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Hubble MW, Martin M, Houston S, Taylor S, Kaplan GR. Influence of Patient Weight on Prehospital Advanced Airway Procedure Success Rates. PREHOSP EMERG CARE 2024:1-8. [PMID: 38569075 DOI: 10.1080/10903127.2024.2338459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/18/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Previous investigations of the relationship between obesity and difficult airway management have provided mixed results. Almost universally, these studies were conducted in the hospital setting, and the influence of patient body weight on successful prehospital airway management remains unclear. Because patient weight could be one readily identifiable risk factor for problematic airway interventions, we sought to evaluate this relationship. METHODS We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. The inclusion criteria consisted of adult patients weighing >30kg with an attempted orotracheal intubation (OTI) and/or blind insertion airway device (BIAD) placement. Separate logistic regression models were developed to determine the influence of weight (dichotomized at 100 kg) on cumulative procedure success for OTI and BIAD, and linear regression models were used to identify trends for each across weight strata. RESULTS A total of 45,344 patients met inclusionary criteria, among which 40,668(89.7%) suffered from a medical emergency, followed by 3,130(6.9%) with traumatic injuries, and 1,546(3.4%) attributable to a combined medical-trauma etiology. Cardiac arrest occurred either prior to EMS arrival or at some point during EMS care in 38,210(84.3%) patients. OTI was attempted in 18,153(40.0%) patients, while 21,597(47.6%) had a BIAD attempt and 5,594(12.3%) had both airway types attempted. The overall cumulative insertion success rates for OTI and BIAD were 79.5% and 92.7%, respectively. Altogether, 2,711(6.0%) had no advanced airway of any type successfully placed, which represents the overall failed advanced airway rate. After controlling for patient age, sex, minority status, and call type (medical vs. trauma), weight >100kg was associated with decreased likelihood of cumulative OTI success (OR = 0.64, p < 0.001), but higher likelihood of cumulative BIAD success (OR = 1.31, p < 0.001). Cumulative OTI success was associated with a negative 0.6% linear trend per 5 kg of body weight (p < 0.001) while cumulative BIAD success had a 0.2% positive trend (p < 0.001). CONCLUSION This retrospective analysis of a national EMS database revealed that increasing patient weight was negatively associated with intubation success. A positive, but smaller, linear trend was observed for BIAD placement. Patient weight may be an easily identifiable predictor of difficult oral intubation and may be a consideration when selecting an airway management strategy.
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Affiliation(s)
- Michael W Hubble
- Department of Emergency Medical Science, Wake Technical Community College, Raleigh, North Carolina
| | - Melisa Martin
- Department of Health Care Administration, Methodist University, Fayetteville, North Carolina
| | - Sara Houston
- Office of Emergency Services, Durham County EMS, Durham, North Carolina
| | - Stephen Taylor
- Emergency Medicine, East Carolina University, Greenville, North Carolina
| | - Ginny R Kaplan
- Department of Health Care Administration & Advanced Paramedicine, Methodist University, Fayetteville, North Carolina
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Olatunji G, Kokori E, Aderinto N, Alsabri MAH. Emergency airway management in resource limited setting. Int J Emerg Med 2024; 17:41. [PMID: 38486140 PMCID: PMC10938719 DOI: 10.1186/s12245-024-00607-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/22/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Emergency airway management in resource-limited settings presents multifaceted challenges due to shortages in essential medical resources, healthcare professionals, and infrastructure. METHODS We conducted a literature search using keywords "Emergency Airway Management" "Low Resource" "Africa" "Asia" from databases such as Pubmed, and Google Scholar, from where we extracted relevant literature for our study. FINDINGS These limitations resulted in delayed interventions, suboptimal care, and higher complication rates during intubation procedures. However, innovative solutions have emerged to address these challenges, including cost-effective airway management devices and training programs tailored for non-medical personnel. Capacity building and local empowerment are critical components of improving emergency airway management in these settings. Additionally, advocating for policy support and investment in healthcare infrastructure is essential to ensure access to essential equipment and adequate staffing. Collaboration and knowledge-sharing networks among healthcare professionals and organisations are pivotal in disseminating best practices and advancing healthcare delivery in resource-limited regions. CONCLUSION Future efforts should focus on tailored training programs, rigorous research, innovative device development, telemedicine solutions, sustainable capacity building, and advocacy to enhance emergency airway management in resource-limited settings.
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Affiliation(s)
- Gbolahan Olatunji
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Emmanuel Kokori
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Ogbomoso, Nigeria
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Gottlieb M, O’Brien JR, Ferrigno N, Sundaram T. Point-of-care ultrasound for airway management in the emergency and critical care setting. Clin Exp Emerg Med 2024; 11:22-32. [PMID: 37620036 PMCID: PMC11009714 DOI: 10.15441/ceem.23.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/19/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - James R. O’Brien
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nicholas Ferrigno
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Tina Sundaram
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Vidhya S, Swain BP, Dash A, Swain A, Sahu S. Ultrasound-Guided Airway Evaluation: Is It a Game Changer for Predicting Difficult Endotracheal Intubation? Cureus 2024; 16:e52557. [PMID: 38371009 PMCID: PMC10874585 DOI: 10.7759/cureus.52557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Airway ultrasound has recently promised to be a valuable addition to preoperative airway assessment tools. This study was undertaken to determine the efficacy of ultrasound-guided measurement of soft tissue thickness (STT) at various levels of the anterior neck in predicting difficult airways in an eastern Indian population. OBJECTIVE The primary objective was to find out the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of anterior neck soft tissue thickness at the level of the hyoid (STT-Hyoid) and vocal cords (STT-VC), distance from the skin to the epiglottis midway (DSEM), and the ratio of the depth of the pre-epiglottic space (Pre-E) to the distance from the epiglottis to the mid-point of the vocal cords (E-VC). The secondary objective was to develop a scoring system using these parameters. MATERIALS AND METHODS One hundred eighty-eight patients aged 18-65 years who received general anesthesia and endotracheal intubation for surgery were included in the study. Anterior neck soft tissue thickness measurements were done preoperatively using ultrasound. The actual difficulty of the airway was graded by the anesthesiologist while performing endotracheal intubation using the intubation difficulty scale (IDS). RESULTS The incidence of a difficult airway (IDS > 5) was 9.04%. The STT-Hyoid and STT-VC had a moderate correlation with IDS. The DSEM and Pre-E/E-VC ratios had a weak correlation with IDS. For difficult airway prediction, the cutoff points of STT-Hyoid and STT-VC were 7.95 mm and 24.25 mm, respectively. The combined cutoff measurements of STT-Hyoid and STT-VC (29.95 mm) were better predictors of difficult airway. CONCLUSION Preoperative airway ultrasound examination measuring the soft tissue thickness at the hyoid and vocal cord levels is an effective modality in predicting a difficult airway. However, further studies are needed to validate this finding in populations of varied ethnicity and demographic distribution.
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Affiliation(s)
- Sri Vidhya
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
| | - Bhanu P Swain
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
- Anaesthesiology, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, IND
| | - Anbesh Dash
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
- Anaesthesiology, Vikash Multi Specialty Hospital, Bargarh, IND
| | - Amlan Swain
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
- Anaesthesiology, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, IND
| | - Seelora Sahu
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
- Anaesthesiology, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, IND
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5
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Tang X, Dong Z, Xu J, Cheng P, Wang M, Wang B, Jiang X, Yao W. Observation of the validity of the upper lip bite test in predicting difficult intubation. Sci Rep 2023; 13:22160. [PMID: 38092862 PMCID: PMC10719328 DOI: 10.1038/s41598-023-49642-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
The upper lip bite test (ULBT) is considered an effective method for predicting difficult airways, but data on the ULBT for predicting difficult tracheal intubation are lacking. This study aimed to examine the clinical utility of the ULBT in predicting difficult endotracheal intubation. We conducted an observational case-cohort study of adult patients undergoing elective surgery and requiring endotracheal intubation for general anesthesia. Difficult airway assessment was performed on the recruited patients before the operation, including the ULBT, mouth opening, thyromental distance, modified Mallampati test, and body mass index. The primary outcome was the incidence of difficult tracheal intubation. The receiver operating characteristic curve analysis was used to compare the performance of variables in predicting difficult tracheal intubation. We successfully recruited 2522 patients for analysis and observed 64 patients with difficult tracheal intubation. When predicting difficult tracheal intubation, grade 2 ULBT had a sensitivity of 0.75 and a specificity of 0.54, and grade 3 had a sensitivity of 0.28 and a specificity of 0.75. Compared with mouth opening, the area under the receiver operating characteristic curve of the ULBT was lower in predicting difficult tracheal intubation (0.69 [95% confidence interval: 0.67-0.71] vs. 0.84 [95% confidence interval: 0.82-0.87], P < 0.05).Clinical Trials Registry: ChiCTR-ROC-16009050, principal investigator: Weidong Yao.
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Affiliation(s)
- Xinyuan Tang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Zhiyuan Dong
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Jianling Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Pingping Cheng
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Mingfang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Bin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xiaogan Jiang
- Anhui Province Clinical Research Center for Critical Care Medicine (Respiratory Disease), The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Weidong Yao
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China.
- Anhui Province Clinical Research Center for Critical Care Medicine (Respiratory Disease), The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China.
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Matsuyama H, Hara M, Seto A, Hiraki T. Predictive underestimation of difficult direct laryngoscopy in a patient with rheumatoid arthritis-associated immobilized craniocervical junction. JA Clin Rep 2023; 9:85. [PMID: 38051390 DOI: 10.1186/s40981-023-00679-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The upper cervical spine is a major focus of damage by rheumatoid arthritis (RA). Specific screening for mobility of the upper cervical spine, which is essential for direct laryngoscopy, is lacking. Herein, we present a case of RA with Cormack-Lehane grade IV, which was not predicted by preoperative examination. CASE PRESENTATION A 66-year-old woman with RA was scheduled for a right total knee arthroplasty and right elbow synovectomy. She had a long history of RA without symptoms related to the cervical spine or spinal cord. Although physical examination suggested moderate risk of difficult intubation with preserved cervical retroflexion, her Cormack-Lehane classification was grade IV under muscle relaxation. Bony integration of the occiput to axis was considered to be the main cause of difficult direct laryngoscopy, and restricted neck rotation was found postoperatively. CONCLUSIONS RA patients may have limited upper cervical spine motion despite normal cervical retroflexion.
