Efficacy and Safety of Video-Laryngoscopy versus Direct Laryngoscopy for Double-Lumen Endotracheal Intubation: A Systematic Review and Meta-Analysis

The available meta-analyses have inconclusively indicated the advantages of video-laryngoscopy (VL) in different clinical situations; therefore, we conducted a systematic review and meta-analysis to determine efficacy outcomes such as successful first attempt or time to perform endotracheal intubation as well as adverse events of VL vs. direct laryngoscopes (DL) for double-lumen intubation. First intubation attempt success rate was 87.9% for VL and 84.5% for DL (OR = 1.64; 95% CI: 0.95 to 2.86; I2 = 61%; p = 0.08). Overall success rate was 99.8% for VL and 98.8% for DL, respectively (OR = 3.89; 95%CI: 0.95 to 15.93; I2 = 0; p = 0.06). Intubation time for VL was 43.4 ± 30.4 s compared to 54.0 ± 56.3 s for DL (MD = −11.87; 95%CI: −17.06 to −6.68; I2 = 99%; p < 0.001). Glottic view based on Cormack–Lehane grades 1 or 2 equaled 93.1% and 88.1% in the VL and DL groups, respectively (OR = 3.33; 95% CI: 1.18 to 9.41; I2 = 63%; p = 0.02). External laryngeal manipulation was needed in 18.4% cases of VL compared with 42.8% for DL (OR = 0.28; 95% CI: 0.20 to 0.40; I2 = 69%; p < 0.001). For double-lumen intubation, VL offers shorter intubation time, better glottic view based on Cormack–Lehane grade, and a lower need for ELM, but comparable first intubation attempt success rate and overall intubation success rate compared with DL.

Paramedic Perception of Endotracheal Intubation Performance: an Examination of Irish Advanced Paramedic Demographics, Characteristics, Confidence and Perceived Barriers to the Performance of Advanced Airway Management.

BackgroundMuch research has occurred internationally with regard to the prehospital ETI (endotracheal intubation), however to date little is known of Paramedics perception of the procedure. In order to gain insight into procedural perception Irish Advanced Paramedics (AP) were invited to participate in an electronic survey. This survey attempted to gather information surrounding AP’s experience of education for and performance of ETI, to identify procedural barriers and gain insight in to the continuing developmental needs of AP’s to maintain confidence and competence in ETI performance. MethodsAn online questionnaire was created and AP’s employed by the National Ambulance Service and the Dublin Fire Brigade, were invited to participate. The objective was to measure the characteristics, attitudes and perceived barriers to ETI by AP’s in Ireland. Participants were asked to categorise their personal characteristics of ETI (frequency, techniques, barriers) through a series of 36 structured questions and answers. ResultsOf the 524 AP surveyed the response rate was 27% (n=140) 77.9% of respondents perform ETI 10 times or less per year. 26.6% of respondents maintain a personal airway management log book. 97.8% of respondents reported ETI as being an important AP skill. Most felt confident at performing the procedure but felt it was of moderate difficulty. There was a lack of consensus on the definition of a failed intubation attempt. Initial supervised intubation practice in Hospital or the clinical skill lab was felt to be very important. Most respondents felt that there should be a minimum number of intubations performed by a paramedic each year, and that if this number was not achieved in the pre-hospital setting in-hospital practice should be an available alternative.Conclusion ETI is perceived to be an important skill by Paramedics. In practice there is wide variances in standards of data reporting, continuing assessment and competency assurance in ETI. A hybrid approach of individuals maintaining an airway portfolio which encompasses a clinical airway logbook, self-directed airway simulation with periodic senior peer appraisal and in-hospital clinical feedback may be the best approach for Paramedics with limited pre-hospital advanced airway management opportunities.

A PROSPECTIVE RANDOMIZED STUDY TO EVALUATE THE ANALGESIC AND SEDATIVE EFFECTS OF FENTANYL AND MIDAZOLAM TO NALBUPHINE AND MIDAZOLAM IN PATIENTS UNDERGOING AWAKE FIBEROPTIC

Background- Awake nasal or oral flexible fiberoptic intubation (AFOI) is technique of choice in known or anticipated difficult airway . The main aim was to have calm and cooperative patient who can follow verbal commands while maintaining adequate oxygenation . In our study, we compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubationmore tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Material and Methods– A prospective, randomized comparison study among patients between the age of 18 and 60yrs of either sex, with anticipated difficult airway . We compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubation. The primary objectives of our study were to observe the level of sedation, intubation score and OAS score after completion of procedure. The secondary objectives included assessment of patient comfort, intubation time, hemodynamic changes and complications. Results – We found that comfort score and intubation time were significant lesser in Group which received fentanyl and midazolam than Group which received nalbuphine and midazolam . (p<0.05). The intubation attempt was similar in both groups (P>0.05). Conclusion– we concluded that both regimens used in this study provided comparable intubating conditions, better sedation and analgesia was observed in group fentanyl for airway procedure events. Our study concluded fentanyl to be the drug of choice for blunting of pressor response in such patients.

