Early versus Delayed Intubation and Technique in COVID-19: A Review Article

Background: The novel coronavirus 2019 is the cause of the 2020 pandemic that was announced by the world health organization in March 2020. The coronavirus attacks the respiratory system and causes mild to severe hypoxemia. Therefore, a fraction of COVID-19 patients may need intubation and mechanical ventilation. Methods: We conducted a narrative review by searching for articles that mentioned the time of intubation for COVID-19 patients and intubation techniques in PubMed, Google Scholar, Scopus, the Web of scenic, the Cochrane library, and Embase, as well as manual searching. All the selected reviews and studies were limited to humans and the English language. Results: The first data from China shows that 5% of patients require intubation and mechanical ventilation (MV), and there has been considerable debate about the timing of intubation for patients with acute respiratory failure and the technique of intubation. At first, the specialists recommended early intubation. Although we are more familiar with the pathophysiology of coronavirus, the drawbacks and the benefits of early intubation are still controversial. In addition, the intubation process itself is an aerosol-generating procedure and carries a high risk for patients and health care providers. In this review, we aim to review the previous studies and guidelines recommendations related to the time of intubation and intubation technique for COVID-19 patients. Conclusion: Previous research has suggested that early tracheal intubation should be prioritized in severe COVID-19 patients, whereas other studies advocate late intubation due to poor intubation outcomes and weaning difficulties. However, intubation timing should be based on personalized medicine and case-by-case decision making to ensure the best care and benefit of patients. And relying only on theoretical justification may not have good consequences.

Anesthesia Management in Intramural Uterine Myoma and Obesity Morbid Patients Who Underwent Myomectomy Perlaparatomy

Introduction. Obesity is a condition that increases the challenges in the surgical process. Obesity increases the risk of sleep apnea and affects anaesthetics. This case report aims to discuss the management of anaesthesia in a patient with morbid obesity. Case. Female, 26 years old, with intramural uterine myoma and morbid obesity, will undergo myomectomy per laparotomy with ASA II physical status, performed anaesthesia with general anaesthesia intubation technique using the anaesthetic agent Propofol 1-2.5 mg/kg titration until the patient falls asleep, fentanyl 1-2 mcg/kg, then the patient was intubated in a ramped position with sleep non-apnea. After it was confirmed that the ETT was entered, 30 mg of a muscle relaxant (atracurium) was added. The operation lasts 1 hour 30 minutes, with a bleeding 250 cc, hemodynamically stable. Conclusion. Morbid obesity has extraordinary implications for anaesthetic management. Various considerations for patients with morbid obesity are needed starting from the preoperative, intraoperative, to postoperative periods. Regional anaesthesia is preferred because the physiological function of unhealthy obese patients is impaired due to excess body weight. Selection of anaesthetic agent and calculation of drug dose is crucial to know because there is a change in the volume of distribution. The pharmacokinetics of most general anaesthetics are affected by the adipose tissue mass, produce a prolonged drug effect, and less predictable.

Anesthetic Management of Patient with Preeclampsia, Pulmonary Edema, and Peripartum Cardiomyopathy in Pregnancy Undergoing Caesarean Section: A Case Report

Preeclampsia is a disease that occurs in pregnancy after 20 weeks of gestation with manifestations involving multi organ systems such as pulmonary edema and ventricle dysfunction. Cardiomyopathy is a heart disorder characterized by myocardial dysfunction unrelated to any other previous heart disease. Case: A 31-year-old woman diagnosed with G1P0A0 full-term pregnancy, preeclampsia, pulmonary edema, cardiomyopathy, and fetal distress, who underwent cesarean section. On physical examination, shortness of breath was found in semi-Fowler position. Patient had high blood pressure and global hypokinesis was found on echocardiography results. She was planned for general anesthesia with semi-closed intubation technique and breath controlled. Anesthetic management should optimize the preoxygenation, provide positive pressure ventilation with positive end-expiratory pressure (PEEP), maintain the minimal myocardial depressant effect of drugs, and maintain a normovolemic state. It could improve the good outcomes. Conclusion: Three things that must be considered when starting the induction are oxygenation, fluid status, and selection of drugs that do not make the heart work harder. The combination of fentanyl, midazolam, and sevoflurane is the drug of choice used for induction, because it can minimize the cardiac depressant effect.

