Successful Surgical Airway Performance in the Combat Prehospital Setting: A Qualitative Study of Experienced Military Prehospital Providers.

INTRODUCTION: Military first responders are in a unique category of the healthcare delivery system. They range in skill sets from combat medic and corpsman to nurses, physician assistants, and occasionally, doctors. Airway obstruction is the second leading cause of preventable battlefield death, and the decision for intervention to obtain an airway depends on the casualty's presentation, the provider's comfort level, and the available equipment, among many other variables. In the civilian prehospital setting cricothyroidotomy (cric) success rates are over 90%, but in the US military combat environment success rates range from 0-82%. This discrepancy in success rates may be due to training, environment, equipment, patient factors and/or a combination of these. Many presumed causes have been assumed to be the root of the variability, but no research has been conducted evaluating the first-person point of view. This research study is focused on interviewing military first responders with real-life combat placement of a surgical airway to identify the underlying influences which contribute to their perception of success or failure. MATERIALS AND METHODS: We conducted a qualitative study with in-depth semi-structured interviews to understand participants' real-life cric experiences. The interview questions were developed based on the Critical Incident Questionnaire. In total, there were 11 participants-4 retired military and 7 active-duty service members. RESULTS: Nine themes were generated from the 11 interviews conducted. These themes can be categorized into 2 groups: factors internal to the provider, which we have called intrinsic influences, and factors external to the provider, which we call extrinsic influences. Intrinsic influences include personal well-being, confidence, experience, and decision-making. Extrinsic influences include training, equipment, assistance, environment, and patient factors. CONCLUSIONS: This study revealed practitioners in combat settings felt the need to train more frequently in a stepwise fashion while following a well-understood airway management algorithm. More focus must be on utilizing live tissue with biological feedback, but only after anatomy and geospatial orientation are well understood on models, mannequins, and cadavers. The equipment utilized in training must be the equipment available in the field. Lastly, the focus of the training should be on scenarios which stress the physical and mental capabilities of the providers. A true test of both self-efficacy and deliberate practice is forced through the intrinsic and extrinsic findings from the qualitative data. All of these steps must be overseen by expert practitioners. Another key is providing more time to focus on medical skills development, which is critical to overall confidence and overcoming hesitation in the decision-making process. This is even more specific to those who are least medically trained and the most likely to encounter the casualty first, EMT-Basic level providers. If possible, increasing the number of medical providers at the point of injury would achieve multiple goals under the self-efficacy learning theory. Assistance would instill confidence in the practitioner, help with the ability to prioritize patients quickly, decrease anxiety, and decrease hesitation to perform in the combat environment.

Lost in transition: the challenges of getting airway clinicians to move from the upper airway to the neck during an airway crisis.

Technical and psychological factors make performance of an emergency front-of-neck airway (eFONA) a challenging procedure for clinical teams involved in airway management. When 'cannot intubate, cannot oxygenate' (CICO) emergencies occur, eFONA is frequently performed too late or not at all. The concept of transition to eFONA comprises simultaneous efforts to prevent and prepare for eFONA before a declaration of CICO in an effort to facilitate its timely and effective implementation. Although such a transition represents an appealing idea, attention to many aspects of airway practice is required for it to become an effective intervention.

Attitudes of Anesthesiology Specialists and Residents toward Patients Infected with the Novel Coronavirus (COVID-19): A National Survey Study.

