Optical Devices in Tracheal Intubation-State of the Art in 2020

A Micro-costing Analysis of Single-use and Reusable Flexible Bronchoscope Usage in the Bronchoscopy Service at A Tertiary Care University Hospital

BACKGROUND

Single-use flexible bronchoscopes (SFBs) are increasingly used to minimize cross-infection risk, particularly in immunocompromised and intensive care unit patients. However, broader adoption requires cost analysis. We conducted a 1-year cost-minimization analysis comparing SFBs and reusable flexible bronchoscopes (RFBs) at a tertiary care university hospital.

METHODS

We evaluated the costs per procedure, considering capital equipment, maintenance, repair, reprocessing, and overhead costs. We also analyzed the impact of annual procedure volume on costs and performed a sensitivity analysis to assess the effect of uncertainty on costs.

RESULTS

A total of 1394 bronchoscopies were performed. RFBs were less expensive for an annual volume of >50 bronchoscopies/year, with a 22% lower cost per procedure than that for SFBs (€203 vs. €259). This cost advantage became increasingly favorable with an increasing number of procedures, reaching a plateau after exceeding 250 bronchoscopies/year. The capital equipment, the annual number of bronchoscopies, and reprocessing were the major cost drivers for RFBs. During nonworking hours, the cost per procedure of RFBs ranged from €349.45 to €392.29. Using RFBs during interventions involving a high risk of bronchoscope damage (frequency of damage >10%) would increase the cost per bronchoscopy to >€263 (exceeding the cost of SFBs).

CONCLUSION

RFBs were 22% less expensive than SFBs for services with a moderate to high volume of bronchoscopies. However, this difference could not justify using RFBs in patients with a high cross-infection risk. SFBs might be less costly for procedures outside working hours and interventions involving a high risk of bronchoscope damage.

Disposcope endoscope guidance versus fiberoptic bronchoscopy guidance for double-lumen tube intubation in patients undergoing thoracic surgery: a randomized controlled non-inferiority trial

Double-lumen tube (DLT) intubation is frequently performed for thoracic surgery, and a fiberoptic bronchoscopy (FOB) can improve the success rate of correct placement. Disposcope endoscope-guided DLT intubation was recently introduced and has a high first-attempt success rate. We tested whether compared with FOB-guided DLT intubation, disposcope endoscope-guided DLT intubation results in a non-inferior first-attempt success rate. A total of 181 patients who underwent thoracic surgery and required DLT intubation were randomly assigned to two groups: FOB guidance (FOB group) and disposcope endoscope guidance (DE group). The primary outcome was the first-attempt success rate. The secondary outcomes included the number of attempts, first intubation time, intraoperative dislodgement, and changes in the mean arterial pressure (MAP) and heart rate (HR) after intubation. The difference in the first DLT attempt success rate between the groups did not exceed the non-inferiority margin of 8% (DE group: 91.3% vs. FOB group: 89.9%; difference: 1.4%, 95% exact CI: -7.1-9.9%). The difference in the number of multiple DLT attempts also did not differ between the DE group and the FOB group (two attempts: 6.5% vs. 6.7%, P = 0.953; three attempts: 2.2% vs. 3.4%, P = 0.120). The first DLT intubation time [66 (55-86) vs. 77 (64-98) s, P = 0.010] was significantly shorter in the DE group. No significant differences were observed in the intraoperative dislodgement or changes in the MAP or HR after intubation (P > 0.05). Compared with FOB guidance, disposcope endoscope guidance provided a non-inferior first-attempt success rate and a shorter first intubation time for DLT intubation.

Awake Tracheal Intubation: An Update

Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills.

