Clinical characteristics and factors associated with mucus plugs under bronchoscopy in children hospitalized for acute asthma attack.

Objective: To describe clinical characteristics of hospitalized children with acute asthma attacks complicated with mucus plugs and to investigate the factors associated with mucus plugs in asthma children. Methods: This retrospective study analyzed hospitalized children and adolescents with acute asthma attacks from January 2016 to December 2021. The demographic information and characteristics were collected. Subjects were categorized into the mucus plug group and the control group based on the bronchoalveolar lavage results. The Logistic regression analyses were utilized to assess the relative factors associated with mucus plugs. All data were analyzed using SPSS 22.0. Results: This study included 242 individuals. Out of the 151 subjects who underwent bronchoscopy, 62.9% were classified in the mucus plug group and 37.1% in the control group. The subjects with dyspnea had a higher proportion in the mucus plug group (52.6% vs. 26.8%). The serum total IgE level of the mucus plug group was lower than the control group. The proportion of subjects who were diagnosed with asthma for the first time during hospitalization (87.4% vs. 76.8%) and combined with respiratory infection (91.6% vs. 82.1%) in the mucus plug group might be higher than that in the control group. More subjects in the mucus plug group were administered systemic glucocorticoid, magnesium sulfate, aminophylline, and mucolytic drugs after hospitalization. In multivariable analysis, diagnosed with asthma for the first time during hospitalization (OR = 4.404; 1.101-17.614), dyspnea (OR = 4.039; 1.306-12.496), and cesarean (OR = 0.274; 0.092-0.812) might be associated with mucus plug in children hospitalized for an acute asthma attack. Suggests: While our retrospective study suggests that some clinical features of children hospitalized with asthma who have mucus plugs differ from those without, further studies are required.

Orotracheal Intubation Challenges in an Anticipated Difficult Mask Ventilation, Preoxygenation, Tricky Laryngoscopy, and Supraglottic Airway Device Insertion: A Case Report.

With the advancement of technology, equipment, and airway management knowledge, anticipated difficult airway (DA) management has come a long way towards excellence. Usually, anticipated difficulties are related to bag-mask ventilation (BMV), laryngoscopy, intubation, or supraglottic airway placement; all in a single patient pose exceptionally challenging airway management. We may electively plan a surgical airway, but the option may not be available, especially when the patient provides tracheostomy permission only for emergency airway management, not for an elective. A 48-year-old male patient with a probable diagnosis of midline lethal granuloma presented with right-side nasal blockade, deformity, and near-total blockade of the left nasal cavity with right-sided mid-facial swelling, pain, and foul-smelling discharge and an ulcerated hard palate and was scheduled for an endoscopic biopsy. The airway examination predicted difficult bag-mask ventilation, pre-intubation oxygenation, risky laryngoscopy, and supraglottic airway insertion. Even airway topicalization, sedation, and preparation for awake intubation were challenging. Resource limitations and unexpected desaturation while attempting awake intubation led to an emergent situation; i-gel came as a rescue, and ultimately, the definitive airway was secured using a 6.5 mm cuffed endotracheal tube (ETT), railroaded over a fibreoptic bronchoscope (FOB), and inserted through i-gel. We present the case to highlight the challenges and discuss the possible remedies where our technique can be an alternative for cases with difficult mask ventilation, intubation, and supraglottic airway insertion.

Value of ultrathin bronchoscope in improving the endobronchial ultrasound localization rate and diagnosing peripheral pulmonary nodules by cryobiopsy.

BACKGROUND: A 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel provides better accessibility to peripheral bronchi. A 4.0-mm thin bronchoscope with a larger 2.0-mm working channel facilitates the use of a guide sheath (GS), ensuring repeated sampling from the same location. The 1.1-mm ultrathin cryoprobe has a smaller diameter, overcoming the limitation of the size of biopsy instruments used with UTB. In this study, we compared the endobronchial ultrasound localization rate and diagnostic yield of peripheral lung lesions by cryobiopsy using UTB and thin bronchoscopy combined with GS. METHODS: We retrospectively evaluated 133 patients with peripheral pulmonary lesions with a diameter less than 30 mm who underwent bronchoscopy with either thin bronchoscope or UTB from May 2019 to May 2023. A 3.0-mm UTB combined with rEBUS was used in the UTB group, whereas a 4.0-mm thin bronchoscope combined with rEBUS and GS was used for the thin bronchoscope group. A 1.1-mm ultrathin cryoprobe was used for cryobiopsy in the two groups. RESULTS: Among the 133 patients, peripheral pulmonary nodules in 85 subjects were visualized using r-EBUS. The ultrasound localization rate was significantly higher in the UTB group than in the thin bronchoscope group (96.0% vs. 44.6%, respectively; P < 0.001). The diagnostic yield of cryobiopsy specimens from the UTB group was significantly higher compared to the thin bronchoscope group (54.0% vs. 30.1%, respectively; p = 0.006). Univariate analysis demonstrated that the cryobiopsy diagnostic yields of the UTB group were significantly higher for lesions ≤ 20 mm, benign lesions, upper lobe lesions, lesions located lateral one-third from the hilum, and lesions without bronchus sign. CONCLUSIONS: Ultrathin bronchoscopy combined with cryobiopsy has a superior ultrasound localization rate and diagnostic yield compared to a combination of cryobiopsy and thin bronchoscopy.