Background: The novel coronavirus (COVID-19) emerged in Wuhan, China, in December 2019. This study aims to evaluate the knowledge of anesthesiology specialists and residents in Turkey about COVID-19 and their attitudes toward the strategies and application methods to be used for a suspected/confirmed COVID-19 case that needs to be operated on or followed up in an intensive care unit, as well as to raise awareness about this issue. Methods: This descriptive study comprised anesthesiology specialists and residents working in various health institutions in Turkey. The data used in this study were obtained online between March 13, 2020 and March 25, 2020 through the website SurveyMonkey (SurveyMonkey, San Mateo, CA) by using a survey form. We contacted members of the Turkish Anaesthesiology and Reanimation Society through the social media platforms Twitter, LinkedIn, and WhatsApp, as well as through their e-mail addresses and invited them to participate in the study. Those who agreed to participate responded to the aforementioned survey. We used SPSS 22.0 (IBM, Armonk, NY) to analyze the survey data statistically. Results: A total of 346 anesthesiology specialists and residents participated in the study. Although the majority of the participants exhibited the correct attitudes toward airway management, research assistants with little professional experience were observed to be undecided or had the tendency to make incorrect decisions. Conclusions: The COVID-19 pandemic is spreading rapidly worldwide. The incidence of COVID-19 cases is increasing daily, and this disease can cause patient death. Anesthesiology specialists and residents who perform emergency operations on these patients in settings other than intensive care units should follow simple and easy-to-understand algorithms to ensure safety. The provision of theoretical and practical training to healthcare providers before they meet patients will help ensure patient-healthcare provider safety and prevent panic, which can cause distress among healthcare providers.

Persistent Adherence to Airway Clearance Therapy in Adults With Cystic Fibrosis.

BACKGROUND: Airway clearance therapy (ACT) is a core component of daily treatment for cystic fibrosis (CF). However, surprisingly little is known about sustained or persistent use of ACT over time among adults with CF. This longitudinal study examined persistent adherence to ACT over 12 months and its modifiable predictors, drawing on aspects of Social Cognitive Theory and the Theory of Planned Behavior. METHODS: Subjects were drawn from a regional CF center in the southern United States. Predictor variables evaluated at baseline included self-efficacy for ACT (ie, self-confidence in overcoming barriers), outcome expectations (ie, perceived necessity of ACT and concerns about its disruptive effects), and subjective norms (ie, perceptions of being influenced by others). The Cystic Fibrosis Treatment Questionnaire (CFTQ) was used to assess self-reported adherence to ACT at baseline, at 6 months, and at 12 months. RESULTS: The mean age of subjects was 27.2 ± 9.1 y, and mean FEV1% predicted was 65.5 ± 24.8. Forty-six percent of subjects reported persistent use of ACT (classified as adherent at all assessment periods). In bivariate analyses, all social cognitive predictor variables assessed at baseline were significantly related to persistent adherence (all P < .03), except subjective norms. In logistic regression analyses that modeled the effects of these predictors simultaneously while controlling for FEV1%, fewer baseline concerns about ACT (odds ratio = 0.82, 95% CI 0.69-0.99) and greater self-efficacy (odds ratio = 1.09, 95% CI 1.01-1.18) remained significant independent predictors. CONCLUSIONS: This longitudinal study addresses an important gap in the literature regarding adherence to ACT over time (12 mo) in a routine clinical setting. Persistent adherence was problematic. As anticipated, social cognitive variables (self-confidence and perceived concerns) predicted self-reported persistence, and these may represent practical targets for intervention.

Protocol for a multicentre randomised controlled trial to investigate the effect on asthma-related quality of life from breathing retraining in patients with incomplete asthma control attending specialist care in Denmark.