Neonatal intubation: Can we make it better? A journey from ideation to intellectual property rights

Objectives: Neonatal intubation is regarded as one of the elite skills a medical professional; particularly a pediatrician could aspire to master. More the practice, the skill gets refined so that the success rate improves. However, it is not uncommon even for most experienced professional to fail in an intubation attempt. Why does it happen? Is there a solution? This article discusses the journey from ideation to intellectual property rights. Materials and Methods: Observational study followed by Randomised control study. Results: Reduction in the pressure exerted on upper jaw during intubation from 455 to 80 KPa and decrease in blocked visual area from 38.5 to 12%. Conclusion: Appropriate design modification of neonatal laryngoscope is potentially more safe and easy to use.

Airway Management in Substernal Goiter Surgery

Objective(s): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques. Methods: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed. Results: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g, P = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3, P = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103, P = .015). Conclusions: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are. Level of evidence: VI

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations.Objective: Aim of this study was to determine the frequency of tracheal intubation–associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit.Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded.Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (&lt;10 intubation encounters) (OR = 2.15; 95% CI, 1.257–3.685) and equipment problems (OR = 3.43; 95% CI, 1.12–10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06–0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25–0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08–4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265–2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04–2.46) were associated with unsuccessful intubation attempts.Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.

BOugie or stylet in patients UnderGoing Intubation Emergently (BOUGIE): protocol and statistical analysis plan for a randomised clinical trial

IntroductionIntubation-related complications are less frequent when intubation is successful on the first attempt. The rate of first attempt success in the emergency department (ED) and intensive care unit (ICU) is typically less than 90%. The bougie, a semirigid introducer that can be placed into the trachea to facilitate a Seldinger-like technique of tracheal intubation and is typically reserved for difficult or failed intubations, might improve first attempt success. Evidence supporting its use, however, is from a single academic ED with frequent bougie use. Validation of these findings is needed before widespread implementation.Methods and analysisThe BOugie or stylet in patients Undergoing Intubation Emergently trial is a prospective, multicentre, non-blinded randomised trial being conducted in six EDs and six ICUs in the USA. The trial plans to enrol 1106 critically ill adults undergoing orotracheal intubation. Eligible patients are randomised 1:1 for the use of a bougie or use of an endotracheal tube with stylet for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is severe hypoxaemia, defined as an oxygen saturation less than 80% between induction until 2 min after completion of intubation. Enrolment began on 29 April 2019 and is expected to be completed in 2021.Ethics and disseminationThe trial protocol was approved with waiver of informed consent by the Central Institutional Review Board at Vanderbilt University Medical Center or the local institutional review board at an enrolling site. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences.Trial registration numberClinicalTrials.gov Registry (NCT03928925).

Tracheal Intubation in Out-Of-Hospital Setting is Associated With A High Failure Rate of The First Attempt: A Multicenter Prospective Study

BackgroundTracheal intubation in an out-of-hospital setting is a frequent and potentially difficult procedure. The risk of adverse events increases dramatically with the number of attempts. The failure rate of the first intubation attempt ranges from 5 to 32% and the risk factors are unclear. We evaluated the failure rate of the first intubation attempt in an out-of-hospital setting and identified variables potentially associated with such failure.MethodsThis was an observational prospective multicenter study performed over 17 months and involving 10 prehospital emergency medical units. Airway management for patients who needed tracheal intubation followed the national guidelines. Rapid sequence intubation with a sedative and myorelaxant drugs was systematically performed for spontaneously breathing patients. After each tracheal intubation, the operator was required to provide, by completing a data-collection form, information on operator and patient characteristics and the environmental conditions during the intubation. The primary endpoint was failure of the first intubation attempt.ResultsDuring the study period, 1546 patients were analyzed, of whom 59% had cardiac arrest, and 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2–32.6]). A multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations, small inter-incisor space, limited extension of the head, macroglossia, ear/nose/throat tumor, cardiac arrest, and vomiting. The frequency of adverse events was 13.4% and increased with each additional attempt.ConclusionsThe failure rate of the first attempt was high. Most risk factors could be identified only at the moment of occurrence and were not easily anticipated. Finally, the risk of complications increased with the number of attempts.