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Affiliation(s)
- Hirotaka Matsuyama
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka, 830-0011, Japan
| | - Masato Hara
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Atsushi Seto
- Nagata Orthopedic Hospital, 1-6-3 Shiranui-Machi, Omuta, Fukuoka, 836-0843, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka, 830-0011, Japan
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Wünsch VA, Köhl V, Breitfeld P, Bauer M, Sasu PB, Siebert HK, Dankert A, Stark M, Zöllner C, Petzoldt M. Hyperangulated blades or direct epiglottis lifting to optimize glottis visualization in difficult Macintosh videolaryngoscopy: a non-inferiority analysis of a prospective observational study. Front Med (Lausanne) 2023; 10:1292056. [PMID: 38098848 PMCID: PMC10720620 DOI: 10.3389/fmed.2023.1292056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/26/2023] [Indexed: 12/17/2023] Open
Abstract
Purpose It is unknown if direct epiglottis lifting or conversion to hyperangulated videolaryngoscopes, or even direct epiglottis lifting with hyperangulated videolaryngoscopes, may optimize glottis visualization in situations where Macintosh videolaryngoscopy turns out to be more difficult than expected. This study aims to determine if the percentage of glottic opening (POGO) improvement achieved by direct epiglottis lifting is non-inferior to the one accomplished by a conversion to hyperangulated videolaryngoscopy in these situations. Methods One or more optimization techniques were applied in 129 difficult Macintosh videolaryngoscopy cases in this secondary analysis of a prospective observational study. Stored videos were reviewed by at least three independent observers who assessed the POGO and six glottis view grades. A linear mixed regression and a linear regression model were fitted. Estimated marginal means were used to analyze differences between optimization maneuvers. Results In this study, 163 optimization maneuvers (77 direct epiglottis lifting, 57 hyperangulated videolaryngoscopy and 29 direct epiglottis lifting with a hyperangulated videolaryngoscope) were applied exclusively or sequentially. Vocal cords were not visible in 91.5% of the cases with Macintosh videolaryngoscopy, 24.7% with direct epiglottis lifting, 36.8% with hyperangulated videolaryngoscopy and 0% with direct lifting with a hyperangulated videolaryngoscope. Conversion to direct epiglottis lifting improved POGO (mean + 49.7%; 95% confidence interval [CI] 41.4 to 58.0; p < 0.001) and glottis view (mean + 2.2 grades; 95% CI 1.9 to 2.5; p < 0.001). Conversion to hyperangulated videolaryngoscopy improved POGO (mean + 43.7%; 95% CI 34.1 to 53.3; p < 0.001) and glottis view (mean + 1.9 grades; 95% CI 1.6 to 2.2; p < 0.001). The difference in POGO improvement between conversion to direct epiglottis lifting and conversion to hyperangulated videolaryngoscopy is: mean 6.0%; 95% CI -6.5-18.5%; hence non-inferiority was confirmed. Conclusion When Macintosh videolaryngoscopy turned out to be difficult, glottis exposure with direct epiglottis lifting was non-inferior to the one gathered by conversion to hyperangulated videolaryngoscopy. A combination of both maneuvers yields the best result. Clinical trial registration ClinicalTrials.gov, NCT03950934.
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Affiliation(s)
- Viktor A. Wünsch
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vera Köhl
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Breitfeld
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Bauer
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip B. Sasu
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannah K. Siebert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Dankert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Stark
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Hardt K, Wappler F. Anesthesia for Morbidly Obese Patients. Dtsch Arztebl Int 2023; 120:779-785. [PMID: 37874129 PMCID: PMC10762842 DOI: 10.3238/arztebl.m2023.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The prevalence of morbid obesity (BMI >35 kg/m2) has risen steadily in recent decades. With the corresponding rise in the number of bariatric operations, anesthesiologists deal with this patient group more commonly than before, particularly in specialized centers. METHODS This review is based on publications retrieved by a selective search in PubMed, including current guidelines and recommendations issued by specialist societies, as well as expert opinion. RESULTS In the anesthesiological care of morbidly obese patients, a preoperative assessment and risk stratification are just as important as the thoughtful selection of the anesthesia technique, the drugs used and their dosage, and perioperative management. A thorough understanding of the pathophysiological changes and comorbidities of morbid obesity and the associated risks is essential. The risk of pulmonary complications such as respiratory failure, hypoxia, and apnea is markedly higher in morbidly obese patients, especially those with obstructive sleep apnea. Short-acting, less lipophilic anesthetic drugs are particularly useful, as is multimodal pain therapy for the avoidance of high opiate doses. The indication for intensified postoperative monitoring depends on the patient's preexisting illnesses, the type of anesthesia, and the type of surgical procedure. Regional anesthetic techniques should be used if possible. CONCLUSION The perioperative care of morbidly obese patients presents special challenges. The anesthesiologist must be aware of potential comorbidities, specific risks, and pathophysiological changes in order to provide adequate care to this patient group.
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Affiliation(s)
- Katharina Hardt
- University Hospital of the Witten/Herdecke University – Cologne, Department of Anesthesiology and Operative Intensive Care Medicine, Cologne-Merheim Hospital
| | - Frank Wappler
- University Hospital of the Witten/Herdecke University – Cologne, Department of Anesthesiology and Operative Intensive Care Medicine, Cologne-Merheim Hospital
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Pintarič TS. Videolaryngoscopy as a primary intubation modality in obstetrics: A narrative review of current evidence. Biomol Biomed 2023; 23:949-955. [PMID: 37021834 PMCID: PMC10655883 DOI: 10.17305/bb.2023.9154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 04/07/2023]
Abstract
Pregnancy-related physiologic and anatomic changes affect oxygenation and airway management, and it is widely believed that airway difficulty may be more common in obstetric patients as a result. In addition, most obstetric intubations are performed under emergency conditions, and preoperative airway assessment poorly predicts airway management outcomes. These considerations necessitate special protocols for airway care in the obstetric population, and the evolution of the videolaryngoscope represents one of the most important milestones in recent decades. However, recommendations for the use of videolaryngoscopy in obstetrics remain unclear. A considerable body of evidence affirms that videolaryngoscopy improves laryngeal visualisation, increases first-attempt and overall intubation success rates, shortens intubation time, and facilitates team communication and education. In contrast, a significant number of studies have also reported conflicting results regarding comparative clinical outcomes and have highlighted other limitations regarding the adoption of videolaryngoscopy in routine obstetric care. Nevertheless, considering the peculiarities of obstetric intubation, the Macintosh-style videolaryngoscope can be suggested as the primary intubation device as it offers the benefits of both videolaryngoscopy and direct laryngoscopy. However, more rigorous evidence is needed to clarify the current blind spots and controversies regarding the role of videolaryngoscopy in obstetrics.
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Affiliation(s)
- Tatjana Stopar Pintarič
- Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Institute of Anatomy, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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10
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Jin C, Pei B, Cao S, Ji N, Xia M, Jiang H. Development and validation of a regression model with nomogram for difficult video laryngoscopy in Chinese population: a prospective, single-center, and nested case-control study. Front Med (Lausanne) 2023; 10:1197536. [PMID: 37727768 PMCID: PMC10505806 DOI: 10.3389/fmed.2023.1197536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023] Open
Abstract
Background Airway management failure is associated with increased perioperative morbidity and mortality. Airway-related complications can be significantly reduced if difficult laryngoscopy is predicted with high accuracy. Currently, there are no large-sample studies on difficult airway assessments in Chinese populations. An airway assessment model based on the Chinese population is urgently needed to guide airway rescue strategy. Methods This prospective nested case-control study took place in a tertiary hospital in Shanghai, China. Information on 10,549 patients was collected, and 8,375 patients were enrolled, including 7,676 patients who underwent successful laryngoscopy and 699 patients who underwent difficult laryngoscopy. The baseline characteristics, medical history, and bedside examinations were included as predictor variables. Laryngoscopy was defined as 'successful laryngoscopy' based on a Cormack-Lehane Grades of 1-2 and as 'difficult laryngoscopy' based on a Cormack-Lehane Grades of 3-4. A model was developed by incorporating risk factors and was presented in the form of a nomogram by univariate logistic regression, least absolute shrinkage and selection operator, and stepwise logistic regression. The main outcome measures were area under the curve (AUC), sensitivity, and specificity of the predictive model. Result The AUC value of the prediction model was 0.807 (95% confidence interval [CI]: 0.787-0.828), with a sensitivity of 0.730 (95% CI, 0.690-0.769) and a specificity of 0.730 (95% CI, 0.718-0.742) in the training set. The AUC value of the prediction model was 0.829 (95% CI, 0.800-0.857), with a sensitivity of 0.784 (95% CI, 0.73-0.838) and a specificity of 0.722 (95% CI, 0.704-0.740) in the validation set. Conclusion Our model had accurate predictive performance, good clinical utility, and good robustness for difficult laryngoscopy in the Chinese population.
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11
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Petzoldt M, Grün C, Wünsch VA, Bauer M, Hardel TT, Grensemann J. Vie Scope® versus videolaryngoscopy in expected difficult airways: a randomized controlled trial. Can J Anaesth 2023; 70:1486-1494. [PMID: 37537324 PMCID: PMC10447594 DOI: 10.1007/s12630-023-02534-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE The management of patients with an anticipated difficult airway remains challenging. We evaluated laryngeal visualization with the recently introduced Vie Scope® as a straight blade laryngoscope consisting of an illuminated tube necessitating bougie-facilitated intubation vs Macintosh videolaryngoscopy. METHODS We conducted a prospective randomized controlled noninferiority trial. Patients undergoing elective ear, nose, and throat or oral and maxillofacial surgery with an anticipated difficult airway were randomized 1:1 to receive tracheal intubation with the Vie Scope or Macintosh videolaryngoscope (C-MAC®). The primary outcome measure was laryngeal visualization by the percentage of glottis opening (POGO) scale. Secondary outcome measures were the time to successful intubation (TTI) and first-attempt and overall success rates. RESULTS We included two sets of 29 patients in our analysis. For visualization, the Vie Scope was noninferior to videolaryngoscopy (VL) with mean (standard deviation [SD]) POGO scores of 71 (31)% vs 64 (30)% in the VL group [difference in means, 7 (8)%; 95% confidence interval, -9 to 23; P = 0.38]. Mean (SD) TTI was 125 (129) sec in the Vie Scope and 51 (36) sec in the VL group (difference in means, 75 sec; 95% confidence interval, 25 to 124; P = 0.005). The first-attempt and overall success rates were 22/29 (76%) and 27/29 (93%) in both groups. Two patients per group were switched to a different device. Four accidental esophageal intubations occurred in the Vie Scope group, these were presumably due to bougie misplacement. CONCLUSION Visualization with the Vie Scope was noninferior to VL in patients with an anticipated difficult airway, but TTI was longer in the Vie Scope group. STUDY REGISTRATION ClinicalTrials.gov (NCT05044416); registered 5 September 2021.
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Affiliation(s)
- Martin Petzoldt
- Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Grün
- Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Viktor A Wünsch
- Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Bauer
- Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim T Hardel
- Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Šklebar I, Habek D, Berić S, Goranović T. AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS. Acta Clin Croat 2023; 62:85-90. [PMID: 38746607 PMCID: PMC11090238 DOI: 10.20471/acc.2023.62.s1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.
