Intubation Procedure
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2021 ◽  
Vol 11 (1) ◽  
Maeva Rodriguez ◽  
Stéphanie Ragot ◽  
Rémi Coudroy ◽  
Jean-Pierre Quenot ◽  
Philippe Vignon ◽  

Abstract Background Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity. Methods Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure. Results Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission. Conclusions Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen. Trial registration Clinical trial number: NCT02668458 (

Zainul Ikhwan Ahmad Khusairi

Introduction: The rapid spread of COVID-19 had expanded into a pandemic, and thousands of medical staff had been infected worldwide. Thus, the access to personal protective equipment (PPE) for health workers had become a key concern. PPE was essential in providing a physical barrier between microorganism and health care providers. In the case of cardiac arrest, the use of a resuscitation device as PPE had provoked various reactions and complaints from physicians.Objective: To determine the effectiveness of the use of an intubation box and ergonomic screening booth as a device during intubation procedures on positive COVID-19 patients in the Department of Emergency and Trauma at Taiping Public Hospital.Methods: The study was designed as a single-blind, prospective, randomized study and was approved by the committee at study location setting. Physicians selected had been given three days of training related to the use of the device as one of the PPE, before being used on patients. The procedure was carried out on three patients with unclear history of COVID-19who required intubation. The time given for each intubation procedure was 5 to10 seconds with a maximum of three attempts for each patient.Results: The results found that all three intubation procedures required longer time whereby all procedures took two attempts for each patient. The process of intubation took more than 30 seconds for the first attempt and failed but all cases took about 5 to 10 seconds for second attempts.Conclusion: This has proven that the use of an intubation box and ergonomic screening booth as a device during intubation procedures was not effective. It is suggested that this device should not be continued by paramedics and a proper management plan is needed to provide appropriate and suitable device innovations.International Journal of Human and Health Sciences Supplementary Issue: 2021 Page: S14

2021 ◽  
Vol 21 (1) ◽  
Chao Zhang ◽  
Min Ou

Abstract Background Optimization of preoxygenation procedure can help to secure the method of intubation by reducing the risks of severe hypoxemia and other problems. There is confusion for efficacy of non-invasive ventilation compared to high-flow oxygen therapy regarding occurrence of severe hypoxemia during the intubation procedure. The purpose of the study was to compare the difference between noninvasive ventilation and high flow oxygen therapy to prevent desaturation during laryngoscopy. Methods Patients underwent high-flow nasal cannula oxygen therapy (HCO cohort, n = 161) or non-invasive ventilation procedure (NIV cohort, n = 154) for oxygenation and ventilation due to acute hypoxemic respiratory failure in the intensive care unit. Data before preoxygenation, preoxygenation, intubation, laryngoscopy, and complications of patients due to tracheal intubation were retrospectively collected and analyzed. Results There was no difference between both cohorts for the demographical and clinical conditions of the patients before preoxygenation (p > 0.05 for all parameters), numbers of patients with severe hypoxia during the intubation procedure (35 vs. 45, p = 0.303), the time duration of laryngoscopy (p = 0.847), number of laryngoscopies attempts (p = 0.804), and immediate and late complications during the intubation procedure. The values of pulse oximetry were reported higher for patients of NIV cohort than those of HCO cohort during preoxygenation. Fewer numbers of patients were reported with severe hypoxia among patients of the NIV cohort than those of the HCO cohort (24 vs., 40, p = 0.042) who have moderate-to-severe hypoxemia (partial pressure of arterial oxygen to fraction of inspired oxygen ratio ≤ 200 mmHg) before preoxygenation. The most common complications were hypertension, pulmonary aspiration, and increased 30-day mortality. Conclusions When compared, there was no difference between non-invasive ventilation technique and high-flow oxygen therapy to minimize severe hypoxia prior to laryngoscopy and endotracheal intubation in patients with acute respiratory failure.

