A Meta-Analysis on the Effectiveness of Video Laryngoscopy versus Laryngoscopy for Emergency Orotracheal Intubation

Background. Video laryngoscopy has been associated with some orotracheal intubations and enhances the glottic view at time of laryngoscopy and the success rate of the intubation in patients from the emergency department and the intensive care unit. In usual cases, direct laryngoscopy is performed among the patients from the emergency department or the intensive care unit. In this systematic review and meta-analysis, we draw the comparison between the video laryngoscopy and direct laryngoscopy for the emergency orotracheal intubation. Objective. The objective of the study was to identify the clinical efficacy of video laryngoscopy versus laryngoscopy for emergency orotracheal intubation. Materials and Methods. MEDLINE, CENTRAL, EMBASE, and Web of Science databases were analyzed from 2003 to 2020. Keywords used for searching the studies were “laryngoscopy,” “video laryngoscopy,” “direct laryngoscopy,” “emergency department,” “intensive care unit,” “orotracheal,” “video laryngoscope,” “glidescope,” “airway scope,” “airway,” “Macintosh laryngoscopy,” “airway management,” “tracheal intubation,” “orotracheal intubation,” and “intubation.” Results. The first-pass intubation success rates in the intensive care unit were low in video laryngoscopy with 95% CI 1.21 (1.13–1.30) and heterogeneity I2 = 78% favoring direct laryngoscopy nonsignificantly with low heterogeneity. Odds ratio for airway trauma or dental damage was 0.67, 95% CI (0.18–2.54), reported higher in video laryngoscopy. Complications with oesophageal laryngoscopy were higher in video laryngoscopy with risk ratio 0.16, 95% CI (0.09–0.29), odds ratio 0.88, 95% CI (0.65–1.18) for sever hypoxemia, risk ratio 1.53, 95% CI (1.02–2.28) for cardiovascular collapse, risk ratio with 95% CI 1.11 (0.59–2.07) for aspiration complications, and odds ratio 1.32, 95% CI (0.95, 1.85) for Inexperienced medical staff handling laryngoscopy. Conclusion. No significant efficiency was noticed in using video laryngoscopy when compared with direct laryngoscopy with the available data. The data reported in studies are not enough for efficient clinical analysis of the benefits of using video laryngoscopy over direct laryngoscopy. Thus, information such as length of stay, mortality, sever complications, and length of hospital stay must be reported.

Non-intubated Thoracoscopic Surgery—Pros and Cons

Pulmonary resection by video-assisted thoracoscopic surgery with single-lung ventilation has become a standardized modality over the last decades. With the aim to reduce surgical stress during operation procedures, some have adopted a uniportal approach in pulmonary resection as an alternative to multiportal VATS. The ERAS program has been widely spread to achieve even better outcomes. In 2004, Pompeo reported the resection of pulmonary modules by conventional VATS under intravenous anesthesia without endotracheal intubation. Within less than a decade thereafter, complete VATS pulmonary resections under anesthesia without endotracheal intubation had been reported for a range of thoracoscopic procedures. Avoiding tracheal intubation under general anesthesia can reduce the incidence of complications such as intubation-related airway trauma, residual neuromuscular blockade, ventilation-induced lung injury, impaired cardiac performance, and postoperative nausea. Numerous studies can be found especially from Asian countries, focusing on comparison of intubated and non-intubated procedures showing that non-intubated VATS could reduce the rate of postoperative complications, shorten hospital stay and decrease the perioperative mortality rate, indicating that non-intubated VATS is a safe, effective and feasible technique for thoracic disease. However, if we look closely at all studies, it is obvious that there are no significant differences between intubated and non-intubated surgery in terms of the standard procedures and maneuvers. In non-intubated procedures it can be less comfortable for the surgeon to manipulate in the thoracic cavity, but the procedural steps remain the same. All the differences between the intubated and non-intubated operation procedure are found in perioperative management of the patient. The patient is still in deep anesthesia during the procedure and hypecapnia can occur. It is easier to manage this if the patient is intubated. In addition, if a complication occurs during the operation and intubation is required, this can cause an emergent situation, which means that not all patients are suitable for such a procedure, especially those with severe emphysema, obese patients and those with a problematic oropharyngeal configuration-Mallampati score. Moreover, studies on non-intubated thoracic surgery point to shortened hospitalization, faster recovery etc. But there are also studies on intubated uniportal VATS procedures in combination with ERAS protocol showing shortened hospitalization and better outcome for patients. Currently, especially with the use of optical intubation canylas, totally intravenous anesthesia (TIVA), BIS and relaxometer, anesthesia is safe for avoiding airway injury, hypercapnia, and there is minimal risk of residual curarization as well as one of the postoperative lung complications such as microaspiration and atelectasis. In addition, the patient recovers rapidly from anesthesia and can be verticalised and mobilized a couple of hours after the operation. It is desirable to take into consideration what type of patient and what lung disease is suitable for non-intubated technique and what is more convenient for intubation.

