Spontaneous Breathing for Panendoscopy? Retrospective Cohort and Results of a French Practice Survey

Objective Avoiding tracheal intubation by using general anesthesia with spontaneous breathing (GASB) is attractive for upper airway panendoscopy. The aim of this study was to estimate the incidence of adverse events during panendoscopy under GASB and to assess the practices of French anesthesiologists. Study Design Two-phase study: monocentric retrospective study and national survey. Setting University hospital center. Methods Patients who underwent a panendoscopy under GASB at the University Hospital of Angers between January 1 and December 31, 2014, were reviewed. Failure of GASB was defined as an episode of hypoxemia (SpO2 ≤88%) or the need for face mask ventilation with or without tracheal intubation. Then, we sent an electronic survey to all members of the French Society of Anaesthesia and Intensive Care. Results Among the 95 included patients, 22 (23%) experienced a failure of GASB: 3 tolerated hypoxemia, 15 had face mask ventilation episodes, and 4 were intubated. Three factors were associated with failure: obesity (odds ratio, 11.94; 95% CI, 3.20-44.64), history of difficult intubation defined as a Cormack score ≥3 (odds ratio, 6.20; 95% CI, 1.51-25.41), and laryngeal tumor (odds ratio, 2.81; 95% CI, 1.04-7.56). Among the 3930 members of the French Society of Anaesthesia and Intensive Care in 2018, 662 (16.8%) responded to the survey. The 2 preferred techniques to perform panendoscopy were intubation (62%) and intravenous sedation with spontaneous breathing (37%). Conclusion Although general anesthesia with orotracheal intubation remains the preferred technique for panendoscopy in France, GASB is an attractive alternative with a low failure rate. Risk factors for failure are obesity, history of difficult intubation, and laryngeal tumor.

Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials

Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.

Feasibility and Effect of Physiological-Based CPAP in Preterm Infants at Birth

Background: Preterm infants are commonly supported with 5–8 cmH2O CPAP. However, animal studies demonstrate that high initial CPAP levels (12–15 cmH2O) which are then reduced (termed physiological based (PB)-CPAP), improve lung aeration without adversely affecting cardiovascular function. We investigated the feasibility of PB-CPAP and the effect in preterm infants at birth.Methods: Preterm infants (24–30 weeks gestation) were randomized to PB-CPAP or 5–8 cmH2O CPAP for the first 10 min after birth. PB-CPAP consisted of 15 cmH2O CPAP that was decreased when infants were stabilized (heart rate ≥100 bpm, SpO2 ≥85%, FiO2 ≤ 0.4, spontaneous breathing) to 8 cmH2O with steps of ~2/3 cmH2O/min. Primary outcomes were feasibility and SpO2 in the first 5 min after birth. Secondary outcomes included physiological and breathing parameters and short-term neonatal outcomes. Planned enrollment was 42 infants.Results: The trial was stopped after enrolling 31 infants due to a low inclusion rate and recent changes in the local resuscitation guideline that conflict with the study protocol. Measurements were available for analysis in 28 infants (PB-CPAP n = 8, 5–8 cmH2O n = 20). Protocol deviations in the PB-CPAP group included one infant receiving 3 inflations with 15 cmH2O PEEP and two infants in which CPAP levels were decreased faster than described in the study protocol. In the 5–8 cmH2O CPAP group, three infants received 4, 10, and 12 cmH2O CPAP. During evaluations, caregivers indicated that the current PB-CPAP protocol was difficult to execute. The SpO2 in the first 5 min after birth was not different [61 (49–70) vs. 64 (47–74), p = 0.973]. However, infants receiving PB-CPAP achieved higher heart rates [121 (111–130) vs. 97 (82–119) bpm, p = 0.016] and duration of mask ventilation was shorter [0:42 (0:34–2:22) vs. 2:58 (1:36–6:03) min, p = 0.020]. Infants in the PB-CPAP group required 6:36 (5:49-11:03) min to stabilize, compared to 9:57 (6:58–15:06) min in the 5–8 cmH2O CPAP group (p = 0.256). There were no differences in short-term outcomes.Conclusion: Stabilization of preterm infants with PB-CPAP is feasible but tailoring CPAP appeared challenging. PB-CPAP did not lead to higher SpO2 but increased heart rate and shortened the duration of mask ventilation, which may reflect faster lung aeration.

A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

Abstract 11045: Pre-Hospital Airway for Out-of-Hospital Cardiac Arrest: A Nationwide Multicenter Study

Introduction: This study investigated whether use of pre-hospital advanced airway management (AAM) is associated with improved survival of adults with out-of hospital cardiac arrest (OHCA) compared to conventional bag-valve-mask ventilation (BVM). Method: The study subjects were derived from Korean Cardiac Arrest Research Consortium (KoCARC), a multi-center OHCA registry of Korea. Patients who underwent AAM or BVM using supraglottic airway, oropharyngeal airway, or endotracheal intubation were compared. The differences in baseline clinical characteristics were adjusted using propensity scoring matching (PSM) or inverse probability of treatment weighting (IPTW). The primary outcome was 30-day survival with neurologically favorable status of cerebral performance category ≤2. The outcome was also compared according to the duration of low-flow time. Results: Of 9,616 patients enrolled, (median age = 71, male sex = 65%) there were 7,583 AAM and 2,033 BVM patients. The unadjusted survival to with neurologically favorable status was lower in AAM compared to BVM (HR = 1.27, 95% confidence interval (CI) = 1.20 - 1.34, p<0.001). However, there was no significant difference of survival to with neurologically favorable status between AAM and BVM after PSM or ITPW-adjusted comparisons (p>0.05, all). This finding was consistent irrespective of duration of low-flow time. Conclusion: In this nationwide real-world data of out-of hospital cardiac arrest study, prehospital advanced airway management compared to bag-and-mask ventilation did not result in an improved clinical outcome at 30 days.