2020 ◽  
pp. 102490792096530
Hui Chun Fai ◽  
Li Alex ◽  
Wong Chi Keung Gordon

Background: Personal protective equipment used for protection of healthcare workers in the combat against Severe Acute Respiratory Syndrome Coronavirus 2 pandemic is in limited supply worldwide at present – 2020. Use of barrier enclosure during endotracheal intubation can potentially act as a cost-effective adjunct to minimize risks of transmitting the infection to healthcare workers. However, there is concern that the enclosure itself will act as a barrier to the intubation procedure in the emergency settings. Objective: To evaluate the negative effect of barrier enclosure (an aerosol box) on the performance of video-assisted intubation in a manikin Methods: A total of 41 Emergency Department doctors from a local hospital were recruited to perform intubation in a manikin simulating normal and more difficult airways (Cormack-Lehane grades I and IIb) with and without the box. The primary outcome was time of successful intubation. The secondary outcomes were first-attempt success rate, number of successful attempts, need of adjuncts, dental injury and ease of intubation as perceived by the participants. Results: The aerosol box had no significant negative effect on the time of successful intubation (p = 0.630 (Grade I airway) and p = 0.436 (Grade IIb airway)), first-attempt success rate, number of successful attempts, need of adjuncts or dental injury. Participants subjectively reported extra yet minor challenges during intubation in the presence of the box. Conclusion: Within limits of the pilot study, the aerosol box had no statistical significant difference but an increasing trend of prolonged endotracheal intubation interval in the Grade IIb airway and negative impact on first-pass success, and could potentially be used to protect healthcare workers during the aerosol-generating intubation procedure.

2020 ◽  
Vol 25 (Supplement_2) ◽  
pp. e9-e9
Anthony Debay ◽  
Sharina Patel ◽  
Pia Wintermark ◽  
Martine Claveau ◽  
François Olivier ◽  

Abstract Background The physiological stress induced by tracheal intubation (TI) is associated with increased risk of neurological injury among very preterm infants. The location of TI procedure and number of attempts required may contribute to adverse outcomes. Objectives We aimed to assess the association of location where TI is performed and the number of TI attempts with death and/or severe neurological injury (SNI) among very preterm infants born &lt;33 weeks and intubated in the first 7 days of life. Design/Methods Retrospective cohort study of 442 infants born 23-32 weeks gestation, admitted to a Level 3 NICU 2015-2018 within the first 7 days of life. We excluded infants who were moribund and the ones with a major congenital anomaly. Data was collected from the Canadian Neonatal Network database and chart review. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. &gt;1) among infants intubated in the first 7 days of life. Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. Results Rate of intubation was 46% (202/442). Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with 1 TI attempt and 23% (27/117) among infants with &gt;1 TI attempt. Rate of premedication use for NICU TI was 97% (102/105). Overall, median number of intubation attempts was 1 [IQR 1-2]. Compared to no TI, TI in the NICU (adjusted odds ratio [AOR] 3.39, 95% CI 1.20-10.53) and TI in the DR (AOR 9.28, 95% CI 3.33-29.43) were associated with higher odds of death and/or SNI. DR TI was associated with higher odds of death and/or SNI compared to NICU TI (AOR 2.73, 95% CI 1.23-6.35). Compared to no TI, 1 TI attempt (AOR 5.25, 95% CI 1.93-15.93) and &gt;1 TI attempt (AOR 5.17, 95% CI 1.93-15.69) were associated with higher odds of death and/or SNI. The number of intubation attempts (1 vs. &gt;1) was not associated with death and/or SNI (AOR 0.99, 95% CI 0.47-2.09). Conclusion Intubated infants have higher odds of death and/or SNI. Among intubated infants, DR TI is associated with higher odds of death and/or SNI vs. TI in the NICU with premedication. Optimizing non-invasive ventilation in the DR may help reduce brain injury in preterm infants.