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Affiliation(s)
- Ivan Šklebar
- Department of Anesthesiology, Resuscitation and Intensive Care, Sveti Duh University Hospital, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
- Bjelovar University of Applied Sciences, Bjelovar, Croatia
| | - Dubravko Habek
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
- Department of Obstetrics and Gynecology, Merkur University Hospital, Zagreb, Croatia
| | - Sanja Berić
- Department of Anesthesiology, Resuscitation and Intensive Care, Sveti Duh University Hospital, Zagreb, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Tatjana Goranović
- Department of Anesthesiology, Resuscitation and Intensive Care, Sveti Duh University Hospital, Zagreb, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Dai Y, Walline JH, Wu Y, Zhu H, Xu J, Yu X. Incidence and diagnostic validity of difficult airway in emergency departments in China: a cross-sectional survey. J Thorac Dis 2023; 15:434-441. [PMID: 36910112 PMCID: PMC9992590 DOI: 10.21037/jtd-22-199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 12/18/2022] [Indexed: 02/10/2023]
Abstract
Background The difficult airway is a topic of concern for any physician performing intubation. Severe adverse events which can happen because of an unexpected difficult airway emphasize the importance of prediction. This study aimed to investigate the incidence of difficult airways in emergency departments in mainland China and ascertain the predictive value of common assessment formulas. Methods This study was a multicentral, cross-sectional investigation of patients intubated in emergency departments in mainland China between March 1-30, 2021. Frequencies and percentages were calculated for patient characteristics. Diagnostic values were analyzed by sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, the area under the curve, and corresponding P values. Results Nine hundred and eighty-five patients in 41 hospitals were enrolled in the study. Elderly male patients occupied most of the intubated patients. The difficult face mask ventilation rate (8.2%) was higher, but the difficult glottic exposure (6.8%) and intubation (2.1%) rates were low, while there was widespread use of enhanced visualization equipment (80.6%). Four combined emergency applicable evaluation methods showed a certain predictive value for the difficult airway with a sensitivity [0.71; 95% confidence interval (CI): 0.47-0.89], specificity (0.79; 95% CI: 0.76-0.81), and the area under the curve (0.75; 95% CI: 0.64-0.87, P<0.01). Conclusions Despite an insufficient predictive ability for current difficult airway evaluation methods, there were relatively low rates of difficult airways during ED intubations in mainland China. Continuing focus on the difficult airway problems and optimizing airway assessment are required.
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Affiliation(s)
- Yili Dai
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Joseph Harold Walline
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Yao Wu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Xu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuezhong Yu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Pantalacci T, Allaouchiche B, Boselli E. Relationship between ANI and qNOX and between MAC and qCON during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants: a prospective observational preliminary study. J Clin Monit Comput 2023; 37:83-91. [PMID: 35445895 DOI: 10.1007/s10877-022-00861-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 03/31/2022] [Indexed: 01/24/2023]
Abstract
This study was designed to investigate qCON and qNOX variations during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants and compare these indices with ANI and MAC. Adult patients undergoing outpatient laparoscopic cholecystectomy were included in this prospective observational study. Maintenance of anesthesia was performed using remifentanil targeted to ANI 50-80 and desflurane targeted to MAC 0.8-1.2 without muscle relaxants. The ANI, qCON and qNOX and desflurane MAC values were collected at different time-points and analyzed using repeated measures ANOVA. The relationship between ANI and qNOX and between qCON and MAC were analyzed by linear regression. The ANI was comprised between 50 and 80 during maintenance of anesthesia. Higher values of qNOX and qCON were observed at induction and extubation than during all other time-points where they were comprised between 40 and 60. A poor but significant negative linear relationship (r2 = 0.07, p < 0.001) was observed between ANI and qNOX. There also was a negative linear relationship between qCON and MAC (r2 = 0.48, p < 0.001) and between qNOX and remifentanil infusion rate (r2 = 0.13, p < 0.001). The linear mixed-effect regression correlation (r2) was 0.65 for ANI-qNOX and 0.96 for qCON-MAC. The qCON and qNOX monitoring seems informative during general anesthesia using desflurane and remifentanil without muscle relaxants in patients undergoing ambulatory laparoscopic cholecystectomy. While qCON correlated with MAC, the correlation of overall qCON and ANI was poor but significant. Additionally, the qNOX weakly correlated with the remifentanil infusion rate. This observational study suggests that the proposed ranges of 40-60 for both indexes may correspond to adequate levels of hypnosis and analgesia during general anesthesia, although this should be confirmed by further research.
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Torossian A. [Difficult Airway Management (DAM) Algorithms - A narrative synopsis and site assessment]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:72-81. [PMID: 36791772 DOI: 10.1055/a-1754-5426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Centuries ago an "algorithm" was originally inaugurated to depicture a pathway to solve mathematical problems using a decision tree. Nowadays this tool is also well established in clinical medicine. Ever since management errors in difficult airway handling and subsequent litigations remain high referring to ASA closed claims database. However, even since 2010, the ESA postulates every institution dealing with airway management should have a DAM algorithm (ESA Declaration of Helsinki on Patient Safety in Anaesthesiology). In 2018 a systematic review of 38 international DAM algorithms was published; most of them show a four-step flow chart: failed tracheal intubation, insufficient bag-mask ventilation and supraglottic airway, leads to establish an emergency sugical airway. In conclusion authors state that a universal, globally valid, DAM algorithm is lacking. German language guideline development is governed by the AWMF, which labels guidelines with the highest evidence levels and methodological strength "S3". The ASA published a revised DAM practice guideline in 2022, which was developed by 13 international members and was endorsed by international anesthesiological societies. - Though it is based on a systematic literature search and evaluation, final recommendations (without grading) were generated by a survey among experts in the field: Pre-procedural evaluation of the airway is essential; meanwhile more data are available especially regarding ultrasound examination of the upper airway and in 2022 a promising nomogram was developed for the prediction of difficult laryngoscopy. Pre-procedural planning of expected DAM: it should be decided beforehand, if awake intubation is feasible for the patient. Preoxygenation of every elective patient (3 mins with PEEP 5 cmH2O, aim: 95% pulse oxymetry) and continuous nasal high-flow oxygen delivery during airway management. In case of unexpectedly difficult/emergency airway, ASA recommends: call for help, use cognitive aid (algorithm), consider restoration of spontaneous breathing, adjust bag-mask ventilation, monitor time passing; if "cannot intubate, cannot oxygenate" situation occurs (etCO2 < 10 mmHg, < 80% pulse oxymetry) establish surgical airway; if failed consider ECMO therapy, if feasible and available. ASA restricts intubation attempts to 3+ based on experience and decision of the clinician, however evidence shows, that attempts should not exceed 2 attempts to avoid serious complications, e.g. hyoxemia and even cardiopulmonary resuscitation (CPR). Additionally, we recommend a cockpit strategy for airway management using crisis resource elements as used in aviation (situation awareness, sterile communication, read-back/hear-back and canned decisions) and a supervisor/team leader as already established in CPR. Last, but not least, continuous airway management training increases algorithm adherence.
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Zhao MY, Macaskill J, McKay W, Hedlin P, Barbour-Tuck E, Walker ME, Gamble J. Assessment of the reliability of virtual preanesthetic airway evaluation compared to traditional in-person airway evaluation: a prospective observational study. Can J Anaesth 2023; 70:79-86. [PMID: 36376750 DOI: 10.1007/s12630-022-02345-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/07/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Airway evaluation is a fundamental component of the preanesthetic examination. Virtual care has increased during the COVID-19 pandemic. We aimed to assess the reliability of a virtual preanesthetic airway evaluation compared with a traditional in-person airway evaluation. METHODS This prospective observational study compared the inter-rater agreement of an in-person airway evaluation performed by a consultant anesthesiologist with a virtual airway evaluation (VAE) performed by consultant anesthesiologists and medical students. The airway evaluation was completed using a comprehensive airway evaluation and scoring tool. The primary outcome was the inter-rater agreement of total scores between in-person anesthesiologist airway evaluations and the VAEs of both the anesthesiologists and medical students, assessed using Cohen's Kappa (CK). Secondary outcomes included the inter-rater agreement for each airway evaluation component between the in-person anesthesiologists and both the anesthesiologist and medical student VAEs, assessed using prevalence-adjusted and bias-adjusted Kappa. RESULTS One hundred out of 111 participants completed all three evaluations. The in-person anesthesiologist airway evaluations had fair and good levels of agreement of total scores with the VAEs of the anesthesiologists (CK, 0.21; 97.5% confidence interval [CI], 0.07 to 0.34) and the medical students (CK, 0.74; 97.5% CI, 0.62 to 0.86), respectively. One participant was reported to have a difficult intubation. CONCLUSION Virtual airway evaluations performed by anesthesiologists and medical students had fair and good inter-rater agreement, respectively, with in-person anesthesiologist airway evaluations. Further study with a focus on patients with difficult airways is required to define the predictive value of VAEs regarding difficult intubations.
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Tobe S, Ishiyama H, Nishiyama A, Miyazono K, Kimura H, Fueki K. Effects of Jaw-Opening Exercises with/without Pain for Temporomandibular Disorders: A Pilot Randomized Controlled Trial. Int J Environ Res Public Health 2022; 19:16840. [PMID: 36554726 PMCID: PMC9779752 DOI: 10.3390/ijerph192416840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 06/17/2023]
Abstract
This study aimed to evaluate the effects of jaw-opening exercises with and without pain on temporomandibular disorders (TMDs), specifically in relation to pain intensity and range-of-mouth opening in patients with TMDs. Participants were randomly assigned to either the jaw-opening exercise with pain (JE w/pain) or the jaw-opening exercise without pain (JE w/o pain) groups, and each exercise was performed for eight weeks. TMDs pain intensity was assessed using a 100-mm visual analog scale (VAS), and the range-of-mouth opening was evaluated at the baseline (T0), 2 weeks (T1), 4 weeks (T2), and 8 weeks (T3). Of the 61 participants, 57 (JE w/pain group, n = 30; JE w/o pain group, n = 27) were included in the analysis. The range-of-mouth opening and TMDs pain intensity improved from T1 to T3 in both groups. The JE w/pain group showed significant differences at T3 compared to T1 (pain-free unassisted mouth opening, p = 0.006; jaw-opening pain, p = 0.014; chewing pain, p = 0.018). In addition, the JE w/pain group showed significantly greater changes in the maximum unassisted mouth opening at T2 and T3 than the JE w/o pain group (T2, p < 0.001; T3, p = 0.003). Thus, jaw-opening exercises, until the occurrence of pain, may be effective in patients with TMDs.
