Barotrauma: a life-threatening complication of fiberoptic endotracheal intubation in a neonate

Oxygen insufflation via the working channel during tracheal intubation guided by a flexible optical scope and benefits, dangers, and future of the method: a narrative review

When performing tracheal intubation guided by a flexible optical scope, the operator may lose the anatomical orientation and hypoxia may occur. Oxygen insufflation through the working channel of the flexible optical scope is used by anaesthetists to prevent blurring of the lens and to prevent hypoxia. However, fatal iatrogenic injuries from this method are reported. Our aim is to review the current literature on oxygen insufflation through the working channel during tracheal intubation guided by a flexible optical scope, to identify its benefits and the source of its dangers, and ultimately to provide a basis for the development of a safer technique. We conducted a literature search of databases, guidelines, and textbooks using search terms related to oxygen insufflation through the working channel during intubation guided by a flexible optical scope. Clinical trials confirm that the technique results in better visibility and better oxygenation during intubation. Gastric rupture and pneumothorax were the most frequent types of injury. We identified that oxygen insufflation without pressure limitation during accidental misplacement of the flexible optical scope in the oesophagus, deep in the lower airways, or via a tear of the airway mucosa was the cause of barotrauma. We conclude that a delivered pressure below 40 cm H2O will likely carry a low risk of serious adverse outcomes. The technique in its current form seems unsafe, and future research should aim at developing a system that delivers oxygen at pressures respecting gastric and airway physiologic pressure thresholds with a flow sufficient to obtain the documented advantages of the technique.

Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis

Objectives

We assessed the efficacies of various corticosteroid treatments for preventing postexubation stridor and reintubation in mechanically ventilated adults with planned extubation.

Methods

We searched the Pubmed, Embase, the Cochrane databases and ClinicalTrial.gov registration for articles published through September 29, 2022. Only randomized controlled trials (RCTs) that compared the clinical efficacies of systemic corticosteroids and other therapeutics for preventing postextubation stridor and reintubation were included. The primary outcome was postextubation stridor and the secondary outcome was reintubation.

Results

The 11 assessed RCTs reported 4 nodes: methylprednisolone, dexamethasone, hydrocortisone, and placebo, which yielded 3 possible pairs for comparing the risks of post extubation stridor and 3 possible pairs for comparing the risks of reintubation. The risk of postextubation stridor was significantly lower in dexamethasone- and methylprednisolone-treated patients than in placebo-treated patients (dexamethasone: OR = 0.39; 95% CI = 0.22-0.70; methylprednisolone: OR = 0.22; 95% CI = 0.11-0.41). The risk of postextubation stridor was significantly lower in methylprednisolone-treated patients than in hydrocortisone-treated: OR = 0.24; 95% CI = 0.08-0.67) and dexamethasone-treated patients: OR = 0.55; 95% CI = 0.24-1.26). The risk of reintubation was significantly lower in dexamethasone- and methylprednisolone-treated patients than in placebo-treated patients: (dexamethasone: OR = 0.34; 95% CI = 0.13-0.85; methylprednisolone: OR = 0.42; 95% CI = 0.25-0.70). Cluster analysis showed that dexamethasone- and methylprednisolone-treated patients had the lowest risks of stridor and reintubation. Subgroup analyses of patients with positive cuff-leak tests showed similar results.

Conclusions

Methylprednisolone and dexamethasone were the most effective agents against postextubation stridor and reintubation.

Review of risk factors, clinical manifestations, rapid diagnosis, and emergency treatment of neonatal perioperative pneumothorax

Perioperative neonatal pneumothorax (NP) is rare but very fatal. Most of the surgeries and treatments in the neonatal period are time-limited or emergent, and there are often some risk factors for pneumothorax before surgery. Physicians, surgeons and anesthesiologists need to identify possible risk factors for pneumothorax before surgery in preterm babies, patients receiving mechanical ventilation and those with underlying lung disease. The clinical presentation of NP is nonspecific, and patients may rapidly develop life-threatening complications if not promptly diagnosed and managed. This review highlights recent progress in the identification of risk factors, clinical manifestations, diagnosis and management of NP during the perioperative period.