INTRODUCTION AND AIM: Uncontrolled asthma is a global health challenge with substantial impact on quality of life (QoL) and overall healthcare costs. Unrecognised and/or unmanaged comorbidities often contribute to presence of uncontrolled asthma. Abnormalities in breathing pattern are termed dysfunctional breathing and are not only common in asthma but also lead to asthma-like symptoms and reduced QoL, and, in keeping with this, improvement with breathing normalisation. Evidence-based guidelines recommend breathing retraining interventions as an adjuvant treatment in uncontrolled asthma. Physiotherapy-based breathing pattern modification interventions incorporating relaxation have been shown to improve asthma-related QoL in primary care patients with impaired asthma control. Despite anecdotal reports, effectiveness of breathing retraining in patients referred to secondary care with incomplete asthma control has not been formally assessed in a randomised controlled trial (RCT). We aim to investigate the effect of breathing exercises on asthma-related QoL in patients with incomplete asthma control despite specialist care. METHODS AND ANALYSIS: This two-armed assessor-blinded multicentre RCT will investigate the effect of physiotherapist-delivered breathing retraining on asthma QoL questionnaire (MiniAQLQ) in addition to usual specialist care, recruiting from seven outpatient departments and one specialised clinic representing all regions of Denmark during 2017-2019. We will include 190 consenting adults with incomplete asthma control, defined as Asthma Control Questionnaire 6-item score ≥0.8. Participants will randomly be allocated to either breathing exercise programme in addition to usual care (BrEX +UC) or UC alone. BrEX compiles three physiotherapy sessions and encouragement to perform home exercise daily. Both groups continue usual secondary care management. Primary outcome is between-group difference in MiniAQLQ at 6 months. Secondary outcomes include patient-reported outcome measures, spirometry and accelerometer. ETHICS AND DISSEMINATION: Ethics Committee, Region Zealand (SJ-552) and Danish Data Protection Agency (REG-55-2016) approved the trial. Results will be reported in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT03127059; Pre-results.

Objective Versus Self-Reported Adherence to Airway Clearance Therapy in Cystic Fibrosis.

BACKGROUND: Historically, studies of adherence to airway clearance therapy in cystic fibrosis (CF) have relied on self-reporting. We compared self-reported airway clearance therapy adherence to actual usage data from home high-frequency chest wall compressions (HFCWC) vests and identified factors associated with overestimation of adherence in self-reports. METHODS: Pediatric patients who perform airway clearance therapy with a HFCWC vest were eligible to participate. Objective adherence data were obtained from the HFCWC device, which records cumulative utilization time. Two readings at least 5 weeks apart were collected. Objective adherence was recorded as a ratio of mean-to-prescribed daily use (%). Self-reported adherence data were collected with a caregiver survey at enrollment. Adherence rates were categorized as low (< 35% of prescribed), moderate (36-79% of prescribed), and high (≥ 80% of prescribed). An overestimation was present when self-reported adherence was at least one category higher than objective adherence. RESULTS: In the final sample (N = 110), mean adherence by usage data was 61%. Only 35% of subjects (n = 38) were highly adherent, and 28% (n = 31) were low adherent. In contrast, 65% of subjects (n = 72) reported high adherence and only 8% (n = 9) reported low adherence (P < .001). Nearly half of self-reports (46%) overestimated adherence. In a multiple regression analysis, overestimation was associated with multiple airway clearance therapy locations (odds ratio 7.13, 95% CI 1.16-43.72, P = .034) and prescribed daily use ≥ 60 min (odds ratio 3.85, 95% CI 1.08-13.76, P < .038). Among subjects with prescribed daily airway clearance therapy ≥ 60 min, the odds of overestimating adherence increased 3-fold (odds ratio 3.04, 95% CI 1.17-7.87, P = .02) in a lower-income (< $50,000/y) environment. CONCLUSIONS: Self-reports overestimated actual adherence to airway clearance therapy, and the overestimation increased with treatment occurring in multiple households and prescribed therapy duration. Among participants with prescribed airway clearance therapy ≥ 60 min, overestimation increased with lower income. Objective measures of adherence are needed, particularly for lower-income children and those receiving treatments in multiple locations.

Human factors enablers and barriers for successful airway management - an in-depth interview study.

Human factors are the individual, team, environmental and organisational aspects of the anaesthetic environment that affect performance and decision-making of anaesthesia teams. This study aimed to identify which human factors were enablers and/or barriers to anaesthesia teams during airway management challenges. Sixteen interviews were conducted with experienced anaesthetists and anaesthetic nurses using an in-depth interview technique (the Critical Decision Method) to identify human factors enablers and/or barriers during successful management of a significant airway challenge. Thematic analysis identified three overarching enablers: equipment location and storage; experience and learning; teamwork and communication. Five overarching barriers were also identified: time and resource limitations; teamwork and communication; equipment location and storage; experience and learning; insufficient back-up planning; and equipment preparation. This study showed that a variety of human factors issues affect the handling of airway challenges, ranging from individual and team to organisational and environmental aspects. Recommendations for the design of airway management decision support tools that relate to equipment standardisation, decision support complexity, inclusive mutual learning and teamwork are discussed.