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Affiliation(s)
- Shoko Tobe
- Department of Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
| | - Hiroyuki Ishiyama
- Department of Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
| | - Akira Nishiyama
- Department of General Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
| | - Keisuke Miyazono
- Department of Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
| | - Hiroko Kimura
- Department of Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
| | - Kenji Fueki
- Department of Masticatory Function and Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8549, Japan
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Zhang F, Xu Y, Zhou Z, Zhang H, Yang K. Critical element prediction of tracheal intubation difficulty: Automatic Mallampati classification by jointly using handcrafted and attention-based deep features. Comput Biol Med 2022; 150:106182. [PMID: 36242810 DOI: 10.1016/j.compbiomed.2022.106182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/14/2022] [Accepted: 10/01/2022] [Indexed: 11/20/2022]
Abstract
Preoperative assessment of the difficulty of tracheal intubation is of great importance in anesthesia practice because failed intubation can lead to severe complications and even death. The Mallampati score is widely used as a critical assessment criterion in combination with other measures to assess the difficulty of tracheal intubation. The performance of existing methods for Mallampati classification with artificial intelligence (AI) is unreliable to the extent that the current clinical judgment of the Mallampati score relies entirely on doctors' experience. In this paper, we propose a new method for automatic Mallampati classification. Our method extracts deep features that are more favorable for the Mallampati classification task by introducing an attention mechanism into the basic deep convolutional neural network (DCNN) and then further improves the classification performance by jointly using attention-based deep features with handcrafted features. We conducted experiments on a dataset consisting of 321 oral images collected online. The proposed method has a classification accuracy of 97.50%, a sensitivity of 96.52%, a specificity of 98.05%, and an F1 score of 96.52% after five-fold cross-validation. The experimental results show that our proposed method is superior to other methods, can assist doctors in determining Mallampati class objectively and accurately, and provide an essential reference element for assessing the difficulty of tracheal intubation.
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Affiliation(s)
- Fan Zhang
- Unmanned System Research Institute, Northwestern Polytechnical University, Xi'an, 710072, Shaanxi, China.
| | - Yuelei Xu
- Unmanned System Research Institute, Northwestern Polytechnical University, Xi'an, 710072, Shaanxi, China.
| | - Zhaoyun Zhou
- Department of Anesthesiology, Tai'an Central Hospital, Tai'an, 271000, Shandong, China.
| | - Han Zhang
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China.
| | - Ke Yang
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650102, Yunnan, China.
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Mushambi MC, Kinsella SM. Hypoxaemia during induction of general anaesthesia in pregnant women – a surrogate for overall airway difficulty? Southern African Journal of Anaesthesia and Analgesia 2022. [DOI: 10.36303/sajaa.2022.28.5.2859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- MC Mushambi
- Leicester Medical School, University of Leicester,
United Kingdom
| | - SM Kinsella
- Department of Anaesthesia, St Michael’s Hospital,
United Kingdom
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Hasani A. REGIONAL ANESTHESIA IN SPINAL SURGERY: COULD IT BE THE SOLUTION FOR DIFFICULT INTUBATION. Acta Clin Croat 2022; 61:129-134. [PMID: 36824630 PMCID: PMC9942463 DOI: 10.20471/acc.2022.61.s2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
This article includes two topics - anesthesia for spinal surgery and difficult airway, both of them are linked with the same topic, which is regional anesthesia. In recent years, regional anesthesia for spinal surgery has gained a great popularity, where neuraxial blocks are the first choice. Regional anesthesia seems to have benefits against general anesthesia due to lower rate of perioperative and postoperative complications, lower cost and length of stay. This is more evident in elderly population or patients with comorbidities. On the other hand, difficult airway is the life threatening condition and requires increased attention. There are many methods and tools for managing difficult airways, but there are few supporters of regional anesthesia as an option or solution in these cases. Of course, special attention is required during regional anesthesia in a patient with difficult airway, the decision must be correct, and an anesthesiologist must have a preformulated strategy for airway management. However, does not the same happen even when we apply general anesthesia?
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Affiliation(s)
- Antigona Hasani
- ConsultantProfessor of Anesthesiology and Reanimation, Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Pristina, Pristina, Kosovo
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Prathep S, Jitpakdee W, Woraathasin W, Oofuvong M. Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study. BMC Anesthesiol 2022; 22:145. [PMID: 35568816 PMCID: PMC9107244 DOI: 10.1186/s12871-022-01685-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background In morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients. Methods This prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale. Results Mean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score. Conclusions Age, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy.
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Affiliation(s)
- Sumidtra Prathep
- Department of Anesthesiology, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla, Songkhla, 90110, Thailand.
| | - Wilasinee Jitpakdee
- Department of Anesthesiology, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla, Songkhla, 90110, Thailand
| | - Wisara Woraathasin
- Department of Anesthesiology, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla, Songkhla, 90110, Thailand
| | - Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla, Songkhla, 90110, Thailand
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Abstract
BACKGROUND Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016. OBJECTIVES To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation. MAIN RESULTS We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit. We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%). AUTHORS' CONCLUSIONS VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.
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Affiliation(s)
| | - Andrew M Rogers
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Tim M Cook
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
- University of Bristol, Bristol, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
- Lancaster University, Lancaster, UK
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Nashibi M, Husain Khan Z, Mottaghi K. Assessment of Ratio of Height to Rhinion-Mentum Distance as a Predictive Tool for Difficult Tracheal Intubation. Tanaffos 2022; 21:362-366. [PMID: 37025314 PMCID: PMC10073948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 06/03/2022] [Indexed: 06/19/2023]
Abstract
BACKGROUND Difficult Intubation (DI) is a constant concern for anesthesiologists and being able to predict it will improve patient safety. Different tests have been presented in anesthesiology practice to increase the accuracy of the DI prediction. Since there is no single sensitive and specific test, most of the practitioners use a combination of them. Here we report a new and novel index of ratio of height to rhinion-mentum distance (RHRMD) to improve the prediction. MATERIALS AND METHODS Four hundred adult patients' candidate for elective surgery were enrolled into the study. Initially, patients' data such as weight, height and rhinion-mentum distance (RMD) were recorded by the first anesthesiologist. After anesthesia induction, the second anesthesiologist performed laryngoscopy and recorded the Cormack-Lehane (CL) score. CL score III or higher was considered as DI. Finally, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for RHRMD was calculated. RESULTS DI was reported in 7.75% of patients. RHRMD is related with CL grade: as the former increased, the latter decreased. RHRMD with cut-off point 25.4 has 90.6% sensitivity, 29.9% specificity, 10.1% PPV and 97.3% NPV in predicting DI. CONCLUSION RHRMD with 90.6% sensitivity and 97.3% NPV could be a valuable tool for prediction of DI.
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Affiliation(s)
- Masoud Nashibi
- Anesthesiology Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahid Husain Khan
- Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Mottaghi
- Anesthesiology Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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24
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Ahmed AM, Zaky MN, El-Mekawy NM, Ollaek MA, Sami WM, Mohamed DM. Evaluation of thyromental height test in prediction of difficult airway in obese surgical patients: An observational study. Indian J Anaesth 2022; 65:880-885. [PMID: 35221360 PMCID: PMC8820326 DOI: 10.4103/ija.ija_675_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/20/2021] [Accepted: 12/05/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Thyromental height test (TMHT) has revealed good potentials for predicting difficult laryngoscopy view (DLV) in non-obese patients, but its accuracy in obese patients is not evident. This study aimed to assess the validity of TMHT as a predictor of DLV in obese surgical patients. METHODS 105 patients, aged 18-60 years, with body mass index (BMI) >30 kg/m2, scheduled for elective surgeries under general anaesthesia with an endotracheal tube inserted using conventional laryngoscope were included. Airway was assessed with TMHT, modified Mallampati test (MMT), neck circumference (NC) and NC/TMHT ratio. The DLV was defined as Cormack-Lehane grade ≥3. The primary endpoint was the validity of TMHT as a predictor of DLV. The secondary endpoints were to compare the accuracy of TMHT with that of the NC, MMT and NC/TMHT ratio as predictors of the difficult airway. RESULTS The BMI was 43.7 ± 6.6 kg/m2. The DLV cases were 23/105 (21.9%). The MMT, TMHT and NC/TMHT ratio had the best predictive ability of DLV with areas under receiver operating characteristic curve of 0.91, 0.92 and 0.80; at cut-off values >2, <47 mm and >7.9, respectively. MMT and TMHT were the only predictors of DLV by multivariate analysis. CONCLUSION In obese surgical patients, TMHT is an excellent predictor of DLV when the cut-off value is <47 mm.
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Affiliation(s)
- Abeer M Ahmed
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
| | - Monica N Zaky
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
| | - Nevan M El-Mekawy
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
| | - Mohamed A Ollaek
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
| | - Wael M Sami
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
| | - Dina M Mohamed
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr Alainy Faculty of Medicine, Cairo University, Egypt
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25
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Introna M, van den Berg JP, Eleveld DJ, Struys MMRF. Bayesian statistics in anesthesia practice: a tutorial for anesthesiologists. J Anesth 2022; 36:294-302. [PMID: 35147768 PMCID: PMC8967750 DOI: 10.1007/s00540-022-03044-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 01/25/2022] [Indexed: 11/20/2022]
Abstract
This narrative review intends to provide the anesthesiologist with the basic knowledge of the Bayesian concepts and should be considered as a tutorial for anesthesiologists in the concept of Bayesian statistics. The Bayesian approach represents the mathematical formulation of the idea that we can update our initial belief about data with the evidence obtained from any kind of acquired data. It provides a theoretical framework and a statistical method to use pre-existing information within the context of new evidence. Several authors have described the Bayesian approach as capable of dealing with uncertainty in medical decision-making. This review describes the Bayes theorem and how it is used in clinical studies in anesthesia and critical care. It starts with a general introduction to the theorem and its related concepts of prior and posterior probabilities. Second, there is an explanation of the basic concepts of the Bayesian statistical inference. Last, a summary of the applicability of some of the Bayesian statistics in current literature is provided, such as Bayesian analysis of clinical trials and PKPD modeling.