Utility of oxygen insufflation through working channel during fiberoptic intubation in apneic patients: a prospective randomized controlled study

BACKGROUND

Airway management is a part of routine anesthetic procedures; however, serious complications, including hypoxia and death, are known to occur in cases of difficult airways. Therefore, alternative techniques such as fiberoptic bronchoscope-assisted intubation (FOB intubation) should be considered, although this method requires more time and offers a limited visual field than does intubation with a direct laryngoscope. Oxygen insufflation through the working channel during FOB intubation could minimize the risk of desaturation and improve the visual field. Therefore, the aim of this prospective randomized controlled study was to evaluate the utility and safety of oxygen insufflation through the working channel during FOB intubation in apneic patients.

METHODS

Thirty-six patients were randomly allocated to an N group (no oxygen insufflation) or an O group (oxygen insufflation). After preoxygenation, FOB intubation was performed with (O group) or without (N group) oxygen insufflation in apneic patients. The primary outcome was the velocity of decrease in the partial pressure of oxygen (PaO₂) during FOB intubation (V_PaO2, mmHg/sec) defined as the difference of PaO₂ before and after intubation divided by the time to intubation. The secondary outcomes included the success rate for FOB intubation, time to intubation, visual field during FOB intubation, findings of arterial blood gas analysis, and occurrence of FOB intubation-related complications.

RESULTS

We found that V_PaO2 was significantly greater in the N group than in the O group (1.0 ± 0.4 vs. 0.4 ± 0.4; p < 0.001), while the visual field was similar between groups. There were no significant intergroup differences in the secondary outcomes.

CONCLUSIONS

These findings suggest that oxygen insufflation through the working channel during FOB intubation aids in extending the apneic window during the procedure.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02625194 , registered at December 9, 2015.

Fiberoptic-guided intubation after insertion of the i-gel airway device in spontaneously breathing patients with difficult airway predicted: a prospective observational study

STUDY OBJECTIVE

To assess the viability of performing fiberoptic-guided orotracheal intubation through the i-gel airway device previously inserted in spontaneously breathing patients with predicted difficult airway to achieve a patent airway.

DESIGN

Prospective observational study.

SETTING

Operating room in a tertiary care hospital.

PATIENTS

Eighty-five adult patients with at least 3 difficult airway predictors or difficult airway management history were included.

INTERVENTIONS

The i-gel device was inserted in spontaneous ventilation under oropharyngeal local anesthesia and sedation. After checking the adequate ventilation through the i-gel with capnography curve, general anesthesia was induced to introduce the endotracheal tube guided by fiberoptic bronchoscope.

MEASUREMENTS

We recorded the i-gel insertion time (tgel), intubation time (tint), and O₂ saturation in pulse oximetry in different moments: basal (t0), after 3 minutes of preoxygenation with a face mask at 100% fraction of inspired O₂ (t1), after i-gel mask insertion (t2), and after intubation (t3). Adverse events during the procedure were also recorded, and patient discomfort was questioned.

MAIN RESULTS

All patients were successfully intubated. O₂ saturation in pulse oximetry values were (mean±SD): 96.9±1.22 (t0), 99.0±0.85 (t1), 96.2±2.37 (t2), and 96.0±2.54 (t3). tgel and tint were 38.0±7.76 seconds and 36.5±5.55 seconds (mean±SD), respectively. No serious adverse events were recorded, and no patient suffered airway damage. Visual analogue scale for patient discomfort was 2 (interquartile range, 1-3).

CONCLUSIONS

i-gel insertion in spontaneously breathing patients avoids the "cannot ventilate" scenario. The subsequent fiberoptic-guided intubation through the i-gel is a safe and effective technique. More studies might be necessary to confirm the results presented, but we consider that the technique described is an adequate alternative to classic orotracheal intubation with fiberoptic bronchoscope in spontaneous ventilation for certain patients with predicted difficult airway.

Tension pneumothorax during flexible bronchoscopy in a nonintubated infant

We describe the case of a tension pneumothorax occurring during flexible bronchoscopy in a nonintubated infant. The pneumothorax likely occurred secondary to wall source oxygen insufflation via the bronchoscope without sufficient gas egress. The use of wall source oxygen via the bronchoscope working channel is inherently dangerous and should be avoided.