Anesthetic Management of Patient with Preeclampsia, Pulmonary Edema, and Peripartum Cardiomyopathy in Pregnancy Undergoing Caesarean Section: A Case Report

Preeclampsia is a disease that occurs in pregnancy after 20 weeks of gestation with manifestations involving multi organ systems such as pulmonary edema and ventricle dysfunction. Cardiomyopathy is a heart disorder characterized by myocardial dysfunction unrelated to any other previous heart disease. Case: A 31-year-old woman diagnosed with G1P0A0 full-term pregnancy, preeclampsia, pulmonary edema, cardiomyopathy, and fetal distress, who underwent cesarean section. On physical examination, shortness of breath was found in semi-Fowler position. Patient had high blood pressure and global hypokinesis was found on echocardiography results. She was planned for general anesthesia with semi-closed intubation technique and breath controlled. Anesthetic management should optimize the preoxygenation, provide positive pressure ventilation with positive end-expiratory pressure (PEEP), maintain the minimal myocardial depressant effect of drugs, and maintain a normovolemic state. It could improve the good outcomes. Conclusion: Three things that must be considered when starting the induction are oxygenation, fluid status, and selection of drugs that do not make the heart work harder. The combination of fentanyl, midazolam, and sevoflurane is the drug of choice used for induction, because it can minimize the cardiac depressant effect.

Methods of Airway securing in patients treated for temporonandibular joint ankylosis

Background: - Temporomandibular joint (TMJ) is a complex structure composed of several components including glenoid fossa of the temporal bone, the condylar head of the mandible, articular disk, as well as several ligaments and associated muscles. Its ankylosis causes distressing conditions including, both functional and aesthetic problems. An anesthetic management is challenging and surgery of TMJ ankylosis falls into the category of difficult airway as direct vocal cord visualization is difficult due to an inability to open the mouth. Fiberoptic intubation is considered as a safest approach and gold standard in TMJ ankylosis surgery as means of airway securing.Objectives: - The aim of this study was to assess method of airway securing in patients treated for temporomandibular joint ankylosis at Addis Ababa University Oral and Maxillofacial surgery affiliate Hospitals. Materials and Methods: - A retrospective cross sectional study was conducted in 22 patients (n=14 male and n=11 female) with mean age of 21.7(ranged 6-50) diagnosed with temporomandibular joint ankylosis at Addis Ababa University, Oral and Maxillofacial Surgery affiliate Hospitals both Yekatit 12 Hospital medical college and St. Peter specialized Hospital. Data was collected from patients’ medical records registered in a period of 3 years from January 2017 to December 2019. EPI- INFO 7 computer software was used for data analysis. Results: - The highest incidence of ankylosis was reported between the age of 11 and 20 (40.91%). Unilateral ankylosis was reported in (59.09%) and (68.18%) was bony ankylosis based on tissue involved. In majority 17 (77%) of patients tracheostomy was used as intubation technique and securing the airway and fibroptic technique is used only in 2(9%) patients. Conclusion: - The findings of this study tracheostomy was the most commonly used intubation technique, due unavailability of fibroptic and skilled professional in practice of other intubation techniques. Institutional capacity building of facilities, increasing service availability and experts for practice of fiberoptic and bland nasal intubation technique is recommended.

Comparison of Video Laryngoscope and Macintosh Laryngoscope for Face-to-Face Intubation in Sitting Manikin Model With Limitation of Neck Motion by Unexperienced Personnel

Background: Trauma patients who entrapped in the accident vehicle are predispose to have cervical spine injuries and they needed to be intubated with face-to-face intubation technique using Macintosh laryngoscope. Nowadays, video laryngoscope has been introduced to improve the intubation technique. Objective: To compare the effectiveness of video laryngoscope and Macintosh laryngoscope for face-to-face intubation in sitting manikin model with limitation of neck motion. Methods: The study was performed in a randomized experimental study. Subjects were divided into 2 groups both did face-to-face intubation using video laryngoscope and Macintosh laryngoscope in a sitting manikin model with limitation of neck motion. The success rate of intubation, time to finish intubation, and vocal cord visualization were analyzed. Results: Of 41 subjects including 2nd and 3rd year paramedic students, 21 subjects went to video laryngoscope group, and 20 subjects went to Macintosh laryngoscopes group. The Macintosh laryngoscope intubation technique showed significantly better success rate compared to video laryngoscope (100% and 25%, P < .001). In addition, intubation time of Macintosh laryngoscope was significantly less than video laryngoscope (mean [SD], 27 [24.7] and 75 [66.3] seconds, P < .001). However, vocal cord visualization from both laryngoscope techniques showed no statistically significant (P = .08). Conclusions: Intubation training of Macintosh laryngoscope for in sitting model with neck motion limitation showed better success rate and less time than video laryngoscope, with the same vocal cord visualization.