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Affiliation(s)
- Michele Introna
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Anesthesiology and Intensive Care Medicine, Cremona Hospital, Cremona, Italy
| | - Johannes P van den Berg
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Douglas J Eleveld
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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26
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Khan M, Siddiqui AS, Raza SA, Samad K. Incidence and Predictors of Difficult Mask Ventilation in High-Risk Adult Population Scheduled for Elective Surgery: A Prospective Observational Study. Cureus 2022; 14:e22002. [PMID: 35282531 PMCID: PMC8906503 DOI: 10.7759/cureus.22002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Mask ventilation is one of the key components in the management of airway during general anaesthesia, particularly when laryngoscopy is challenging. Adequate mask ventilation provides anaesthesiologists a safe time in case of unanticipated or anticipated difficult airway situations. The aim of this study was to determine the incidence of difficult bag-mask ventilation and intubation in patients having three or more predictors for difficult mask ventilation (DMV) in adult patients scheduled for elective surgery under anaesthesia. Methods A total of 294 patients requiring endotracheal intubation for elective surgical procedure having three or more risk factors were evaluated for the presence of difficulty in bag-mask ventilation and intubation by the anaesthesiologist. Chi-square test or Fisher's exact test and a multivariable stepwise logistic regression model were performed to identify predictors of DMV. Crude and adjusted odds ratio with 95% confidence interval were reported. Results In this study, the average age of the patients was 53.59±13.32 years with a 2:1 male-to-female ratio. DMV and difficult intubation (DI) were observed in 31.6% and 3% of patients, respectively. Multivariate analysis identified history of snoring, BMI (>35 kg/m2), presence of beard and Mallampati III or IV as independent predictors for DMV. Patients with multiple factors (≥3 factors) had a threefold (OR=2.57) increased risk of difficulty in mask ventilation and a nearly fivefold (OR=4.63) increased risk of difficulty with intubation. Conclusion In our study, the incidence of DMV was observed in 93 (31.6%) patients and DI was found in 9 (3%) patients. A simple DMV risk score may help to predict DMV better, potentially improving safety during difficult airway management, decreasing morbidity and mortality associated with it.
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27
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Xia M, Cao S, Zhou R, Wang JY, Xu TY, Zhou ZK, Qian YM, Jiang H. Acoustic features as novel predictors of difficult laryngoscopy in orthognathic surgery: an observational study. Ann Transl Med 2021; 9:1466. [PMID: 34734018 PMCID: PMC8506731 DOI: 10.21037/atm-21-4359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 01/19/2023]
Abstract
Background The evaluation of the difficult intubation is an important process before anaesthesia. The unanticipated difficult intubation is associated with morbidity and mortality. This study aimed to determine whether acoustic features are valuable as an alternative method to predict difficult laryngoscopy (DL) in patients scheduled to undergo orthognathic surgery. Methods This study included 225 adult patients who were undergoing elective orthognathic surgery under general anaesthesia with tracheal intubation. Preoperatively, clinical airway evaluation was performed, and the acoustic data were collected. Twelve phonemes {[a], [o], [e], [i], [u], [ü], [ci], [qi], [chi], [le], [ke], and [en]} were recorded, and their formants (f1-f4) and bandwidths (bw1-bw4) were extracted. Difficult laryngoscopy was defined as direct laryngoscopy with a Cormack-Lehane grade of 3 or 4. Univariate and multivariate logistic regression analyses were used to examine the associations between acoustic features and DL. Results Difficult laryngoscopy was reported in 59/225 (26.2%) patients. The area under the curve (AUC) of the backward stepwise model including en_f2 [odds ratio (OR), 0.996; 95% confidence interval (CI), 0.994–0.999; P=0.006], ci_bw4 (OR, 0.997; 95% CI, 0.993–1.000; P=0.057), qi_bw4 (OR, 0.996; 95% CI, 0.993–0.999; P=0.017), le_f3 (OR, 0.998; 95% CI, 0.996–1.000; P=0.079), o_bw4 (OR, 1.001; 95% CI, 1.000–1.003; P=0.014), chi_f4 (OR, 1.003; 95% CI, 1.000–1.005; P=0.041), a_bw4 (OR, 0.999; 95% CI, 0.998–1.000; P=0.078) attained a value of 0.761 in the training set, but a value of 0.709 in the testing set. The sensitivity and specificity of the model in the testing set are 86.7% and 63.0%, respectively. Conclusions Acoustic features may be considered as useful predictors of DL during orthognathic surgery.
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Affiliation(s)
- Ming Xia
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuang Cao
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ren Zhou
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia-Yi Wang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tian-Yi Xu
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Kai Zhou
- X-LANCE Lab, Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yan-Min Qian
- X-LANCE Lab, Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Jiang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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28
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Zhang L, Yan YR, Li SQ, Li HP, Lin YN, Li N, Sun XW, Ding YJ, Li CX, Li QY. Moderate to severe OSA screening based on support vector machine of the Chinese population faciocervical measurements dataset: a cross-sectional study. BMJ Open 2021; 11:e048482. [PMID: 34535476 PMCID: PMC8451311 DOI: 10.1136/bmjopen-2020-048482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Obstructive sleep apnoea (OSA) has received much attention as a risk factor for perioperative complications and 68.5% of OSA patients remain undiagnosed before surgery. Faciocervical characteristics may screen OSA for Asians due to smaller upper airways compared with Caucasians. Thus, our study aimed to explore a machine-learning model to screen moderate to severe OSA based on faciocervical and anthropometric measurements. DESIGN A cross-sectional study. SETTING Data were collected from the Shanghai Jiao Tong University School of Medicine affiliated Ruijin Hospital between February 2019 and August 2020. PARTICIPANTS A total of 481 Chinese participants were included in the study. PRIMARY AND SECONDARY OUTCOME: (1) Identification of moderate to severe OSA with apnoea-hypopnoea index 15 events/hour and (2) Verification of the machine-learning model. RESULTS Sex-Age-Body mass index (BMI)-maximum Interincisal distance-ratio of Height to thyrosternum distance-neck Circumference-waist Circumference (SABIHC2) model was set up. The SABIHC2 model could screen moderate to severe OSA with an area under the curve (AUC)=0.832, the sensitivity of 0.916 and specificity of 0.749, and performed better than the STOP-BANG (snoring, tiredness, observed apnea, high blood pressure, BMI, age, neck circumference, and male gender) questionnaire, which showed AUC=0.631, the sensitivity of 0.487 and specificity of 0.772. Especially for asymptomatic patients (Epworth Sleepiness Scale <10), the SABIHC2 model demonstrated better predictive ability compared with the STOP-BANG questionnaire, with AUC (0.824 vs 0.530), sensitivity (0.892 vs 0.348) and specificity (0.755 vs 0.809). CONCLUSION The SABIHC2 machine-learning model provides a simple and accurate assessment of moderate to severe OSA in the Chinese population, especially for those without significant daytime sleepiness.
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Affiliation(s)
- Liu Zhang
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Ru Yan
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shi Qi Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Peng Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Ni Lin
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xian Wen Sun
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Jie Ding
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuan Xiang Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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29
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Ampanozi G, Franckenberg S, Schweitzer W, Thali MJ, Chatzaraki V. Prevalence of calcified epiglottis in postmortem computed tomography. Is there a correlation to failed endotracheal intubation? Dentomaxillofac Radiol 2021; 50:20200615. [PMID: 33591846 DOI: 10.1259/dmfr.20200615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Calcification of the epiglottis is a normal physiological degenerative process, although it can also be a consequence of infection or trauma. There are three possible forensically relevant consequences from epiglottic calcification: misinterpretation as foreign bodies, dysphagia as a major contributing factor to aspiration, and association with difficult intubation or a misplaced ventilation tube. It is the aim of this study (I) to inquire about the prevalence of epiglottic calcification in postmortem CT in general and (II) to investigate whether calcification of the epiglottis is linked to a higher incidence of failed endotracheal intubation. METHODS We retrospectively analysed 2930 consecutive cases in postmortem CT at the Institute of Forensic Medicine. RESULTS The prevalence of epiglottic calcification was 4.1%. Higher age and male sex are associated with an increased risk of epiglottic calcification. There was no calcification of the epiglottis in the cases with misplacement of the ventilation tube in the esophagus. CONCLUSIONS To verify the result of our study, that is, the calcification of the epiglottis is not linked to a higher incidence of failed endotracheal intubation, it might be reasonable to repeat this study with a more representative study population. The high interindividual variations of calcified epiglottis could be used for identification.
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Affiliation(s)
- Garyfalia Ampanozi
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Sabine Franckenberg
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland.,Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Wolf Schweitzer
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Michael J Thali
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Vasiliki Chatzaraki
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland.,Department of Radiology, Cantonal Hospital Baden, Baden, Switzerland
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30
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Zheng Z, Ma W, Du R. Effectiveness and validity of midsagittal tongue cross-sectional area and width measured by ultrasound to predict difficult airways. Minerva Anestesiol 2021; 87:403-413. [PMID: 33591134 DOI: 10.23736/s0375-9393.20.14769-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Increased tongue volume measured by ultrasound has been proven to be related to difficult airways. Tongue volume is an indirect parameter and is derived from multiplying the midsagittal tongue cross-sectional area (CSA) by the tongue width. However, few studies have focused on the ability of tongue CSA and tongue width to predict difficult airways. This study aimed to investigate the predictive value of tongue CSA and tongue width for predicting difficult laryngoscopy and difficult intubation. METHODS This study included 244 adult patients who underwent general anesthesia and endotracheal intubation. Demographic variables were collected, and clinical airway assessments were performed. A curvilinear low-frequency probe was used for ultrasonography, and midsagittal tongue CSA and tongue width were measured before anesthesia. The laryngoscopic view and the difficulty of intubation was graded or scored after induction of anesthesia. RESULTS A total of 230 patients were analyzed. Twenty-eight (12.2%) patients experienced difficult laryngoscopy and twelve (5.2%) patients experienced difficult intubation. Midsagittal tongue CSA evaluated by ultrasonography could help identify patients with difficult laryngoscopy (sensitivity 0.71, specificity 0.60) and patients with difficult intubation (sensitivity 0.50, specificity 0.97). And tongue width could help identify patients with difficult laryngoscopy (sensitivity 0.39, specificity 0.89). CONCLUSIONS Ultrasonic measurement of midsagittal tongue CSA may be a valuable predictor of difficult laryngoscopy and difficult intubation. By contrast, tongue width measured by ultrasound may be a weak predictor of difficult laryngoscopy, but its predictive ability was questionable.
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Affiliation(s)
- Zhenwei Zheng
- Department of Anesthesiology, First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Anesthesiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Wuhua Ma
- Department of Anesthesiology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China -
| | - Ruiming Du
- Department of Anesthesiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
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31
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DI Filippo A, Adembri C, Paparella L, Esposito C, Tofani L, Perez Y, DI Giacinto I, Micaglio M, Sorbello M. Risk factors for difficult Laryngeal Mask Airway LMA-Supreme™ (LMAS) placement in adults: a multicentric prospective observational study in an Italian population. Minerva Anestesiol 2021; 87:533-540. [PMID: 33591142 DOI: 10.23736/s0375-9393.20.15001-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Supraglottic airway devices (SADs) are precious tools for airway management in both routine and rescue situations; few studies have analyzed the risk factors for their difficult insertion. METHODS The aim of this study was to identify the risk factors for difficult insertion for a specific SAD, the Laryngeal Mask Airway LMA-Supreme™ (LMAS). This was a prospective multicentric observational study on a cohort of Italian adult patients receiving general anesthesia for elective surgery. The possible causes of difficulty in LMAS placement (difficulty in insertion or unsatisfactory ventilation) were identified based on literature and on the opinion of international airway management experts. A dedicated datasheet was prepared to collect patients' data, including anthropometric-parameters and parameters for the prediction of difficult airway management, as well as technical choices for the use of LMAS. Data were analyzed to discover the risk factors for difficult LMAS placement and the association between each risk factor and the proportion of incorrect positioning was evaluated through the relative risk and its confidence interval. RESULTS Four hundred thirty-two patients were enrolled; seventy required two or more attempts to insert the LMAS; nine required a change of strategy. At multivariate analysis, the following factors were significantly associated with difficult LMAS placement: Mallampati III-IV with either phonation or not; inter-incisor distance < 3 cm; reduced neck mobility; no administration of neuromuscular blocking agents (NMBAs). CONCLUSIONS The alignment of the laryngeal and pharyngeal axes seems to facilitate the procedure, together with NMBA administration; on the contrary, Mallampati grade III-IV are associated with difficult LMAS placement.