Emergency management plan for paediatric patients with tracheostomies during the COVID-19 pandemic

Objectives: Paediatric patients living with tracheostomies are a medically vulnerable group. During the COVID-19 pandemic, there may be apprehension about their susceptibility to SARS-CoV-2 infection with unknown consequences. Healthcare workers managing this cohort can be anxious about viral transmission from respiratory secretions and aerosols emerging from the open airway. Our objective is to share a systematic approach to minimise incidental mismanagement, avoid iatrogenic airway injury, reduce aerosolisation and decrease staff exposure when treating these patients. Methods: A COVID-19 emergency management plan was created for paediatric patients with tracheostomies in the event of presentation with unknown, suspected or proven SARS-CoV-2 infection. Three documents were developed: a generic tracheostomy management plan detailing troubleshooting measures to reduce air leak from around the tube; a personalised management plan with customised recommendations; a guide for tracheostomy tube change with emphasis on minimising aerosol production. Results: Our plan was distributed to 31 patients (age range 11 months - 17 years) including 23 (74.2%) with uncuffed tubes and 9 (29%) on long term ventilation. There have been 10 occasions in which the plan was utilised and influenced care, including 4 situations where successful troubleshooting avoided tube manipulation and 6 situations where an uncuffed tube was safely replaced with a pre-selected cuffed tube to reduce air leak. Conclusions: A structured approach to emergency presentations during the COVID-19 pandemic may safeguard paediatric patients from unnecessary manipulation of their tracheostomy tube and airway trauma, as well as provide guidance to minimise viral exposure and allow provision of expeditious care.

Palliative Withdrawal of Mechanical Ventilation and Other Life Supports

Palliative or compassionate withdrawal of mechanical ventilator support at the end of life aims to optimize comfort, alleviate suffering, and allow a natural death in patients for whom life supports are not achieving desired goals. Palliative withdrawal is a medical procedure and must be treated as such. Appropriate planning and preparations are required to optimize patient comfort, which is the goal of the procedure. Many institutions have a “one size fits all” approach to this process, but individual patient factors require consideration to meet the patient’s needs. Some of these factors include patient pathophysiology (airway edema, airway trauma, hemoptysis, secretions), current treatment modalities (ventilator settings, medications including sedatives, vasopressors, inotropes, inhaled agents, neuromuscular blockade agents), and patient and family values and preferences. This chapter will discuss the implications of each of these factors and propose methods for successful transitions to comfort-focused care. Case vignettes will demonstrate the thought processes involved and model optimal management. Common ethical considerations and questions regarding palliative withdrawal of life support will also be discussed.

Comparison of fibre-optic-guided endotracheal intubation through a supraglottic airway device versus hyperangulated video laryngoscopy by emergency physicians: A randomised controlled study in cadavers

Background: After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined. Objective: The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope. Methods: A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819). Results: Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group; a difference of 15.2 s (95% confidence interval = 8.7–21.7, p < 0.001). All intubations were completed within 2 min, and there were no equipment failures or evidence of airway trauma. Conclusion: Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.

Airway Trauma: Assessment and Management

Recognizing airway trauma and safety management is challenging for any anaesthesiologist. Many types of airway injuries require identifying airway anatomy correctly; early assessment and proper management are crucial for saving many lives. Proper management involves the classification of those patients into three categories. Each one has a unique and different control. Knowing your capabilities and skills are very important for safe airway management. It does not matter where you are but skills, knowledge of airway management algorithms and tools you have. After reading this book chapter, the participant will be able to define airway trauma, proper airway risk assessment and safety management.