Quantifying patient centered outcomes associated with the use of bilateral endobronchial coil treatment in patients with severe emphysema.

OBJECTIVE: To determine the impact of endobronchial coils on health-related quality-of-life (HRQoL). This paper utilizes trial data to identify the predictors of HRQoL in patients with severe emphysema, and subsequently estimates the impact of a new treatment on HRQoL (measured by utilities). These utility estimates are used to generate indicative long-term QALY estimates for a range of clinically plausible scenarios as a precursor to cost-effectiveness analyses. METHODS: Patient level HRQoL data from RENEW and the National Emphysema Treatment Trial (NETT) were combined and mapped to generic EuroQol 5-dimension health utility questionnaire (EQ-5D) values using a published algorithm. Multilevel statistical models were developed using treatment, time, response, and baseline characteristics (EQ-5D, age, gender, FEV1, lung RV) to predict EQ-5D over time. Lifetime QALY estimates were generated using published survival data from NETT (assuming no impact of treatment on mortality) and four clinically plausible response profiles. Each response profile was combined with assumptions around treatment impact (constant or time varying). RESULTS: After controlling for baseline characteristics, both treatment and response had a statistically significant impact (p < .001) on utility (+0.101 and +0.061, respectively). When combined with selected baseline characteristics and time, Coils and Standard of Care (SoC) generated more QALYs than SoC alone in all scenarios, with incremental lifetime benefit ranging from 0.29-0.55 QALYs. CONCLUSIONS: Coils and SoC resulted in statistically significant improvements in HRQoL compared to SoC alone in patients with severe emphysema.

Contributions of a hand-held fan to self-management of chronic breathlessness.

This study explored the benefits of a hand-held fan as perceived by patients with chronic breathlessness and their carers.A secondary multimethod analysis was conducted of interview data collected in three clinical trials. Two researchers independently coded level of benefit qualitatively reported by each patient. Univariate and multivariate statistics were used to explore perceived benefit as a factor of sex, age and diagnosis. Qualitative analysis used an integrative method.133 patients commented on the fan, of whom 72 had a carer. Diagnoses included nonmalignant (n=91, 68.4%) and malignant (n=21, 15.8%) conditions. Of 111 patients who provided codable data, four (3.6%) perceived no benefit, 16 (14.4%) were uncertain, 80 (72.0%) perceived some benefit and 11 (10.0%) perceived very substantial benefit. Multivariate analysis was inconclusive. Benefit was described in terms of shorter recovery time, especially after activity. 10 (7.5%) patients said the fan reduced their need for home oxygen or inhaled ß-agonist medications. Negative perceptions of a few included dislike of the cooling sensation and embarrassment in public.Findings suggest that a hand-held fan is a portable intervention with few disadvantages from which most patients with chronic breathlessness will derive benefit alongside other nonpharmacological and pharmacological strategies. Research is needed to optimise guidance on fan administration.

Use of the gastro-laryngeal tube in endoscopic retrograde cholangiopancreatography cases under sedation/analgesia.