Intensive reprocessing of reusable bronchoscopes can reduce the false positive rate of Xpert MTB/RIF caused by nucleic acid residue.

Background/Purpose: Tuberculosis remains a leading cause of infectious death worldwide, The potential for nucleic acid residue on bronchoscopes to cause false positive results in molecular diagnostic methods and subsequently lead to tuberculosis misdiagnosis has long perplexed clinical. Methods: We utilized Xpert MTB/RIF to analyze the liquid collected after bronchoscope washing, employed by patients either with or without active pulmonary tuberculosis, and subjected to standard reprocessing (SR) or intensive reprocessing (IR) procedures. The IR procedure included specialized training and the provision of patient information to cleaning staff before the SR procedure, and repeated washing and suction of the bronchoscope with sterilized water post SR procedure. Results: 55 participants enrolled in the study were divided into three groups: SR group (n = 28), IR group(n = 14), and the control group(n = 13). Among the 55 enrolled patients, neither Mycobacterium tuberculosis nor contamination was detected by MIGT 960 liquid culture in the washing liquid. The positive rate of MTB/RIF in the SR group (12/28) was significantly higher than that in the IR group (1/14), with a statistically significant difference observed between them (42.86 % vs. 7.14 %, P=0.018). Conclusions: Nucleic acid residue on reusable bronchoscopes cleaned via the SR procedure was found to potentially cause false positives in MTB/RIF tests. Reprocessing bronchoscopes via the IR procedure was effective in significantly reducing nucleic acid residue, although complete elimination was not achieved.

Bronchoscopic holmium laser ablation continuous cryoablation for the treatment of airway stenosis caused by tissue hyperplasia after tracheal intubation: clinical case observation.

This study aimed to design a standardised bronchoscopic holmium laser ablation continuous cryoablation for the treatment of airway stenosis caused by tissue hyperplasia after tracheal intubation and to retrospectively analyse its safety and feasibility. We collected the data of patients who had undergone bronchoscopic holmium laser ablation continuous cryoablation due to airway stenosis caused by tracheal mucosal tissue hyperplasia after tracheal intubation. The patients' baseline characteristics, ablation effects, surgical complications and other data were analysed. In total, 16 patients were enrolled in this study. On average, airway stenosis occurred 96.00 (interquartile range, 69.75-152.50) days after tracheal intubation and bronchoscopic holmium laser ablation continuous cryoablation took an average of 90.38 minutes (standard deviation: 16.78). After the first continuous cryoablation, 75.0% (12/16) of the patients had complete ablation of hyperplastic tissue, and 25.0% (4/16) had most of the hyperplastic tissue (>50%) removed. Altogether, 18.75% (3/16) and 6.25% (1/16) of the patients had complete ablation of hyperplastic tissue after the second and third cryoablation, respectively. Moreover, one patient (6.25%) had minimal wound bleeding postoperatively, and no other surgical complications occurred. No airway stenosis was found in all enrolled patients during follow-up 1 and 6 months after the last cryoablation. According to the above results of our small sample study indicated that bronchoscopic holmium laser ablation continuous cryoablation seems safe and effective for treating airway stenosis caused by tissue hyperplasia after tracheal intubation.

Patient in Mayfield Head Pins Requiring Prone Bronchoscopy for Mucus Plug Obstruction: A Case Report.