Two Endotracheal Tubes in One Trachea with a Traumatic Injury

Background. Traumatic airway injuries often require improvising solutions to altered anatomy under strict time constraints. We describe here the use of two endotracheal tubes simultaneously in the trachea to facilitate securing an airway which has been severely compromised by a self-inflicted wound to the trachea. Case Presentation: A 71-year-old male presented with a self-inflicted incision to his neck, cutting deep into the trachea itself. An endotracheal tube was emergently placed through the self-inflicted hole in the trachea in the ED. The patient was bleeding profusely, severely somnolent, and desaturating upon arrival to the operating room. Preservation of the tenuous airway was a priority while seeking to establish a more secure one. A video laryngoscope was used to gain a wide view of the posterior oropharynx and assist with oral intubation using a fiberoptic scope loaded with a second endotracheal tube. The initial tube’s cuff was deflated as the second tube was advanced over the fiberoptic scope, thereby securing the airway while a completion tracheostomy was performed. Conclusions. Direct penetrating airway trauma may necessitate early, albeit less secure, intubations though the neck wounds prior to operating room arrival. The conundrum is weighing the risk of losing a temporary airway while attempting to establish a more secure airway. Here, we demonstrate the versatility of common anesthesia tools such as a video laryngoscope and a fiberoptic bronchoscope and the welcome discovery of the trachea’s ability to accommodate two endotracheal tubes simultaneously so as to ensure a patent airway at all points throughout resuscitation.

Association of advanced age with intubation-related adverse events in the emergency department: a multicentre prospective observational study

BackgroundWhile the older population accounts for an increasing proportion of emergency department (ED), little is known about intubation-related adverse events in this high-risk population. We sought to determine whether advanced age is associated with a higher risk of intubation-related adverse events in the ED.MethodsThis is an analysis of data from a prospective, 15-centre, observational study—the second Japanese Emergency Airway Network (JEAN-2) study. The current analysis included adult (aged ≥18 years) patients who underwent intubation in the ED between 2012 and 2018. The primary exposure was age (18–39, 40–64, 65–74, 75–84 and ≥85 years). The primary outcome was overall intubation-related adverse events during or immediately after an intubation. Adverse events were further categorised into major (hypotension, hypoxaemia, oesophageal intubation, cardiac arrest, dysrhythmia and death) and minor (endobronchial intubation, oesophageal intubation with early recognition, dental/lip trauma, airway trauma and regurgitation) adverse events. We constructed multivariable logistic regression models adjusting for seven potential confounders with generalised estimating equations that account for patients clustering within the ED.ResultsAmong 9714 patients eligible for the analysis, 15% were aged ≥85 years, and 16% had adverse events. In the unadjusted models, advanced age was not significantly associated with the risk of overall adverse events. In the adjusted models, the association was significant (adjusted OR 1.41 in age ≥85 years (95% CI, 1.09 to 1.81) compared with age 18–39 years). Specifically, older patients had a significantly higher risk of major adverse events (adjusted OR in age ≥85 years 2.65 (95% CI, 1.78 to 3.94)), which was driven by the association of advanced age with an increased risk of hypotension (adjusted OR in ≥85 years, 5.69 (95% CI, 3.13 to 10.37)). By contrast, advanced age was not associated with minor adverse events.ConclusionBased on the data from a prospective multicentre study, advanced age was associated with higher risks of major adverse events.

Diagnostic and therapeutic approach to post-traumatic tracheobronchial injuries

Post-traumatic tracheobronchial lesions are associated with high mortality unless adequately diagnosed and treated. They may be caused by blunt and penetrating trauma, although iatrogenic lesions are also increasingly observed. An early and accurate diagnosis significantly impacts the results of treatment. Radiological assessment with computed tomography is highly accurate, but bronchoscopy remains the gold standard technique in the diagnosis of airway trauma and plays an important role in determining the therapeutic approach. For a long time, surgery has been considered the treatment of choice for post-traumatic airway lesions, but recent reports have shown that favourable results may also be obtained with a conservative approach, especially in the treatment of iatrogenic lesions. The indication for a conservative or surgical treatment has to be defined on the basis of a thorough clinical, radiological, and endoscopic assessment. Specific issues concerning airway management in the emergency setting and during surgical treatment must also be addressed. A multidisciplinary approach in a center with specific experience in the treatment of airway lesions is of utmost importance to obtain favourable results.

Premedication for Nonemergent Intubation in the NICU: A Call for Standardized Practice

This paper discusses neonatal endotracheal intubation and the need for standardization in practice regarding the use of premedication. Intubation is common in the NICU because of resuscitation, surfactant administration, congenital anomalies, apnea, and sedation for procedures or surgery. Intubation is both painful and stressful. Unmedicated intubation is associated with several adverse outcomes including repeat and prolonged attempts, airway trauma, bradycardia, severe desaturation, and need for resuscitation. Most providers believe intubation is painful and that premedication should be provided; however, there is still resistance to provide premedication and inconsistency in doing so. Reasons for not providing premedication include concerns about medication side effects such as chest wall rigidity or prolonged respiratory depression inhibiting immediate extubation after surfactant administration. Premedication should include an opioid analgesic for pain, a benzodiazepine for an adjuvant sedation, a vagolytic to decrease bradycardia, and the optional use of a muscle relaxant for paralysis.