Prediction of difficult airway management in traumatic cervical spine injury: influence of retropharyngeal space extension

Identification of difficult laryngoscopy using an optimized hybrid architecture

BACKGROUND

Identification of difficult laryngoscopy is a frequent demand in cervical spondylosis clinical surgery. This work aims to develop a hybrid architecture for identifying difficult laryngoscopy based on new indexes.

METHODS

Initially, two new indexes for identifying difficult laryngoscopy are proposed, and their efficacy for predicting difficult laryngoscopy is compared to that of two conventional indexes. Second, a hybrid adaptive architecture with convolutional layers, spatial extraction, and a vision transformer is proposed for predicting difficult laryngoscopy. The proposed adaptive hybrid architecture is then optimized by determining the optimal location for extracting spatial information.

RESULTS

The test accuracy of four indexes using simple model is 0.8320. The test accuracy of optimized hybrid architecture using four indexes is 0.8482.

CONCLUSION

The newly proposed two indexes, the angle between the lower margins of the second and sixth cervical spines and the vertical direction, are validated to be effective for recognizing difficult laryngoscopy. In addition, the optimized hybrid architecture employing four indexes demonstrates improved efficacy in detecting difficult laryngoscopy.

TRIAL REGISTRATION

Ethics permission for this research was obtained from the Medical Scientific Research Ethics Committee of Peking University Third Hospital (IRB00006761-2015021) on 30 March 2015. A well-informed agreement has been received from all participants. Patients were enrolled in this research at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn , identifier: ChiCTR-ROC-16008598) on 6 June 2016.

Expert consensus on difficult airway assessment

Background

Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety.

Methods

Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts.

Results

This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.

Conclusions

This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

Perioperative management of spinal cord injury: the anesthesiologist's point of view

BACKGROUND

Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge.

METHODS

We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries.

RESULTS

Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient.

CONCLUSIONS

A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.

Radiological indicators to predict the application of assistant intubation techniques for patients undergoing cervical surgery

Background

We aimed to distinguish the preoperative radiological indicators to predict the application of assistant techniques during intubation for patients undergoing selective cervical surgery.

Methods

A total of 104 patients were enrolled in this study. According to whether intubation was successfully accomplished by simple Macintosh laryngoscopy, patients were divided into Macintosh laryngoscopy group (n = 78) and Assistant technique group (n = 26). We measured patients’ radiographical data via their preoperative X-ray and MRI images, and compared the differences between two groups. Binary logistic regression model was applied to distinguish the meaningful predictors. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to describe the discrimination ability of indicators. The highest Youden’s index corresponded to an optimal cut-off value.

Results

Ten variables exhibited significant statistical differences between two groups (P <  0.05). Based on logistic regression model, four further showed correlation with the application of assistant techniques, namely, perpendicular distance from hard palate to tip of upper incisor (X2), atlanto-occipital gap (X9), angle between a line passing through posterior-superior point of hard palate and the lowest point of the occipital bone and a line passing through the anterior-inferior point and the posterior-inferior point of the second cervical vertebral body (Angle E), and distance from skin to hyoid bone (MRI 7). Angle E owned the largest AUC (0.929), and its optimal cut-off value was 19.9° (sensitivity = 88.5%, specificity = 91.0%). the optimal cut-off value, sensitivity and specificity of other three variables were X2 (30.1 mm, 76.9, 76.9%), MRI7 (16.3 mm, 69.2, 87.2%), and X9 (7.3 mm, 73.1, 56.4%).

Conclusions

Four radiological variables possessed potential ability to predict the application of assistant intubation techniques. Anaesthesiologists are recommended to apply assistant techniques more positively once encountering the mentioned cut-off values.