Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury

Background Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation. Methods We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS). Results Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P = 0.0144) in multivariate analyses. Conclusion Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Direct Laryngoscopy or Video Laryngoscopy: Which Is Better for Performing Endotracheal Intubation?

Background: Endotracheal intubation is known as the best and challenging procedure to airway control for patients in shock or with unprotected airways. Failed intubation can have serious consequences and lead to high morbidity and mortality of the patients. Videolaryngoscope is a new device that contains a miniaturized camera at the blade tip to visualize the glottis indirectly. Fewer failed intubations have occurred when a videolaryngoscope was used. Other types of videolaryngoscopes were then developed; all have been shown to improve the view of the vocal cords. It may be inferred that for the professional group, including emergency physicians, paramedics, or emergency nurses, video laryngoscopy may be a good alternative to direct laryngoscopy for intubation under difficult conditions. The incidence of complications was not significantly different between the C-MAC 20% versus direct laryngoscopy 13%. The main goal of this review was to compare the direct laryngoscopy with the (indirect) video laryngoscopy in terms of increased first success rate and good vision of the larynx to find a smooth induction of endotracheal intubation. Methods: Currently available evidence on MEDLINE, PubMed, Google scholar and Cochrane Evidence Based Medicine Reviews, in addition to the citation reviews by manual search of new anesthesia and surgical journals related to laryngoscopies and tracheal intubation. Results: This review of recent studies showed that the laryngoscopic device design would result in smooth approach of endotracheal intubation by means of good visualization of glottis and the best success rates in the hands of both the experienced and novice. Video laryngoscopes may improve safety by avoiding many unnecessary attempts when performing tracheal intubation with DL compared to VL as well as easy learning of both direct and indirect laryngoscopy. Conclusion: The comparative studies of different video laryngoscopes showed that DL compared with VL, reveal that video laryngoscopes reduced failed intubation in anticipated difficult airways, improve a good laryngeal view and found that there were fewer failed intubations using a videolaryngoscope when the intubator had equivalent experience with both devices, but not with DL alone. And therefore, knowledge about ETI and their skills, are crucial in increasing the rate of survival.

Ventilation via nose cone results in similar hemodynamic parameters and blood gas levels as endotracheal intubation during open chest surgery in rats

Open chest surgery in rodents requires assisted breathing and the most common approach for ventilation is via an endotracheal tube. Even with well-trained operators the endotracheal intubation is technically challenging and may lead to prolonged procedures and endotracheal intubation complications. Nose cone ventilation is a simpler procedure compared to endotracheal intubation and has the potential to improve animal welfare by reducing procedure time and endotracheal intubation associated complications. Rats are obligate nose breathers, and therefore replacing intubation with air supply from a nose cone would be an advantage and a more natural way of breathing. Here, we compared the values for several blood gases, blood pressure and heart rate from rats that were nose cone ventilated with rats that underwent endotracheal intubation at 12 timepoints equally distributed across three surgical stages: baseline, open chest and closed chest. Throughout the monitoring period the hemodynamic and blood gas values for both methods of ventilation were within published, normal ranges for the rat and were biologically equivalent (equivalence test p value ≤ 0.05). Our data showed that nose cone ventilation-maintained blood gases and hemodynamic homeostasis equivalent to endotracheal intubation. Nose cone ventilation can be recommended as an alternative to endotracheal intubation in rat experiments where investigators require airway control.

Timely Intubation With Early Prediction of Respiratory Exacerbation in Acute Traumatic Cervical Spinal Cord Injury

Background: Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in context of the recent advances in multidisciplinary respiratory management, the absolute indication for intubation in CSCI patients based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation. Methods: We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regressions were performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS). Results: Among the analyzed 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE in 3.5 days (mean) post-injury; 3 (37.5%) of eight motor-complete CSCI patients above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P=0.0144) in multivariate analyses. Conclusion: Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Emerging Perspectives of Endotracheal Intubation in Patients with Severe COVID- 19 Pneumonia: A Narrative Review

The coronavirus disease 2019 (COVID -19) pandemic that has engulfed the world has put an immense strain on the existing healthcare systems. The rapid, insidious and often dramatic deterioration of the respiratory function of an infected patient, has led to an increased need for effective and rapid airway control. However, such airway control techniques put the healthcare workers to an increased risk of exposure to the virus. Therefore, interventions aimed at minimising such risks, while preventing the complications inherent to securing an airway are imperative to the management of a COVID-19 patient in acute respiratory failure (ARF). Personal protective equipment (PPE) is sine qua non to keep the intubator safe, however some barrier equipment’s have been employed with limited success. There are varied schools of thought on whether to intubate early or late, and the use of non-invasive methods for management of respiratory failure, however, most consensus statements reinforce the need for rapid sequence induction (RSI), which provides ideal intubating environment for an experienced intubator. Techniques, which decrease the number of required personnel as well as time, to secure the airway and increase the distance of the intubating physician from the patient, are recommended. Routine use of, videolaryngoscope, if available, is recommended. While intubation with an endotracheal tube is the gold standard airway technique, second generation supraglottic airway devices (SAD) are increasingly being recommended, particularly in cases of failure to intubate or in an unanticipated difficult airway. Awake intubation techniques are contraindicated due to increased risk of cough and subsequent aerosolization; however, few modifications were innovated when if it all required. In this review, we summarise the existing data with respect to the modifications and guidelines in severe COVID-19 patients who requires endotracheal intubation for invasive mechanical ventilatory support.