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Affiliation(s)
- Alessandro DI Filippo
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy.,Careggi University Hospital, Florence, Italy
| | - Chiara Adembri
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy - .,Careggi University Hospital, Florence, Italy
| | | | - Clelia Esposito
- Department of Anesthesiology, Resuscitation and Postoperative Intensive Care, AORN Ospedali dei Colli, Naples, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Ylenia Perez
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
| | - Ida DI Giacinto
- Department of Organ Failure and Transplantation, St.Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Massimiliano Sorbello
- Anestesiology and Intensive Care Unit, Vittorio Emanuele San Marco University Hospital, Catania, Italy
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Abstract
BACKGROUND Unanticipated difficult airway is a potentially life-threatening event during elective surgery or management of critical conditions. Nevertheless, predicting difficult mask ventilation currently remains a challenge due to the poor sensitivity of available clinical tests. Our primary goal was to verify whether preoperative upper airway ultrasound measurements were useful to predict difficult face mask ventilation. Our secondary goal was to evaluate clinical characteristics and differences between patients who are difficult to ventilate and patients who are not. METHODS We performed a prospective observational study, enrolling 250 adult patients selected for colorectal, gastric, bariatric and pancreatic elective surgery between September 2017 and October 2018. We performed a preoperative US assessment of the airways, following a standardized protocol. We measured the hyomental distance (DIM), the thickness of the base of the tongue (SBL), the thickness of the soft tissues anterior to the hyoid bone (STTi), thyro-hyoid distance (DTI), the thickness of soft tissue anterior to the epiglottis (STTe), to the arytenoid (STTa) and to the commissure of the vocal cords (STTcv). RESULTS SBL had a predictive role of difficult mask ventilation in curarized and noncurarized patients for values higher than 50 mm. Hyomental distance with hyperextension of the head and subluxation of the mandible (DIMs) had a predictive role in the curarized patient (protective parameter). CONCLUSIONS Airways ultrasound evaluation could be an important tool to predict difficult mask ventilation. Further studies are necessary to validate the parameters found and correlate them to the preoperative clinical evaluation.
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Affiliation(s)
- Amedeo Bianchini
- Department of Organ Deficiencies and Transplants, Anesthesia and Intensive Care Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ludovica Nardozi
- Specialization School of Anesthesia and Intensive Care, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Elena Nardi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Maria F Scuppa
- Specialization School of Cardiology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Kopanaki E, Piagkou M, Demesticha T, Anastassiou E, Skandalakis P. Sternomental Distance Ratio as a Predictor of Difficult Laryngoscopy: A Prospective, Double-Blind Pilot Study. Anesth Essays Res 2020; 14:49-55. [PMID: 32843792 PMCID: PMC7428112 DOI: 10.4103/aer.aer_2_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/19/2020] [Accepted: 02/07/2020] [Indexed: 11/05/2022] Open
Abstract
Background: No single test has shown to be an accurate predictor of difficult laryngoscopy. Aims: This study aims to evaluate the effectiveness of the ratio of the sternomental distance (SMD) in neutral and full neck extension position SMD ratio (SMDR) as a predictor of difficult laryngoscopy and any need of assisted intubation. Settings and Design: Prospective, double-blind pilot study. Materials and Methods: This study included 221 consecutive adult patients scheduled to undergo elective surgery under general anesthesia. Physical and airway characteristics, SMDR, difficult laryngoscopy (using Cormack/Lehane [C/L] scale), and any kind of assisted intubation were assessed. Statistical Analysis: The optimal cutoff point for SMDR was identified using receiver operating characteristic (ROC) analysis. The association between SMDR and the intubation method was evaluated through multiple logistic regression analysis. Results: A SMDR below 1.55 led in 33% of the cases to assisted intubation and 33%–53% of C/L III–IV glottic views for McCoy and Macintosh blades, respectively. On the other hand, SMDR above 1.9 led to no C/L IV glottic views for both blades and 4% and 11% C/L III views glottic views for McCoy and Macintosh, respectively. The best sensitivity and specificity cutoff point as defined by the ROC curve was identified for an SMDR value of 1.7 (area[s] under the curve: 0.815; 95% confidence interval: 0.743–0.887). Assisted intubation rates were significantly higher in patients with an SMDR inferior to 1.7 (30.5% compared to 3.5%, P < 0.001). Conclusions: SMDR is a simple, objective, and easy to perform test. The present study indicates that SMDR may be helpful in predicting difficult laryngoscopy and assisted intubation.
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Affiliation(s)
- Evangelia Kopanaki
- Department of Anesthesiology, Thriasio General Hospital of Elefsina, Magoula-Elefsina, Greece
| | - Maria Piagkou
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Zografou, Athens, Greece
| | - Theano Demesticha
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Zografou, Athens, Greece
| | - Emmanouil Anastassiou
- Department of Anesthesiology, Thriasio General Hospital of Elefsina, Magoula-Elefsina, Greece
| | - Panagiotis Skandalakis
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Zografou, Athens, Greece
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Lim MJ, Tan HS, Tan CW, Li SY, Yao WY, Yuan YJ, Sultana R, Sng BL. The effects of labor on airway outcomes with Supreme™ laryngeal mask in women undergoing cesarean delivery under general anesthesia: a cohort study. BMC Anesthesiol 2020; 20:213. [PMID: 32847548 PMCID: PMC7449044 DOI: 10.1186/s12871-020-01132-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pregnancy is associated with higher incidence of failed endotracheal intubation and is exacerbated by labor. However, the influence of labor on airway outcomes with laryngeal mask airway (LMA) for cesarean delivery is unknown. METHODS This is a secondary analysis of a prospective cohort study on LMA use during cesarean delivery. Healthy parturients who fasted > 4 h undergoing Category 2 or 3 cesarean delivery with Supreme™ LMA (sLMA) under general anesthesia were included. We excluded parturients with BMI > 35 kg/m2, gastroesophageal reflux disease, or potentially difficult airway (Mallampati score of 4, upper respiratory tract or neck pathology). Anesthesia and airway management reflected clinical standard at the study center. After rapid sequence induction and cricoid pressure, sLMA was inserted as per manufacturer's recommendations. Our primary outcome was time to effective ventilation (time from when sLMA was picked up until appearance of end-tidal carbon dioxide capnography), and secondary outcomes include first-attempt insertion failure, oxygen saturation, ventilation parameters, mucosal trauma, pulmonary aspiration, and Apgar scores. Differences between labor status were tested using Student's t-test, Mann-Whitney U test, or Fisher's exact test, as appropriate. Quantitative associations between labor status and outcomes were determined using univariate logistic regression analysis. RESULTS Data from 584 parturients were analyzed, with 37.8% in labor. Labor did not significantly affect time to effective ventilation (mean (SD) for labor: 16.0 (5.75) seconds; no labor: 15.3 (3.35); mean difference: -0.65 (95%CI: - 1.49 to 0.18); p = 0.1262). However, labor was associated with increased first-attempt insertion failure and blood on sLMA surface. No reduction in oxygen saturation or pulmonary aspiration was noted. CONCLUSIONS Although no significant increase in time to effective ventilation was noted, labor may increase the number of insertion attempts and oropharyngeal trauma with sLMA use for cesarean delivery in parturients at low risk of difficult airway. Future studies should investigate the effects of labor on LMA use in high risk parturients. TRIAL REGISTRATION The study was prospectively registered at clinicaltrials.gov ( NCT02026882 ) on 3 January 2014.
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Affiliation(s)
- Ming Jian Lim
- Department of Women's Anesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Hon Sen Tan
- Department of Women's Anesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Chin Wen Tan
- Department of Women's Anesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Shi Yang Li
- Department of Anesthesiology and Perioperative Medicine, Quanzhou Macare Women's Hospital, Quanzhou, Fujian Province, China
| | - Wei Yu Yao
- Department of Anesthesiology and Perioperative Medicine, Quanzhou Macare Women's Hospital, Quanzhou, Fujian Province, China
| | - Yong Jing Yuan
- Department of Anesthesiology, Qinghai University Affiliated Hospital, Xining, Qinghai Province, China
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Ban Leong Sng
- Department of Women's Anesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Daggupati H, Maurya I, Singh RD, Ravishankar M. Development of a scoring system for predicting difficult intubation using ultrasonography. Indian J Anaesth 2020; 64:187-192. [PMID: 32346164 PMCID: PMC7179788 DOI: 10.4103/ija.ija_702_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/02/2019] [Accepted: 02/03/2020] [Indexed: 12/26/2022] Open
Abstract
Background and Aims: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation. Methods: Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack–Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named USED-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated. Results: Difficult intubation was observed in 62/310 patients (20%). The AUC for USED-MSH score was greater than the MSH score (0.93, 95% CI [0.89–0.97] vs 0.76, 95% CI [0.69–0.84], P value <0.001). USED-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score. Conclusion: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.