Mucus plug obstruction is a common complication in prone patients associated with loss of ventilation and hemodynamic instability. This case presents a 62-year-old female with chronic bronchitis who underwent posterior cervical fusion for a type III dens fracture with extension into the pars articularis and pedicles. Glycopyrrolate was administered to assist with fiberoptic intubation. After successful intubation, bronchoscopy revealed copious endotracheal secretions requiring preoperative therapeutic removal. Despite extensive removal of thick endotracheal secretions preoperatively, obstructive mucus plugging developed intraoperatively with complete loss of end-tidal carbon dioxide (ETCO2) while the patient was in Mayfield head pins. With limited airway access, suctioning and prone flexible bronchoscopy were performed, successfully restoring ETCO2. This experience underscores the need for heightened awareness and preparedness for mucus plug obstruction in chronic bronchitis patients undergoing prone cervical spine surgeries.

Distinct clinical characteristics of bocavirus and Mycoplasma pneumoniae infection in children plastic bronchitis.

BACKGROUND: This study investigated clinical and laboratory characteristics of human bocavirus type 1 (HBoV1)-plastic bronchiolitis (PB), Mycoplasma pneumoniae (MP)-associated plastic bronchitis (PB) and MP-NPB in children, highlighting inflammation, coagulation, and bronchoscopic needs. METHODS: Data on preschool children with PB during HBoV1 or MP infection were collected, comparing MP-PB to severe Mycoplasma pneumoniae pneumonia. RESULT: Compared with the MP-PB group, the HBoV1-PB group, with younger children, had significantly milder clinical symptoms but higher WBC counts (p = .028). The MP-PB group exhibited notably elevated Fibrinogen (p = .045) and d-dimer levels (p < .001). When contrasting the MP-PB with the MP-NPB group, children in MP-PB group still had higher levels of d-dimer and increased inflammatory indicators such as C-reactive protein, procalcitonin, lactate dehydrogenase, and interleukin-6, which were significantly elevated compared with the MP-NPB group. MP-PB showed a higher prevalence of plastic bronchial casts in lower lobes (p = .016) and a dominance of neutrophils in BALF cytology. Additionally, children in the MP-PB group tended to undergo a greater number of bronchoscopies. CONCLUSION: This study identifies key differences in plastic bronchitis in children due to HBoV1 and MP, highlighting HBoV1's milder inflammation in younger kids and MP's link to severe inflammatory and coagulation responses, guiding clinical diagnosis and treatment.

Navigating Diagnostic Pitfalls: False Positivity in GeneXpert Mycobacterium Tuberculosis/Rifampicin Assay.

Tuberculosis (TB), which is predominantly caused by Mycobacterium tuberculosis (MTB), poses severe diagnostic hurdles, especially with pulmonary tuberculosis (PTB), which spreads by aerosols. Sputum culture, the gold standard for MTB diagnosis, is time-consuming, expensive, and easily contaminated. The GeneXpert MTB/RIF (Xpert) assay, a molecular diagnostic tool, can quickly detect MTB and rifampicin (RIF) resistance. However, the ability to identify both live and non-viable MTB DNA, for example, in patients with a previous history of pulmonary tuberculosis or sampling from a contaminated bronchoscope, can result in false positives, as demonstrated in this case series. We present three cases of PTB diagnosed with Xpert, each with no conventional TB symptoms.

A Novel Imaging Device for Percutaneous Dilatational Tracheostomy.

Objective: The purpose of this article is to introduce a novel imaging device and technique for percutaneous dilatational tracheostomy (PDT) and evaluate its clinical application. Methods: We have modified the bronchoscope to generate a novel imaging device. The handle of the bronchoscope was removed and replaced with added fixation pieces to secure the new device to the endotracheal tube. Nine mechanically ventilated patients admitted to the intensive care department of Shandong Public Health Clinical Center who underwent PDT between July 2023 and January 2024 have been treated with this novel imaging device. The number of medical staff members needed for the operation, number of needle interventions, operation time, arterial blood gas analysis, and intraoperative complications were observed. Results: Three medical staff were involved in the procedure: an operator, an assistant, and a nurse. The first attempted needle intervention was successful in all patients, and no serious complications such as major bleeding, pneumothorax, mediastinal emphysema, accidental extubation, desaturation, hypercarbia, respiratory acidosis, hemodynamic abnormality, or posterior tracheal puncture occurred. The average time was 11.63 ± 1.56 minutes from skin incision to the needle insertion and 4.43 ± 1.99 minutes from needle insertion to tracheal placement. Conclusions: PDT guided by the novel device is safe, preserves human resources, saves operating space, keeps the view stable, and makes the procedure easy. It is worthy of further research and application.

Development of a Novel Airway-Exchange Broncholaryngoscope.