Healthcare ◽  
2020 ◽  
Vol 8 (3) ◽  
pp. 205
Fang-Suey Lin ◽  
Hong-Chun Shi ◽  
Kwo-Ting Fang

Regarding long-term home care needs, nurses need to communicate effectively and reasonably when teaching home caregivers. Designers can assist medical staff and develop pictorial tools to enhance communication. The purpose of this study is to explore a theoretical basis from the perspective of designers, patients’ home caregivers, and medical staff to construct a theoretical framework that can jointly develop pictorial health education tools and healthcare system. The qualitative methods, including in-depth interview and observation, are applied to this study; ground theory sets out to construct a framework from the verbatim transcript of the interviews. Based on interview results, six axial codes were extracted: (1) the method of interdisciplinary cooperation; (2) medical research ethics; (3) communication methods; (4) forms of health education tools; (5) development of health education tools; (6) home care intubation procedure. Eight groups of home caregivers offered suggestions from their experiences. The designers need to assist medical staff to solve real problems, pay attention to professional norms, and forms of cooperation. Health education tools need to meet the needs of medical staff and home caregivers and designers should pay attention to the processes of communication. This study can also assist in interdisciplinary cooperation to explore the theoretical basis of pictorial health education tools for nurses in the context of long-term care at home.

2020 ◽  
pp. emermed-2019-208425
John Glasheen ◽  
Jeff Hooper ◽  
Andrew Donohue ◽  
Emmeline Finn ◽  
Bronwyn Murray-Smith ◽  

IntroductionFirst attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.MethodsLifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.ResultsOf the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.ConclusionAlthough a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

2019 ◽  
Vol 19 (1) ◽  
Lianxiang Jiang ◽  
Shulin Qiu ◽  
Peng Zhang ◽  
Weidong Yao ◽  
Yan Chang ◽  

Abstract Background Previous studies have demonstrated that the common laryngoscopic approach (right-sided) and midline approach are both used for endotracheal intubation by direct laryngoscopy. Although the midline approach is commonly recommended for video laryngoscopy (VL) in the clinic, there is a lack of published evidences to support this practice. This study aimed to evaluate the effects of different video laryngoscopic approaches on intubation. Methods Two hundred sixty-two patients aged 18 years who underwent elective surgery under general anaesthesia and required endotracheal intubation were included in the present prospective, randomized, controlled study. The participants were randomly and equally allocated to the right approach (Group R) or midline approach (Group M). All the intubations were conducted by experienced anaesthetists using GlideScope video laryngoscopy. The primary outcomes were Cormack-Lehane laryngoscopic views (CLVs) and first-pass success (FPS) rates. The secondary outcomes were the time to glottis exposure, time to tracheal intubation, haemodynamic responses and other adverse events. Comparative analysis was performed between the groups. Results Finally, 262 patients completed the study, and all the tracheas were successfully intubated. No significant differences were observed in the patient characteristics and airway assessments (P > 0.05). Compared with Group R, Group M had a better CLV (χ2 = 14.706, P = 0.001) and shorter times to glottis exposure (8.82 ± 2.04 vs 12.38 ± 1.81; t = 14.94; P < 0.001) and tracheal intubation (37.19 ± 5.01 vs 45.23 ± 4.81; t = 13.25; P < 0.001), but no difference was found in the FPS rate (70.2% vs 71.8%; χ2 = 0.074; P = 0.446) and intubation procedure time (29.86 ± 2.56 vs 30.46 ± 2.97, t = 1.75, P = 0.081). Between the groups, the rates of hoarseness or sore throat, minor injury, hypoxemia and changes in SBP and HR showed no significant difference (P > 0.05). Conclusion Although the FPS rate did not differ based on the laryngoscopic approach, the midline approach could provide better glottis exposure and shorter times to glottis exposure and intubation. The midline approach should be recommended for teaching in VL-assisted endotracheal intubation. Trial registration The study was registered on May 18, 2019 in the Chinese Clinical Trial Registry (ChiCTR1900023252).

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