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Affiliation(s)
- Harith Daggupati
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pillaiyarkuppam, Pondicherry, India
| | - Indubala Maurya
- Department of Anaesthesiology, Super Speciality Cancer Institute and Hospital, CG City, Lucknow, Uttar Pradesh, India
| | - Roshan D Singh
- Department of Anaesthesiology, American Mission Hospital, Kingdom of Bahrain
| | - M Ravishankar
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pillaiyarkuppam, Pondicherry, India
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De Cassai A, Boscolo A, Rose K, Carron M, Navalesi P. Predictive parameters of difficult intubation in thyroid surgery: a meta-analysis. Minerva Anestesiol 2020; 86:317-326. [DOI: 10.23736/s0375-9393.19.14127-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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37
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Christie J. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Int J Nurs Pract 2020; 26:e12805. [PMID: 32036623 DOI: 10.1111/ijn.12805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 11/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Janice Christie
- Division of Nursing Midwifery and Social Work, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Roth D, Kadoglou N, Leeflang M, Spijker R, Herkner H, Trivella M. Diagnostic accuracy of cardiac MRI, FDG-PET, and myocardial biopsy for the diagnosis of cardiac sarcoidosis: a protocol for a systematic review and meta-analysis. Diagn Progn Res 2020; 4:5. [PMID: 32399494 PMCID: PMC7204224 DOI: 10.1186/s41512-020-00073-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/16/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND CS constitutes a rare but potentially underdiagnosed and fatal disease. Its diagnosis remains difficult owing to the infrequent and indistinguishable symptoms and the lack of formal diagnostic criteria dependent upon the diagnostic techniques used. Early diagnosis and treatment, however, may help to counter its poor prognosis.We aim to characterize and compare the diagnostic accuracy of cardiac MRI, FDG-PET and myocardial biopsy for the diagnosis of cardiac sarcoidosis and to advance and compare methods for complex diagnostic test accuracy reviews and meta-analysis. METHODS Following a systematic review on DTA studies on the aforementioned topic, a four-part approach to meta-analysis will be used: (1) direct comparison of index tests with clinical reference standard, (2) indirect comparison of index tests with clinical reference standard, (3) addition of an alternative test to that indirect comparison (4) and Bayesian meta-analysis using results of part 3 as informative prior for comparisons analogous to part 1 and 2. DISCUSSION The most widely recognized diagnostic algorithm for cardiac sarcoidosis is considered out of date, as it precedes the introduction of imaging techniques in diagnostic pathways. These novel imaging techniques, like CMR and FDG-PET scan, have emerged as promising diagnostic tools which may fill the current diagnostic gap. Thus, a systematic review and evaluation of CS diagnosis are much needed. Such an attempt is anticipated to alter the current diagnostic guidelines for CS by shedding more light on the role of sophisticated imaging techniques on prompt CS therapy and follow-up. TRIAL REGISTRATION PROSPERO, CRD42019047126.
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Affiliation(s)
- Dominik Roth
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
- grid.22937.3d0000 0000 9259 8492Department of Emergency Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Nikolaos Kadoglou
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
| | - Mariska Leeflang
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Rene Spijker
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Harald Herkner
- grid.22937.3d0000 0000 9259 8492Department of Emergency Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Marialena Trivella
- grid.4991.50000 0004 1936 8948Centre for Statistics in Medicine, NDORMS, University of Oxford, Windmill Road, Oxford, OX 3 7LD UK
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Mostafa M, Saeed M, Hasanin A, Badawy S, Khaled D. Accuracy of thyromental height test for predicting difficult intubation in elderly. J Anesth 2019; 34:217-223. [PMID: 31858239 DOI: 10.1007/s00540-019-02721-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Studies of the accuracy of different airway tests are lacking in elderly. We evaluated and compared the accuracy of thyromental height in predicting difficult intubation in relation to the other traditional airway tests in elderly. METHODS We included 120 patients aged ≥ 65 years scheduled for general anesthesia with tracheal intubation. Thyromental height, modified Mallampati test, thyromental distance and sternomental distance were evaluated. Cormack-Lehane grade > 2 was considered difficult laryngoscopy. Difficult tracheal intubation was considered if successful intubation required more than 2 attempts. The accuracy of different tests in predicting difficult intubation and difficult laryngoscopy were evaluated through area under receiver operating characteristic (AUROC) curves. Univariate and multivariate analyses were conducted to identify risk factors for difficult intubation and difficult laryngoscopy. RESULTS Our cohort had a mean age of 71(7) years. We encountered difficult laryngoscopy in 15/120 (12%) patients, difficult intubation in 20/120 (17%) patients, and failed laryngoscopy requiring alternative methods for securing the airway in 3/120 (3%) patients. For predicting difficult intubation, thyromental height and modified Mallampati test showed the highest accuracy AUROC (95% confidence interval): 0.9 (0.83-0.95), cut-off value ≤ 5.9 cm, and AUROC (95% confidence interval): 0.89 (0.82-0.94), cut-off value > 2, respectively. Low thyromental height and high modified Mallampati test were the only independent risk factors for difficult laryngoscopy and difficult intubation. CONCLUSION In elderly scheduled for elective procedure, both thyromental height and modified Mallampati tests showed good accuracy in predicting difficult intubation and difficult laryngoscopy, whilst thyromental distance and sternomental distance were poor predictors.
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Affiliation(s)
- Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, 11559, Cairo, Egypt.
| | - Mai Saeed
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, 11559, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, 11559, Cairo, Egypt
| | - Sahar Badawy
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, 11559, Cairo, Egypt
| | - Dalia Khaled
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, 01 Elsarayah Street, Elmanyal, 11559, Cairo, Egypt
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40
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Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2019; 75:509-528. [PMID: 31729018 PMCID: PMC7078877 DOI: 10.1111/anae.14904] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
Abstract
Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - I Hodzovic
- Department of Anaesthesia, Cardiff University School of Medicine, Cardiff, UK.,Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - F Mir
- Department of Anaesthesia, St. George's University Hospital NHS Foundation Trust, London, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
| | - A Patel
- Department of Anaesthesia, Royal National Throat Nose and Ear Hospital and University College London Hospitals NHS Foundation Trust, London, UK
| | - M Stacey
- Department of Anaesthesia, Cardiff and Vale NHS Trust (HEIW), Cardiff, UK
| | - D Vaughan
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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Sawyer T, Foglia EE, Ades A, Moussa A, Napolitano N, Glass K, Johnston L, Jung P, Singh N, Quek BH, Barry J, Zenge J, DeMeo SD, Brei B, Krick J, Kim JH, Nadkarni V, Nishisaki A. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F461-F466. [PMID: 30796059 DOI: 10.1136/archdischild-2018-316336] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/07/2019] [Accepted: 02/06/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU). DESIGN Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates. SETTING Ten academic NICUs. PATIENTS Neonates intubated in the NICU at each of the sites between October 2014 and March 2017. MAIN OUTCOME MEASURES Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation. RESULTS Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53). CONCLUSIONS Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.
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MESH Headings
- Airway Management/methods
- Clinical Competence
- Emergencies/epidemiology
- Female
- Humans
- Hypoxia/etiology
- Hypoxia/prevention & control
- Incidence
- Infant, Newborn
- Infant, Premature
- Intensive Care Units, Neonatal/standards
- Intensive Care Units, Neonatal/statistics & numerical data
- Intubation, Intratracheal/adverse effects
- Intubation, Intratracheal/methods
- Intubation, Intratracheal/standards
- Intubation, Intratracheal/statistics & numerical data
- Male
- Outcome Assessment, Health Care
- Practice Patterns, Physicians'/standards
- Quality Improvement/standards
- Registries
- Retrospective Studies
- United States/epidemiology
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Affiliation(s)
- Taylor Sawyer
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ahmed Moussa
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Sainte-Justine, Canada
| | - Natalie Napolitano
- Nursing and Respiratory Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State - Hershey, Hershey, Pennsylvania, USA
| | | | - Philipp Jung
- University Hospital Schleswig-Holstein, Department of Pediatrics, Luebeck, Germany
| | - Neetu Singh
- Department of Pediatrics, Dartmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Bin Huey Quek
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - James Barry
- Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Stephen D DeMeo
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Brianna Brei
- Department of Pediatrics, University of Washington, Seattle, USA
| | - Jeanne Krick
- Department of Pediatrics, University of Washington, Seattle, USA
| | - Jae H Kim
- Department of Pediatrics, University of California San Diego Medical Center, San Diego, California, USA
| | - Vinay Nadkarni
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Simulation, Advanced Education, and Innovation, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Simulation, Advanced Education, and Innovation, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Dong F, Wang Y, Wang X, Zhao H, Ma W. Changes in the upper airway following induction of anaesthesia: a prospective observational study protocol to determine the use of ultrasound in the assessment of a difficult airway in China. BMJ Open 2019; 9:e029782. [PMID: 31352422 PMCID: PMC6661669 DOI: 10.1136/bmjopen-2019-029782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Difficult airway management is closely related to the safety and quality of medical care. However, the low incidence of correct prediction of difficult airway in clinical screening tests presents physicians with a dilemma. Depressed airway neuromuscular tension during sleep and anaesthesia tends to cause collapse of fragile parts of the upper airway. Although previous studies have confirmed that anterior cervical tissue thickness is associated with difficult airways, there is no evidence to support a correlation between a difficult airway and specific patterns or findings of anaesthesia-induced airway collapse. Thus, this study aims to examine changes in airway dimensions before and after induction of general anaesthesia to explore whether it could provide useful information regarding the specific anatomic changes occurring which may cause difficult airways. METHODS AND ANALYSIS This will be a single-centre prospective observational single-blinded study, conducted in a tertiary teaching hospital in Guangzhou, China. Subjects will be recruited from patients (aged 18-65 years) scheduled for elective surgery under general anaesthesia. Sonographic measurement will be performed to detect changes in the thickness of the anterior cervical soft tissue before and after anaesthetic induction. Based on the resulting data distribution, analyses will initially compare these changes using a paired t-test or the Wilcoxon signed-rank test. The correlation of sonographic changes and Cormack-Lehane grade will be evaluated by using receiver-operating characteristic curves to detect the sensitivity and specificity of a measurement for detecting difficulties. Linear stepwise regression analysis will be used to assess the correlation between airway changes and demographic variables as well as clinical tests. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine (ZYYECK (2018) 041). The results will be disseminated through conference presentations, professional journals and peer-reviewed publications. TRIAL REGISTRATION NUMBER ChiCTR1900021123; Pre-results.