OBJECTIVE: The purpose of this project was to develop a novel airway-exchange broncholaryngoscope (AEBLScope) to improve the efficiency and accuracy of airway-exchange procedures. METHODS: The AEBLScope was designed to combine a bronchoscope and airway-exchange catheter (AEC) into a single device and to reduce the blind placement of AECs. The prototype was constructed by modifying an existing distal-chip bronchoscope. A custom AEC was procured to fit concentrically over the flexible portion of the scope. The catheter was connected to the scope handpiece by a customized push-pull locking attachment. The AEBLScope was used to perform airway-exchange procedures with both tracheostomy and endotracheal tubes using two different airway models. Experimental procedures were recorded with still photography to evaluate the exchange of tubes and placement of AECs. RESULTS: In two airway models using the AEBLScope, both tracheostomy and endotracheal tubes were successfully exchanged on first-pass attempt, and AECs were accurately placed under visual guidance. CONCLUSION: The AEBLScope combines a bronchoscope and AEC into a single tool. Based on these first results, this novel scope has the potential to perform airway-exchange procedures more safely compared with standard procedures by increasing the accuracy of placement, decreasing procedural time, and reducing the morbidity and mortality that can occur from blind placement of AECs. LEVEL OF EVIDENCE: NA Laryngoscope, 134:4488-4493, 2024.

Minimally Invasive Common Bile Duct Stone Management in Gastric Bypass Patients: Laparoscopic Common Bile Duct Exploration with Disposable Bronchoscope.

BACKGROUND: Bariatric surgery patients may develop common bile duct stones, and the alterations in their anatomy present challenges in treating this condition. Methods such as laparoscopic bile duct exploration is impractical in many healthcare facilities, due to the absence of a choledochoscope. This study assesses the feasibility of laparoscopic exploration of the common bile duct using a disposable bronchoscope in these individuals. METHOD: The study involved 32 participants who had undergone gastric bypass surgery. These participants presented with both bile duct stones and bile ducts exceeding 8 mm in diameter, diagnosed through either MRCP or cholangiography conducted during the surgery. Stone extraction was carried out through either choledotomy or transcystic routes using a disposable bronchoscope and endoscopic baskets. RESULTS: The patients' ages ranged from 27 to 66 years, with a mean bile duct diameter of 11.6 mm (SD 3.1 mm). A 100% stone clearance rate was achieved for all patients. None of the patients required conversion to open surgery. No T-tubes were placed. One patient developed biloma and intra-abdominal abscesses, which were successfully treated with a percutaneous drain over the course of a week. No mortalities were recorded during the course of this study. CONCLUSION: Our study results demonstrate that laparoscopic bile duct exploration is both feasible and safe in patients who have undergone gastric bypass surgery. The utilization of a disposable bronchoscope emerges as a practical and cost-effective alternative to a choledochoscope in this procedure.

Successful ultrathin bronchoscopy with cryobiopsy for diagnosing and removing mucus plugs in allergic bronchopulmonary mycosis mimicking lung cancer.

In patients presenting with abnormal pulmonary nodules, especially those with a history of asthma, allergic bronchopulmonary mycosis should be considered. Eosinophil counts and IgE levels should be checked in such patients.

Airway and anesthesia management in tracheoesophageal fistula closure implantation: a single-centre retrospective study.

OBJECTIVE: To review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management. METHOD: We searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients' disease course and follow-up records were analyzed and summarized. RESULTS: The airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia. CONCLUSION: During the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.

Factors associated with damages and repair costs of reusable flexible bronchoscopes in pediatrics in China.

BACKGROUND: Frequent repairs of pediatric flexible bronchoscopes can lead to a huge financial burden for the hospital. This study aimed to investigate the common causes of the failures in pediatric flexible bronchoscopes and propose the measures to prevent the failures. METHODS: This was a retrospective study. We collected repair information of the pediatric flexible bronchoscopes reprocessed in the Department of Sterile Processing at a hospital between September 1, 2018 and September 1, 2022 in order to investigate the causes and possible factors associated with the failures in pediatric flexible bronchoscopes. RESULTS: The Department of Sterile Processing staff reprocessed the pediatric flexible bronchoscopes 4280 times. A total of 29 failures were identified. The failure rate was 0.678%. The average repair cost was USD7246.60. The common failures in the pediatric flexible bronchoscopes included dim video image, black dots, improper video image display or no image during angulation adjustment, and pressure marks in the insertion tube. The failure rates in flexible electronic bronchoscopes and small-diameter flexible bronchoscopes were 65.5% and 93.1%, respectively. The failure rate in the pediatric flexible bronchoscopes reprocessed by the staff members with less work experience was 75.9%. CONCLUSION: The failure rate in the pediatric flexible bronchoscopes was not high but the repair costs were extremely high. The types and size of the flexible bronchoscopes and work experience of the staff members responsible for bronchoscope reprocessing were the possible factors associated with the failure rate in the pediatric flexible bronchoscopes. It is advisable to further optimize the central workflow and management mode for reprocessing the pediatric flexible bronchoscopes, thereby extending their useful life and reducing costs.

