital and equipotential mistakes/errors.

Application of bedside real-time tracheal ultrasonography for confirmation of emergency endotracheal intubation in patients in the intensive care unit

Objective Critically ill patients often require emergency endotracheal intubation and mechanical ventilation. When esophageal intubation is not confirmed early, treatment may be delayed, even for life-threatening conditions. We examined the accuracy of bedside real-time airway ultrasonography in confirming the endotracheal tube (ETT) position during emergency endotracheal intubation in patients in the intensive care unit (ICU). Methods This single-center prospective observational study included 118 patients who underwent urgent endotracheal intubation in the ICU of Taizhou Hospital of Integrated Traditional Chinese and Western Medicine. Tracheal ultrasonography was used to confirm the ETT position during endotracheal intubation, after which fiberoptic bronchoscopy was performed. The accuracy of bedside real-time tracheal ultrasonography in determining the ETT position was examined. Results Twelve (10.2%) patients underwent endotracheal intubation. The kappa value was 0.844, indicating perfect consistency between tracheal ultrasonography and fiberoptic bronchoscopy in identifying esophageal intubation. The sensitivity, specificity, and positive and negative predictive values of tracheal ultrasonography in determining the ETT position were 75.0%, 100%, 100%, and 97.2%, respectively. Conclusions Bedside real-time tracheal ultrasonography accurately assesses the ETT position in the ICU and can identify the ETT position during intubation. These findings have important clinical applications and are of great significance for treatment of ICU patients.

Endotracheal and Enteric Tubes

The Endotracheal and Enteric Tubes chapter addresses these frequently used medical devices. An endotracheal tube (ETT) is a catheter placed into the airway for mechanical ventilation. It serves to protect the airway and provide adequate gas exchange. The ideal position of the endotracheal tube tip is approximately 5 cm above the carina. Complications of ETT placement include inadequate ventilation if placed too high or too low, esophageal intubation and tracheal injury. Tracheostomy tubes are used in patients who require long-term intubation. Enteric tubes are thin flexible hollow catheters that course into the stomach and beyond. They may be placed via nasal (nasogastic) or oral (orogastric) approach. When used for suctioning, the ideal position of the tube tip is within the stomach. When used for administration of drugs or nutrition, the tube tip is ideally advanced beyond the pylorus. Enteric tube malposition may be due to coiling within the esophagus or inadvertent malposition within the airway. Malpositioning could result in aspiration, lung injury, and pneumothorax.