A dual analysis of bougie and stylet development trend and impact of Chinese regulations on medical devices innovation

Medical device research and development are characterized by high costs, extended timelines, inherent risks, and the necessity for interdisciplinary knowledge and skills. It is significantly influenced by policies, making the understanding of medical device innovation both important and challenging. This paper takes a dual approach to analyze medical device innovation. We reviewed representative clinical product of bougie and stylet and summarized the common characteristics and trend of these product. Innovations in these products often involve adding depth markings, replacing material and design structure, enhancing visualization, deciding between reusable or disposable designs, and integrating multi-functional features. This underscores the delicate balance between technological advancements and medical costs for widespread clinical applicability. We explored the guiding role of policy in medical device innovation, emphasizing its impact through an analysis of medical device regulations and policies in China. By offering insights from the perspectives of medical device companies and regulators, this paper aims to elucidate the critical aspects of medical device innovation, assisting researchers in mitigating risks during product development.

Vigilant Fiberoptic Orotracheal Intubation in a Patient With Severe Craniofacial Trauma During the Last Morocco Earthquake

Maxillofacial trauma is prevalent, particularly among the young population, often stemming from assaults, road accidents, or sports-related mishaps. Traditional intubation methods for managing these injuries can be challenging, especially with occluso-facial fractures requiring intermaxillary blocking for dental articulation restoration. Effective management requires interdisciplinary collaboration between emergency physicians, anesthetists, and maxillofacial surgeons. Proficiency in techniques like the vigilant fiberoptic approach should be emphasized through specialized training courses. This collaborative approach ensures the best possible strategy for managing difficult airways, with input from all stakeholders including patients, students, and practitioners. In this case, we successfully conducted a rapid-sequence awake fiberoptic oral intubation on a trauma patient, during the last earthquake that hit Morocco, with severe craniofacial injuries and an unstable skull. The patient, a 40-year-old woman, presented with complex facial fractures, including hemi lefort III on the right and hemi lefort II on the left, along with minimal subarachnoid hemorrhage and frontal pneumocephalus. Due to the patient's compromised airway from diffuse facial bleeding and low oxygen saturation, we opted for awake fiberoptic intubation once immediate life-threatening issues were addressed. This approach allowed us to maintain the patient's spontaneous respirations and navigate around unstable craniofacial structures. The procedure was performed with meticulous care, considering the patient's unstable skull, and was successful without complications. Post-intubation, the patient was extubated, and her recovery was uneventful.

An Approach to Improve the Effectiveness of the Video-Assisted Intubating Stylet Technique for Tracheal Intubation: A Case Series Report

Direct laryngoscopy and videolaryngoscopy are currently the dominant tools for endotracheal intubation. However, the video-assisted intubating stylet, a type of videolaryngoscopy, has been shown to offer some advantages over these tools, such as rapid intubation time, high first-attempt success rates, less airway stimulation, and high subjective satisfaction. On the other hand, this optical intubating technique also has some technical limitations that need to be addressed, including camera lens fogging, airway path disorientation, and obscured visibility due to secretions. In this clinical report, we describe an approach that improves the visibility of the glottis by introducing a suctioning catheter into the nasopharyngeal airway to enhance the efficiency and accuracy of using the intubating stylet technique for tracheal intubation.

Current Considerations in Emergency Airway Management

Purpose of Review

Emergency airway management is populated by many new concepts, evolving equipment, and contemporary strategies for optimal procedural success. This review aims to discuss various topics within these realms and to continue the ongoing conversation regarding improvement of emergency airway management.

Recent Findings

Various literature, opinion pieces, podcasts, and trials have prompted renewed interest in the field of emergency airway management. Though common threads can be found, there is significant debate on optimal practice. Accompanying these conversations is continuous production of new equipment which can be beneficial to providers. However, this ongoing accumulation of material, data, and pathways can create challenges in remaining up to date. Rather than a comprehensive review of current literature and discussion of research findings, this article aims to discuss selected and impactful concepts in real time context and provide potentially immediate additions to emergency airway manager practice.

Summary

As emergency airway management evolves, it remains a significant task to maintain up to date on current trends, data, and new equipment. This article aims to discuss several of these items in a digestible fashion and provide immediate impact for emergency airway providers.

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

BACKGROUND

Patients undergoing oral and maxillofacial surgeries under general anesthesia usually require nasotracheal intubation. When presented with patients with equally patent nostrils, selection of the nostril to use for intubation is an important decision for facilitating intubation. The objective of this trial is to determine whether choice of nostril impacts nasotracheal intubation when using a video rigid stylet in patients undergoing oral and maxillofacial surgery.