Palliation of malignant esophageal stent esophagorespiratory fistula with rigid bronchoscope and Y silicone trachea stent: experience with seven patients.

Background: Malignant esophageal stent esophagorespiratory fistula (ERF) is an abnormal communication between esophagus and airway among advanced tumor patients with indwelling esophageal stent, which is devastating and life-threatening. This study aims to provide a new feasible treatment scheme for malignant esophageal stent ERF and report its potential advantage compared with double stenting, which was recommended by European Society of Gastrointestinal Endoscopy Guideline. Methods: We retrospectively analyzed the medical data of malignant esophageal stent ERF patients between January 2018 to May 2023 at the First Affiliated Hospital of Guangzhou Medical University and divided them into two groups. Group 1 consisted of patients treated with rigid bronchoscopy to remove the esophageal stent and implant Y silicone trachea stent, while group 2 consisted of patients treated with additional airway stenting without removing the esophageal stent. Demographic parameters, disease diagnoses and treatment, radiological findings before and after the intervention, and complications caused by the stents were obtained and analyzed with chi-squared, Mann-Whitney U, independent-samples t-tests, Kaplan-Meier methods, and log-rank test. Results: Ten patients (seven patients in group 1 and three in group 2) were included. No procedure complications occurred in both groups. The mean Karnofsky Performance Score after the procedure significantly improved compared to the pre-procedure (57.14 vs. 77.14, P=0.001) in group 1, while decreased in group 2 (50 vs. 40, P=0.026). The control of pneumonia in group 1 patients is better than that in group 2. There was significant improvement in the degree of dysphagia after the procedure (3.86 vs. 2.43, P=0.002) in group 1, while no improvement was found in group 2 (4.00 vs. 3.33, P=0.423). The mean survival of group 1 was significantly longer group 2 (381.00 vs. 80.33 days, P<0.001, log-rank test). No patient needed stent repositioning due to migration in both groups. Cause of death in the group 1 included disease progression, novel coronavirus pneumonia, massive hemoptysis, and respiratory insufficiency, while group 2 included severe pneumonia and disease progression. No death was directly attributed to the procedure in both groups. Conclusions: Removing the esophageal stent and implanting Y silicone trachea stent through a rigid bronchoscopy is a safe and feasible treatment for malignant esophageal stent ERF. This procedure can effectively seal the fistula, prevent from recurrent aspiration pneumonia, improve the quality of life, and prolong the survival time.

Temporomandibular Joint Ankylosis: Anesthetic Challenge.

Temporomandibular joint ankylosis cases serve as a challenge for both surgeons and anesthesiologists possibly due to the unavailability of resources in remote locations. Distressing issues brought on by its ankylosis include functional as well as esthetic issues such as considerable difficulties in managing the airway, especially in children because of the physiology and structure of their airways being different. Fiberoptic bronchoscopy (FOB) has a well-established role in patients with difficult airways, but it is especially challenging in pediatric patients because of their lack of cooperation and diminished lung reserve. Techniques used to secure airways in adults may not be ideal for children and sometimes dedicated equipment may not be available. Here we present a case of a 14-year-old boy with temporomandibular joint (TMJ) ankylosis. This study aimed to describe the difficulties experienced in managing his airway.

Balloon Dilatation for Bronchoscope Delivery in a Swine Model: A Novel Technique for Ultra-Peripheral Lung Field Access and Accurate Biopsy.

