Supraglottic airway device versus a channeled or non-channeled blade-type videolaryngoscope for accidental extubation in the prone position: A randomized crossover manikin study

'Sealing the deal': An innovative use of the endotracheal cuff manometer

Introduction

Intraoperative air leakage from the endotracheal tube (ETT) cuff can lead to significant complications, including compromised tidal volume delivery, ineffective ventilation, and an increased risk of pulmonary aspiration. These issues, if unrecognized and unmanaged, contribute to heightened perioperative morbidity and mortality. While structural defects in the ETT cuff or pilot balloon system are common causes of leakage, additional factors such as cuff malposition, excessive airway pressure, and material degradation can also contribute. Early identification of the underlying etiology is critical for implementing appropriate interventions, mitigating airway-related complications, and ensuring surgical continuity.

Case Report

This report presents a case of intraoperative ETT cuff leakage identified after surgical positioning in the prone position. To address this challenge, an innovative approach utilizing an ETT cuff manometer was employed, allowing for continuous monitoring of cuff pressure. This strategy enabled real-time detection of pressure deviations and facilitated prompt reinflation whenever the cuff pressure dropped below 20 cm H₂O or a fresh gas flow leak was observed. This technique effectively maintained adequate cuff inflation, preventing intraoperative airway compromise.

Discussion

ETT cuff leaks can be categorized into two primary mechanisms: (1) those resulting from structural failure of the cuff or inflation system and (2) those occurring due to inadequate sealing despite an intact cuff. Intraoperative air leaks pose risks to the patient-through impaired ventilation and aspiration risk-and to operating room personnel by potentially exposing them to unfiltered anesthetic gases. Various strategies for managing ETT leaks have been described, including conservative approaches such as pharyngeal packing, application of lubricating agents like lidocaine jelly, and continuous inflation via an oxygen flowmeter. In cases where these measures fail, ETT replacement remains the definitive intervention. However, exchanging the ETT presents a significant challenge in prone-positioned patients, necessitating a thorough risk-benefit assessment before attempting tube replacement or repositioning the patient. While previous studies have explored methods for addressing intraoperative ETT leaks, continuous quantitative monitoring of cuff pressure using a manometer has not been widely reported. This technique provides a dynamic assessment of cuff integrity and allows for proactive management of intraoperative air leaks.

Conclusion

In this case, the application of an ETT cuff manometer enabled continuous, quantitative assessment of cuff pressure, facilitating early leak detection and effective management. This approach represents a valuable adjunct in the intraoperative setting, enhancing patient safety and reducing the likelihood of airway-related complications. Further research is warranted to explore the broader clinical implications of continuous ETT cuff pressure monitoring in perioperative airway management.

Emergency airway management in the prone position: an observational mannequin-based simulation study

INTRODUCTION

Accidental extubation during prone position can be a life-threatening emergency requiring rapid establishment of the airway. However, there is limited evidence of the best airway rescue method for this potentially catastrophic emergency. The aim of this study was to determine the most effective method to recover the airway in case of accidental extubation during prone positioning by comparing three techniques (supraglottic airway, video laryngoscopy, and fiber-optic bronchoscopy) in a simulated environment.

METHODS

Eleven anesthesiologists and 12 anesthesia fellows performed the simulated airway management using 3 different techniques on a mannequin positioned prone in head pins. Time required for definitive airway management and the success rates were measured.

RESULTS

The success rates of airway rescue were 100% with the supraglottic airway device (SAD), 69.6% with the video laryngoscope (CMAC), and 91.3% with the FOB. The mean (SD) time to insertion was 18.1 (4.8) s for the supraglottic airway, 78.3 (32.0) s for the CMAC, and 57.3 (24.6) s for the FOB. There were significant differences in the time required for definitive airway management between the SAD and FOB (t = 5.79, p < 0.001, 95% CI = 25.92-52.38), the SAD and CMAC (t = 8.90, p < 0.001, 95% CI = 46.93-73.40), and the FOB and CMAC (t = 3.11, p = 0.003, 95% CI = 7.78-34.25).

CONCLUSION

The results of this simulation-based study suggest that the SAD I-gel is the best technique to manage accidental extubation during prone position by establishing a temporary airway with excellent success rate and shorter procedure time. When comparing techniques for securing a definitive airway, the FOB was more successful than the CMAC.

Simulation in Anesthesia for Perioperative Neuroscience: Present and Future

The brain's sensitivity to fluctuations in physiological parameters demands precise control of anesthesia during neurosurgery, which, combined with the complex nature of neurosurgical procedures and potential for adverse outcomes, makes neuroanesthesia challenging. Neuroanesthesiologists, as perioperative physicians, work closely with neurosurgeons, neurologists, neurointensivists, and neuroradiologists to provide care for patients with complex neurological diseases, often dealing with life-threatening conditions such as traumatic brain injuries, brain tumors, cerebral aneurysms, and spinal cord injuries. The use of simulation to practice emergency scenarios may have potential for enhancing competency and skill acquisition amongst neuroanesthesiologists. Simulation models, including high-fidelity manikins, virtual reality, and computer-based simulations, can replicate physiological responses, anatomical structures, and complications associated with neurosurgical procedures. The use of high-fidelity simulation can act as a valuable complement to real-life clinical exposure and training in neuroanesthesia.

Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)-A Prospective, Randomised Controlled Study

BACKGROUND

The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios.

METHODS

After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min.

RESULTS

In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02).

CONCLUSION

The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial.

Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review

Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.

Prevention of Oxygen Desaturation in Morbidly Obese Patients During Electroconvulsive Therapy: A Narrative Review

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Different classes of videoscopes and direct laryngoscopes for double-lumen tube intubation in thoracic surgery: A systematic review and network meta-analysis

Background

Double-lumen tube is commonly used in thoracic surgeries that need one-lung ventilation, but its big size and stiff structure make it harder to perform intubation than a conventional tracheal intubation tube.

Objectives

To investigate the effectiveness and safety of videoscopes for double-lumen tube insertion. The primary outcome was the success rate of first attempt intubation. Secondary outcomes were intubation time, malposition, oral mucosal damage, sore throat, and external manipulation.

Design

Systematic review and network meta-analysis

Data sources

Databases (Pubmed, Embase, Cochrane, Kmbase, Web of science, Scopus) up to June 23, 2020 were searched.

Eligibility

Randomized controlled trials comparing different videoscopes for double-lumen tube intubation were included in this study.

Methods

We classified and lumped the videoscope devices into the following groups: standard (non-channeled) videolaryngoscope, channeled videolaryngoscope, videostylet, and direct laryngoscope. After assessing the quality of evidence, we statistically analyzed and chose the best device based on the surface under the cumulative ranking curve (SUCRA) by using STATA software (version 16).

Results

We included 23 studies (2012 patients). Based on the success rate of the first attempt, a rankogram suggested that the standard videolaryngoscope (76.4 of SUCRA) was the best choice, followed by videostylet (65.5), channeled videolaryngoscope (36.1), and direct laryngoscope (22.1), respectively. However, with regard to reducing the intubation time, the best choice was videostylet, followed by a direct laryngoscope, channeled videolaryngoscope, and standard videolaryngoscope, respectively. Direct laryngoscope showed the lowest incidence of malposition but required external manipulation the most. Channeled videolaryngoscope showed the highest incidence of oral mucosal damage, but showed the lower incidence of sore throat than standard videolaryngoscope or direct laryngoscope.

Conclusion

Most videoscopes improved the success rate of double-lumen tube intubation; however, they were time-consuming (except videostylet) and had a higher malposition rate than the direct laryngoscope.

A Comparison of a Standard Macintosh Blade Laryngoscope, Pentax-AWS Videolaryngoscope and Intubrite Videolaryngoscope for Tracheal Intubation in Manikins in Sitting and Prone Positions: A Randomized Cross-Over Study

Background: Intubation of a patient in different positions may be done not only in emergency settings, but also in routine anesthesia (e.g., prone position for lumbar spine surgery). Methods: The aim of the study was to compare the classic Macintosh blade laryngoscope with two videolaryngoscopes: the Pentax-AWS and the Intubrite in a simulated scenario of a manikin placed in a sitting and prone position. Additionally, intubation with the use of all three devices was performed in a standard supine position as the control group. The time of intubation and the pressure exerted on the tongue was assessed. The ANOVA Friedman (analysis of variance) and Wilcoxon with Bonferroni correction tests were used for statistical analysis. Results: The time of intubation in a prone position was significantly shorter for the Pentax-AWS videolaryngoscope compared to the Macintosh and the Intubrite. There were no significant differences in the obtained results of the evaluated devices in sitting and standard positions. The lowest pressure exerted on the tongue was with the Pentax-AWS, followed by the Intubrite and the Macintosh laryngoscopes. Conclusions: The use of the Pentax-AWS was associated with faster tracheal intubation, creating lower pressure on tongue when compared with standard Macintosh and Intubrite laryngoscopes in both prone and sitting positions.

C-arm fluoroscopy for tracheal intubation in a patient with severe cervical spine pathology

Tracheal intubation is challenging in patients with severe cervical spine pathology. In such cases, awake fiberoptic intubation is the gold standard and safest option for tracheal intubation. However, this technique requires the patient's understanding and cooperation, and therefore, may be contraindicated in patients with refusal or poor tolerance. Herein, we report successful orotracheal intubation in a patient with limited mouth opening and severe cervical spine rigidity under general anesthesia using an extraglottic airway device and a gum-elastic bougie under C-arm fluoroscopic guidance.