Asymptomatic Ileal Neuroendocrine “Carcinoid” Tumor Incidentally Diagnosed on Colorectal Cancer Screening Colonoscopy: Does Routine TI Intubation Matter?

Gastrointestinal neuroendocrine tumors (GINETs) (also known as “carcinoids”) are rare tumors with reported incidence of up to 6.98 per 100,000 which has increased significantly due to the increased detection on imaging and endoscopy. They are most commonly located in the small bowel, particularly the terminal ileum. Patients with small bowel NETs may present with abdominal pain, diarrhea, or carcinoid syndrome. However, the disease is mostly asymptomatic, and patients are usually diagnosed incidentally during routine colonoscopy. Although the ileum is the most common site for GINETs, terminal ileal (TI) intubation is not always completed during routine colonoscopy. With terminal ileum intubation being successful in at least 70% of colonoscopies and the rate of neuroendocrine tumor detection 0.1–1% of those intubations, one critical question remains unanswered: should terminal ileal intubation be considered a part of the definition of a complete colonoscopy? Herein, we present nine cases of NETs found incidentally on routine colon cancer screening colonoscopy in asymptomatic patients. This case series adds to the sparse literature and highlights the importance of TI intubation technique in early detection of small bowel NETs which could potentially affect the outcome.

Rapid Sequence Intubation with Remifentanil During COVID-19 Pandemic

We greatly appreciate the interest that De Melo MS, et al. showed on the use of remifentanil in a rapid sequence intubation technique that we recently proposed for patients undergoing surgery during the current SARS-CoV-2 pandemic [1, 2]. The authors also reported the response that Tang and Wang wrote to comment on that paper [3]. Given the interest aroused by our article, we think it would be worth making some clarifications. In brief, in order to limit aerosolization, we proposed to systematically perform rapid induction and intubation in the surgical patient after he had reached a state of deep analgesia with a continuous infusion of high-dose remifentanil (0.2-0.3 g/kg/min) [2]. Although in the title of the article this method is labeled as a rapid sequence induction, in the text, we explain how this technique, far from being standard rapid sequence intubation, was a rather longer technique in which the patient, although in a state of profound analgesia and sedation induced by remifentanil, breathed spontaneously and at last on command, until hypnosis, and muscle paralysis was rapidly induced with a low dose of propofol (<0.5 mg/kg) or midazolam (0.05-0.1 mg/kg) and a full dose of rocuronium (1 mg/kg) [2].

A clinical study on laryngotracheal injuries following endotracheal intubation

<p class="abstract"><strong>Background:</strong> Despite major advances in the design of endotracheal tubes and developments in the management of difficult airways, endotracheal intubation remains by far the most common cause of laryngotracheal injuries (LTI). These LTI are challenging to manage and are associated with significant morbidity and mortality. Hence, the present study was done to find out the incidence, types of LTI and to study the factors affecting the same.</p><p class="abstract"><strong>Methods:</strong> A prospective study was conducted on patients who were intubated for more than 48 hours and admitted in medical intensive care units in a tertiary referral hospital, for a period of 1 year. All patients following extubation were evaluated for LTI by x-ray neck (antero-posterior and lateral view), rigid endoscopy and flexible naso-pharyngo-laryngoscopy. </p><p class="abstract"><strong>Results:</strong> Thirty patients were included in the study. Majority of the patients (56.6%) were found normal while 43.2% patients were having LTI following extubation in the form of bilateral vocal cord fixation, subglottic stenosis, granulation tissue in the posterior commissure and in the trachea. Majority of these patients were aged less than 45 years, with duration of intubation for more than 10 days, with tube size more than 7 mm. Organo-phosphourous (OP) poisoning was the etiology for LTI in 69.2% cases.</p><p class="abstract"><strong>Conclusions:</strong> A high incidence of LTI especially in cases of OP poisoning warrants one to be cautious in managing these intubated patients. Those patients requiring prolonged intubation should be considered for other alternative airway managements like tracheostomy in addition to using low pressure, high volume cuffed tubes. Adequate training of the emergency personnel in the intubation technique and its subsequent care is important especially in a tertiary referral center.</p>