INTRODUCTION: In transbronchial biopsy of peripheral pulmonary lesions, the bronchoscope can reach only a limited depth due to the progressive narrowing of bronchi, which may reduce the diagnostic rate. This study examined the balloon dilatation for bronchoscope delivery (BDBD) technique, employing a novel balloon device to enhance bronchoscopy into the peripheral lung areas. METHODS: Anaesthetised swine served as our primary model. Using computed tomography (CT) scans, we positioned virtual targets characterised by a positive bronchus sign and a diameter of 20 mm beneath the pleura. The bronchoscope was navigated along the pathways determined from the CT images. We performed balloon dilatation when bronchial narrowing obstructed progress to assess whether balloon dilatation would enable the bronchoscope to enter further into the periphery. RESULTS: We established 21 virtual targets on the CT scans. An average of 12.1 branches were identified along the pathways on the CT scans; however, bronchoscopy without BDBD only allowed access to an average of 6.7 branches. Based on 72 balloon dilatations with 3.0-mm or 4.0-mm ultra-thin bronchoscopes, there was an average increased access of 3.43 and 5.14 branches per route, respectively, with no significant BDBD complications. The bronchoscope was able to reach the planned location along all pathways, and the mean final bronchoscopic endpoints were at an average distance of 14.7 mm from the pleura. Post-procedure CT confirmed biopsy accuracy. CONCLUSION: The BDBD technique can enhance access of a flexible bronchoscope into the peripheral lung fields, which could potentially allow more accurate transbronchial interventions for peripheral targets.

Flexible bronchoscopic intubation through a supraglottic airway device: An evaluation of consultant anaesthetist performance.

BACKGROUND: Few clinical studies investigate technical skill performance in experienced clinicians. METHODS: We undertook a prospective observational study evaluating procedural skill competence in consultant anaesthetists who performed flexible bronchoscopic intubation (FBI) under continuous ventilation through a second-generation supraglottic airway device (SAD). Airway management was recorded on video and performance evaluated independently by three external assessors. We included 100 adult patients undergoing airway management by 25 anaesthetist specialists, each performing four intubations. We used an Objective Structured Assessment of Technical Skills-inspired global rating scale as primary outcome. Further, we assessed the overall pass rate (proportion of cases where the average of assessors' evaluation for every domain scored ≥3); the progression in the global rating scale score; time to intubation; self-reported procedural confidence; and pass rate from the first to the fourth airway procedure. RESULTS: Overall median global rating scale score was 29.7 (interquartile range 26.0-32.7 [range 16.7-37.7]. At least one global rating scale domain was deemed 'not competent' (one or more domains in the evaluation was scored <3) in 30% of cases of airway management, thus the pass rate was 70% (95% CI 60%-78%). After adjusting for multiple testing, we found a statistically significant difference between the first and fourth case of airway management regarding time to intubation (p = .006), but no difference in global rating scale score (p = .018); self-reported confidence before the procedure (p = .014); or pass rate (p = .109). CONCLUSION: Consultant anaesthetists had a median global rating scale score of 29.7 when using a SAD as conduit for FBI. However, despite reporting high procedural confidence, at least one global rating scale domain was deemed 'not competent' in 30% of cases, which indicates a clear potential for improvement of skill competence among professionals.

Clinical Effect of Endosonography on Overall Survival in Patients with Radiological N1 Non-Small Cell Lung Cancer.

PURPOSE: It is unclear whether performing endosonography first in non-small cell lung cancer (NSCLC) patients with radiological N1 (rN1) has any advantages over surgery without nodal staging. We aimed to compare surgery without endosonography to performing endosonography first in rN1 on the overall survival (OS) of patients with NSCLC. MATERIALS AND METHODS: This is a retrospective analysis of patients with rN1 NSCLC between 2013 and 2019. Patients were divided into 'no endosonography' and 'endosonography first' groups. We investigated the effect of nodal staging through endosonography on OS using propensity score matching (PSM) and multivariable Cox proportional hazard regression analysis. RESULTS: In the no endosonography group, pathologic N2 occurred in 23.0% of patients. In the endosonography first group, endosonographic N2 and N3 occurred in 8.6% and 1.6% of patients, respectively. Additionally, 51 patients were pathologic N2 among 249 patients who underwent surgery and mediastinal lymph node dissection (MLND) in endosonography first group. After PSM, the 5-year OSs were 68.1% and 70.6% in the no endosonography and endosonography first groups, respectively. However, the 5-year OS was 80.2% in the subgroup who underwent surgery and MLND of the endosonography first group. Moreover, in patients receiving surgical resection with MLND, the endosonography first group tended to have a better OS than the no endosonography group in adjusted analysis using various models. CONCLUSION: In rN1 NSCLC, preoperative endosonography shows better OS than surgery without endosonography. For patients with rN1 NSCLC who are candidates for surgery, preoperative endosonography may help improve survival through patient selection.