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Affiliation(s)
- Fang Dong
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yong Wang
- Department of Anaesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xia Wang
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Huanyi Zhao
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wuhua Ma
- Department of Anaesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Tan HS, Li SY, Yao WY, Yuan YJ, Sultana R, Han NLR, Sia ATH, Sng BL. Association of Mallampati scoring on airway outcomes in women undergoing general anesthesia with Supreme™ laryngeal mask airway in cesarean section. BMC Anesthesiol 2019; 19:122. [PMID: 31286890 PMCID: PMC6615162 DOI: 10.1186/s12871-019-0796-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
Background Obstetric dfficult airway is a leading cause of maternal morbidity and mortality. The laryngeal mask airway (LMA) is often used as a rescue airway device after failed intubation, however, little is known about predictors of difficult LMA insertion, particularly in obstetrics. Since Mallampati scores of III/IV has been associated with difficult tracheal intubation, our present study aims to investigate if Mallampati score (MP) could predict airway outcomes for LMA use in obstetrics. Methods This prospective cohort study was performed at a single-center: Quanzhou Women’s and Children’s Hospital, Fujian Province, China. Five hundred and eighty-four parturients undergoing elective cesarean section under general anesthesia were recruited. The primary outcome was time to effective ventilation, and secondary outcomes included first attempt insertion success, seal pressure, ventilation and hemodynamic parameters, occurrence of clinical aspiration, and maternal and fetal outcomes. Results The parturients were classified into two groups based on MP of III/IV (High MP: 61) versus I/II (Low MP: 523). BMI was higher in the High MP group than in the Low MP group (mean (SD) 29.3 (7.0) vs 26.8 (3.1), p < 0.0001). There was no difference in maternal age, ASA status and gestational age. There was similar time to effective ventilation (mean (SD) High MP: 14.9 (4.5) vs Low MP: 15.7 (4.4) seconds, p = 0.2172), and first attempt success rate, seal pressure, and peak airway pressure. No clinical aspiration was noted. The incidence of blood on SLMA was higher in the High MP group than in Low MP (4 (6.6%) vs 4 (0.8%), p = 0.001). There was no difference in sore throat, voice hoarseness, maternal satisfaction and fetal outcomes. Conclusion High MP was not associated with reduced SLMA airway outcomes in cesarean section under general anesthesia, but may increase the risk of blood found on SLMA upon removal. Trial registration This study was registered at http://www.clinicaltrials.gov, identifier: NCT02026882, retrospectively registered. Date of registration: December 31, 2013.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Shi Yang Li
- Department of Anesthesiology and Perioperative Medicine, Quanzhou Macare Women's Hospital, Quanzhou, Fujian Province, China
| | - Wei Yu Yao
- Department of Anesthesiology and Perioperative Medicine, Quanzhou Macare Women's Hospital, Quanzhou, Fujian Province, China
| | - Yong Jing Yuan
- Department of Anesthesiology, Qinghai University Affiliated Hospital, Xining, Qinghar Province, China
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Nian-Lin R Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Alex Tiong Heng Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.,Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore. .,Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.
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Vourc’h M, Huard D, Feuillet F, Baud G, Guichoux A, Surbled M, Tissot M, Chiffoleau A, Guitton C, Jaber S, Asehnoune K. Preoxygenation in difficult airway management: high-flow oxygenation by nasal cannula versus face mask (the PREOPTIDAM study). Protocol for a single-centre randomised study. BMJ Open 2019; 9:e025909. [PMID: 31028041 PMCID: PMC6501956 DOI: 10.1136/bmjopen-2018-025909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Although preoxygenation and airway management respond to precise algorithms, difficult intubation (DI) remains a daily challenge in intensive care units and in the operating rooms because of its frequent complications, including hypoxaemia. To prevent desaturation during DI, high-flow oxygenation by nasal cannula (HFNC) could prove beneficial. Indeed, contrary to standard preoxygenation device, it can be held in place throughout the intubation trying to perform apnoeic oxygenation during DI. Hence, recent guidelines recommend HFNC during DI, but its relevance has never been evaluated in this setting in a large randomised study until now. METHODS AND ANALYSIS The PREOPTIDAM trial is a prospective, single-centre, randomised, controlled study in Nantes University Hospital. In anticipated DI, we hypothesised that HFNC can decrease the incidence of desaturation ≤94% or face mask ventilation from 16% to 4% compared with standard device. Using a two-sided t-test with a first species risk of 5% and 80% power, a total of 186 patients will be included. Using a computer-generated randomisation, with a 1:1 allocation ratio, patients will be randomised to HFNC or face mask preoxygenation. Randomisation will be stratified on intubation sequence: Rapid sequence intubation or awake fibreoptic intubation. The primary objective is to determine whether HFNC is more efficient than standard oxygenation techniques to prevent desaturation ≤94% or face mask ventilation during DI. Intent-to-treat and per-protocol analysis are planned for the primary outcome. ETHICS AND DISSEMINATION The study project has been approved by an independent ethics committee. Written informed consent will be obtained before study inclusion. Participant recruitment begins in September 2018. Results will be submitted to international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT03604120.
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Affiliation(s)
- Mickael Vourc’h
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
- UPRES EA 3826, "Thérapeutiques Cliniques et Expérimentales des infections", IRS2 Nantes Biotech, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Donatien Huard
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Fanny Feuillet
- Methodology and Biostatistics Platform, Research Promotion Department, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Gabrielle Baud
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Arthur Guichoux
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Marielle Surbled
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Melanie Tissot
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Anne Chiffoleau
- Unité de vigilance des essais cliniques, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
| | - Christophe Guitton
- Centre Hospitalier du Mans, Médecine intensive réanimation, Le Mans, France
| | - Samir Jaber
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Karim Asehnoune
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
- UPRES EA 3826, "Thérapeutiques Cliniques et Expérimentales des infections", IRS2 Nantes Biotech, Centre Hospitalier Universitaire de Nantes, Nantes, PAYS-DE-LA-LOIRE, France
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Nausheen F, Niknafs NP, MacLean DJ, Olvera DJ, Wolfe AC, Pennington TW, Davis DP. The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis. Scand J Trauma Resusc Emerg Med 2019; 27:50. [PMID: 31018857 PMCID: PMC6480652 DOI: 10.1186/s13049-019-0614-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 03/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background Existing difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI). Methods A retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade. Results A total of 5137 RSI patients over 24 months were included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria. Conclusion The HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI. Electronic supplementary material The online version of this article (10.1186/s13049-019-0614-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fauzia Nausheen
- Department of Medical Education, California University of Science & Medicine, School of Medicine, 217 E Club Center Dr Suite A, San Bernardino, CA, 92408, USA.
| | - Nichole P Niknafs
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Derek J MacLean
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - David J Olvera
- Air Methods Corporation, Greenwood Village, Colorado, USA
| | - Allen C Wolfe
- Air Methods Corporation, Greenwood Village, Colorado, USA
| | - Troy W Pennington
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.,Air Methods Corporation, Greenwood Village, Colorado, USA
| | - Daniel P Davis
- Department of Medical Education, California University of Science & Medicine, School of Medicine, 217 E Club Center Dr Suite A, San Bernardino, CA, 92408, USA.,Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.,Air Methods Corporation, Greenwood Village, Colorado, USA
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Abstract
Conscious sedation is a commonly used approach to provide pain relief during transvaginal oocyte retrieval. It has been shown to be effective with high levels of acceptability and patient satisfaction. Fundamental Standards and Development Standards in safe sedation practice have been set out by the Royal College of Anaesthetists and they recommend that Royal Colleges, in association with the relevant sub-specialty organizations, should develop guidelines on sedation methods appropriate to clinical practice in their sphere of influence. This Policy and Practice paper outlines the human resources and equipment necessary to optimize patients' safety for the administration of intravenous (I.V.) sedation in assisted conception units, based on the most current evidence and guidance available.
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Rossi M. The entropic world of the difficult airway. Minerva Anestesiol 2019; 85:454-456. [DOI: 10.23736/s0375-9393.18.13239-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Xie MR, Zhu YF, Zhou MQ, Wu SB, Xu GW, Xu SB, Xu MQ. Analysis of factors related to chronic cough after lung cancer surgery. Thorac Cancer 2019; 10:898-903. [PMID: 30875149 PMCID: PMC6449237 DOI: 10.1111/1759-7714.13021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background In this study, we investigated the relationship between chronic cough and clinicopathological features in postoperative patients with non‐small cell lung cancer (NSCLC) and evaluated the effectiveness of acupuncture therapy for the treatment of postoperative chronic cough in patients with NSCLC. Methods We retrospectively evaluated 171 patients with NSCLC who received lobectomy at our center between September 2017 and February 2018. The Mandarin Chinese version of the Leicester Cough Questionnaire (LCQ‐MC) was used to evaluate the degree of cough in patients. Postoperative cough was assessed by a visual analog scale (VAS). Results The total LCQ‐MC score for the whole group was 19.79 ± 0.53 before surgery and 18.40 ± 0.70 after surgery (p < 0.001). Logistic regression analysis showed that right lung cancer, difficult airway, acute cough and history of COPD were independent predictors of chronic cough. Of the 68 patients diagnosed with chronic cough, 41 received acupuncture therapy (acupuncture therapy group), and 27 received no acupuncture therapy (no therapy group). No significant difference was found between the two groups in terms of their LCQ‐MC scores at eight weeks after surgery (p = 0.756). However, the acupuncture therapy group had a significantly higher LCQ‐MC score than the no therapy group at 10 weeks after surgery (p = 0.002). Conclusions Right lung cancer, difficult airway, acute cough, and history of COPD are independent predictors of chronic cough after surgery. For patients with chronic cough, acupuncture therapy can shorten the recovery time and improve quality of life after surgery.
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Affiliation(s)
- Ming-Ran Xie
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yong-Fu Zhu
- Graduate School of Anhui University of Chinese Medicine, Hefei, China.,Department of Oncology, The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Mei-Qi Zhou
- Bozhou Research Institute of Chinese Medicine, Anhui Academy of Chinese Medicine, Bozhou, China.,Research Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medicine, Hefei, China
| | - Sheng-Bing Wu
- Research Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medicine, Hefei, China
| | - Guang-Wen Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Shi-Bin Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Mei-Qing Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Metodiev Y, Mushambi M, Kinsella S. Airway assessment in the obstetric patient – are we there yet? Trends in Anaesthesia and Critical Care 2019; 24:20-21. [DOI: 10.1016/j.tacc.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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50
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Bjurström MF, Bodelsson M, Sturesson LW. The Difficult Airway Trolley: A Narrative Review and Practical Guide. Anesthesiol Res Pract 2019; 2019:6780254. [PMID: 30833967 DOI: 10.1155/2019/6780254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/06/2018] [Accepted: 01/01/2019] [Indexed: 01/14/2023] Open
Abstract
Death and severe morbidity attributable to anesthesia are commonly associated with failed difficult airway management. When an airway emergency develops, immediate access to difficult airway equipment is critical for implementation of rescue strategies. Previously, national expert consensus guidelines have provided only limited guidance for the design and setup of a difficult airway trolley. The overarching aim of the current work was to create a dedicated difficult airway trolley (for patients>12 years old) for use in anesthesia theatres, intensive care units, and emergency departments. A systematic literature search was performed, using the PubMed, Embase, and Google Scholar search engines. Based on evidence presented in 11 national or international guidelines, and peer-reviewed journals, we present and outline a difficult airway trolley organized to accommodate sequential progression through a four-step difficult airway algorithm. The contents of the top four drawers correspond to specific steps in the airway algorithm (A = intubation, B = oxygenation via a supraglottic airway device, C = facemask ventilation, and D = emergency invasive airway access). Additionally, specialized airway equipment may be included in the fifth drawer of the proposed difficult airway trolley, thus enabling widespread use. A logically designed, guideline-based difficult airway trolley is a vital resource for any clinician involved in airway management and may aid the adherence to difficult airway algorithms during evolving airway emergencies. Future research examining the availability of rescue airway devices in various clinical settings, and simulation studies comparing different types of difficult airway trolleys, are encouraged.
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