Anesthesia for Airway Endoscopy and Micro-Laryngeal Surgery

Pre- and intra-operative anesthetic management considerations for airway endoscopy and micro-laryngeal surgery are covered in this chapter. Often presenting with critically obstructed or otherwise compromised airways, a carefully devised induction and airway control plan is essential. Unique to this type of surgery is the shared surgical field, requiring the utmost level of communication and cooperation between the surgical and anesthesia teams. Included is a discussion of ventilation options, routine and otherwise, and associated airway instrumentation such as jet ventilation catheters. Challenges of patient management during suspension laryngoscopy, are presented. Also addressed are laser basics, specific anesthetic considerations including risks and potential harms in the setting of these high-risk for fire procedures. This review contains 5 figures, 2 tables, and 40 references. Keywords: airway endoscopy, micro-laryngeal surgery, anesthetic considerations, obstructed airway, preoperative evaluation, airway intubation, laryngeal microsurgery, fire, OR

Carotid approach to anterior circulation thromboembolectomy in an adult with failing fontan physiology: a case report

Background Anesthetic management of an adult with failing Fontan physiology is complicated given inherent anatomical and physiological alterations. Neurosurgical interventions including thromboembolectomy may be particularly challenging given importance of blood pressure control and cerebral perfusion. Case Presentation We describe a 29 year old patient born with double outlet right ventricle (DORV) with mitral valve atresia who after multi-staged surgeries earlier in life, presented with failing Fontan physiology. She was admitted to the hospital almost 29 years after her initial surgeries to undergo workup for a dual heart and liver transplant in the context of a failing Fontan with elevated end diastolic pressures, NYHA III heart failure symptoms, and liver cirrhosis from congestive hepatopathy. During the workup in the context of holding anticoagulation for invasive procedures, she developed a middle cerebral artery (MCA) stroke requiring a thromboembolectomy via left carotid artery approach. Discussion and Conclusions This case posed many challenges to the anesthesiologist including airway control, hemodynamic and cardiopulmonary monitoring, evaluation of perfusion, vascular access, and management of anticoagulation in an adult patient in heart and liver failure with Fontan physiology undergoing thromboembolectomy for MCA embolic stroke.

Biologic Treatments for Asthma and Chronic Obstructive Pulmonary Disorder

The global COVID-19 pandemic has brought respiratory disease to the forefront of public health, but asthma prevalence has been rising globally for decades. Asthma is mediated by errant immune activation and airway remodeling, but the influences of environment, nutrition, and comorbidities (e.g., asthma-chronic obstructive pulmonary disorder-overlap [ACO]) are still poorly understood. Even as a new generation of biologic-based treatments offer better airway control and reductions in mortality, a lack of prophylactic treatments and mechanistic understanding complicates efforts to prevent pathogenesis. This review will explicate and synthesize current knowledge on the effect of ACO and biologics (omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab) on pathogenesis, treatment, and prognosis.

Bronchoscopy in COVID-19 patients: When, how and why. Experience in clinical practice

Severe Acute Respiratory Syndrome due to Coronavirus-19 (SARS-CoV-2) is caused by combined alveolar-capillary lung damage, with bilateral pneumonia and thrombosis, which often causes respiratory failure. Proper COVID-19 management requires high skills in airway control and the need to perform aerosol-generating procedures such as bronchoscopy, which can increase the possibility of virus spreading among healthcare professionals. In an epidemiologically delicate moment, the multidisciplinary decision on “WHEN, HOW and WHY” to perform bronchoscopies minimizing the risk of COVID-19 transmission, represented a great challenge for all specialists engaged in bronchoscopic procedures. In this work authors want to share all technical aspects of 87 videobronchoscopies performed in confirmed or suspected COVID-19 patients, from 3rd to 6th January 2020, describing the reason, the organizational and operational model and patients characteristics. Was also evaluated the impact of high-risk procedures such as bronchoscopy on the personnel involved. The disclosure of all technical details, represents, in the opinion of the authors, an important contribution, capable of providing support to all physicians engaged in bronchoscopy procedures in confirmed or suspected COVID-19 patients.