METHODS

Fifty patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly allocated into two groups to undergo nasotracheal intubation through the left nostril (Group L, n = 25) or the right nostril (Group R, n = 25). Intubation was performed by experienced anesthesiologists using a video rigid stylet. The primary endpoint was time to successful intubation, which was defined as the duration from when the tip of the stylet-tube assembly entered the selected nostril to when the tube entered the trachea. Secondary outcomes included: length of time for device insertion; length of time for tube insertion; total success rate; first-attempt success rate; number of intubation attempts; requirement of airway assisted maneuvers; incidence and severity of epistaxis. Intubation-related adverse events were monitored for up to postoperative 24 h.

RESULTS

Median time (interquartile range) to tracheal intubation was 25.3 seconds (20.7 to 27.6) in Group L and 26.8 seconds (22.5 to 30.0) in Group R (median difference (MD) = 1.9; 95% confidence interval (CI) -1.8 to 5.7, P = 0.248). Nasotracheal intubation was successful in all patients in both groups and the first-attempt success rates in both groups were similar (Group L: 96% (24/25); Group R: 96% (24/25); relative risk (RR) 1.0; 95% CI 0.9 to 1.1; P > 0.999). No significant difference of requirement of assisted maneuvers was noted between the two groups (Group L: 36% (9/25); Group R: 28% (7/25); RR 0.8; 95% CI 0.3-1.8; P = 0.544). Furthermore, all patients showed a high quality of visualization of the glottis (Cormack and Lehane Grade I). For safety outcomes, the incidence and severity of epistaxis during intubation was comparable between the two groups. There were no significant differences between the selection of nostrils and intubation-related adverse events up to 24 h after surgery.

CONCLUSIONS

When considering which nostril to use for intubation with video rigid stylet, either nostril can be used similarly.

TRIAL REGISTRATION

Clinicaltrials.gov . Identifier: NCT05218590.

Clinical value of video-assisted single-lumen endotracheal intubation and application of artificial intelligence in it

Visualization techniques and artificial intelligence (AI) are currently used for intubation device. By providing airway visualization during tracheal intubation, the technologies provide safe and accurate access to the trachea. The ability of AI to automatically identify airways from images of intubation device makes it attractive for use in intubation devices. The purpose of this review is to introduce the state of application of visualization techniques and AI in certain intubation devices. We reviewed the evidence of clinical implications of the use of video-assisted intubation device in the intubation time, first attempt success rate, and intubation of the difficult airway. Especially, VivaSight single-lumen tube with an incorporated optics allows direct viewing of the airway. VivaSight single-lumen tube has more advantages in tracheal intubation. AI has been applied to fiberoptic bronchoscopy (FOB) and video laryngoscope with automatic airway image recognition, and has achieved certain accomplishment. Further, we discussed the possibility of applying AI to the VivaSight single-lumen tube and proposed future directions of research and application.

Comparison of the UEscope Video Laryngoscope with the Traditional Direct Laryngoscope in Neonates and Infants: A Randomized Clinical Trial

The role of video laryngoscopy in adults is well established, but its role in children is still inconclusive. Previous studies on the UEscope in pediatric patients with difficult airways showed that it could reduce the time to intubation (TTI) compared to a conventional direct laryngoscope. The main objective of the current study was to investigate if the use of the UEscope could reduce the TTI in neonates and infants. Forty patients under 12 months old were recruited from a single tertiary hospital from March 2020 to September 2021 and were randomly assigned to the direct laryngoscope group (n = 19, neonates = 4, infants = 15) or UEscope group (n = 21, neonates = 6, infants = 15). Although the quality of glottic view was comparable in both groups, the TTI was significantly lower in the UEscope group in both the “intention-to-treat” (–19.34 s, 95% confidence interval = –28.82 to –1.75, p = 0.0144) and “as treated” (–11.24 s, 95% confidence interval: –21.73 to 0, p = 0.0488) analyses. The UEscope may be a better choice for tracheal intubation than conventional direct laryngoscope in neonates and infants.

Development of endotracheal intubation devices for patients with tumors

The incidence and mortality of malignant tumors are rapidly increasing in the world. Patients with malignant tumors often need surgery for treatment. Endotracheal intubation is a necessary technique for surgical patients undergoing general anesthesia. It is also an important procedure for critically ill patients in the emergency room or ICU. Most patients with head and neck tumors and some specific patients have difficult airways, so the operator may need to use a variety of intubation devices. The commonly used devices for endotracheal intubation include endotracheal tube, direct laryngoscope, video laryngoscope, introducer, optical stylet, fiberoptic bronchoscope. With the advancement in science and technology, the endotracheal intubation devices have been improved, and new devices have been developed. These devices are safer and more feasible in clinical practice. In this review, we summarized the features and applications of some of the currently used devices. Each device has its own uniqueness and meets different needs. The devices and their respective properties are strongly suggested to be mastered by the anesthesiologists as well as related staffs, so as to select the appropriate device for intubation.

Video-Assisted Intubating Stylet Technique for Difficult Intubation: A Case Series Report

Induction of anesthesia can be challenging for patients with difficult airways and head or neck tumors. Factors that could complicate airway management include poor dentition, limited mouth opening, restricted neck motility, narrowing of oral airway space, restricted laryngeal and pharyngeal space, and obstruction of glottic regions from the tumor. Current difficult airway management guidelines include awake tracheal intubation, anesthetized tracheal intubation, or combined awake and anesthetized intubation. Video laryngoscopy is often chosen over direct laryngoscopy in patients with difficult airways because of an improved laryngeal view, higher frequency of successful intubations, higher frequency of first-attempt intubation, and fewer intubation attempts. In this case series report, we describe the video-assisted intubating stylet technique in five patients with difficult airways. We believe that the intubating stylet is a feasible and safe airway technique for anesthetized tracheal intubation in patients with an anticipated difficult airway.

Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery

The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.

Evaluation of the insertion parameters and complications of the i-gel Plus airway device for maintaining patent airway during planned procedures under general anaesthesia: a protocol for a prospective multicentre cohort study

INTRODUCTION

Supraglottic airway devices represent a less invasive method of airway management than tracheal intubation during general anaesthesia. Their continued development is focused mainly on improvements in the insertion success rate and minimalisation of perioperative and postoperative complications. The i-gel Plus is a novel, anatomically preshaped supraglottic airway device which achieves a perilaryngeal seal due to a non-inflatable cuff made of a soft thermoplastic elastomer. The purpose of this cohort study is to assess the success rate of the i-gel Plus use during elective procedures under general anaesthesia, its intraoperative performance, and the degree of postoperative complications.

METHODS AND ANALYSIS

This is a multicentre, prospective, interventional cohort study. The enrolment will take place in seven centres in four European countries. We plan to enrol 2000 adult patients in total, who are scheduled for elective surgery under general anaesthesia, and with an indication for use of a supraglottic airway device for management of their airway. The study is projected to run over a period of 18 months. The primary outcome of the study is the total success rate of the i-gel Plus insertion in terms of successful ventilation and oxygenation through the device. Secondary outcomes include perioperative parameters, such as insertion time, seal/leak pressures, number of insertion attempts and postoperative adverse events and complications. Postoperative follow-up will be performed at 1 hour, 24 hours in all patients, and for selected patients at 3 and 6 months.

ETHICS AND DISSEMINATION

The cohort study has received the following ethical approvals: General University Hospital Prague, University Hospital Olomouc, University Military Hospital Prague, University Hospital Barcelona, University Hospital Lodz, Antrim Area Hospital, Craigavon Area Hospital, Office for Research Ethics Committees Northern Ireland. The results will be published in peer-reviewed journals and presented at relevant anaesthesia conferences.

TRIAL REGISTRATION NUMBER

ISRCTN86233693;Pre-results.