BACKGROUND/AIMS: In this study, we aimed to analyze the effects of Gastro-Laryngeal Tube (GLT) use on intraoperative and postoperative hemodynamic parameters, comfort of the procedure, and patients' satisfaction in endoscopic retrograde cholangiopancreatography (ERCP). MATERIALS AND METHODS: A total of 80 patients between the ages of 20 and 75 years who were scheduled for elective ERCP were enrolled. The patients were randomly assigned to two groups: groups N and G. Those in group N underwent the procedure with sedation without any airway instruments and those in group G underwent procedure after sedation and airway management with GLT. Intraoperative and postoperative vital signs as well as the satisfaction of the patients were recorded. RESULTS: The duration to esophageal visualization was found to be significantly higher in group N (16 s) than in group G (7 s) (p=0.001). The mean Visual Analogue Scale for Pain (VAS) was significantly higher in group G (1.85) than in group N (0.45) (p=0.016). Group G had higher endoscopist satisfaction scores than group N. The incidence of desaturation during ERCP was significantly higher in group N (60%) than in group G (0%) (p=0.000). CONCLUSION: In conclusion, ERCP should be performed under optimal conditions to avoid the occurrence of unwanted complications, such as aspiration-related disorders. Therefore, according to the structural properties of GLT, sedation anesthesia application with GLT in ERCP will be safer, more comfortable, and more effective.

The effect of a standardised source of divided attention in airway management: A randomised, crossover, interventional manikin study.

BACKGROUND: Dual-tasking, the need to divide attention between concurrent tasks, causes a severe increase in workload in emergency situations and yet there is no standardised training simulation scenario for this key difficulty. OBJECTIVES: We introduced and validated a quantifiable source of divided attention and investigated its effects on performance and workload in airway management. DESIGN: A randomised, crossover, interventional simulation study. SETTING: Center for Training and Simulation, Department of Anaesthesiology, Erlangen University Hospital, Germany. PARTICIPANTS: One hundred and fifty volunteer medical students, paramedics and anaesthesiologists of all levels of training. INTERVENTIONS: Participants secured the airway of a manikin using a supraglottic airway, conventional endotracheal intubation and video-assisted endotracheal intubation with and without the Paced Auditory Serial Addition Test (PASAT), which served as a quantifiable source of divided attention. MAIN OUTCOME MEASURES: Primary endpoint was the time for the completion of each airway task. Secondary endpoints were the number of procedural mistakes made and the perceived workload as measured by the National Aeronautics and Space Administration's task load index (NASA-TLX). This is a six-dimensional questionnaire, which assesses the perception of demands, performance and frustration with respect to a task on a scale of 0 to 100. RESULTS: All 150 participants completed the tests. Volunteers perceived our test to be challenging (99%) and the experience of stress and distraction true to an emergency situation (80%), but still fair (98%) and entertaining (95%). The negative effects of divided attention were reproducible in participants of all levels of expertise. Time consumption and perceived workload increased and almost half the participants make procedural mistakes under divided attention. The supraglottic airway technique was least affected by divided attention. CONCLUSION: The scenario was effective for simulation training involving divided attention in acute care medicine. The significant effects on performance and perceived workload demonstrate the validity of the model, which was also characterised by high acceptability, technical simplicity and a novel degree of standardisation.

The effects of feedback on volitional manipulation of airway protection during swallowing.

Volitional control of autonomic responses, such as heart rate and blood pressure, can be facilitated with the use of augmented feedback. Oropharyngeal swallowing typically includes both volitional and reflexive components, offering a unique opportunity for observing how performance is affected by feedback. Sixteen healthy participants (M age=29 years, SD=10 years) completed multiple trials of a novel airway closure technique during swallowing under one of two conditions: no feedback or feedback. The feedback condition included knowledge of performance and knowledge of results. Only the feedback group improved performance across trials (p=.01), with no difference from baseline seen for the no feedback group (p=.66). These results show that airway closure during swallowing can be volitionally manipulated with augmented feedback.

Human factors in the development of complications of airway management: preliminary evaluation of an interview tool.

The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) analysed reports of serious events arising from airway management during anaesthesia, intensive care and the emergency department. We conducted supplementary telephone interviews with 12 anaesthetists who had reported to NAP4, aiming to identify causal factors using a method based on the Human Factors Investigation Tool (HFIT). We identified contributing human factors in all cases (median [range] 4.5 [1-10] per case). The most frequent related to: situation awareness (failures to anticipate, wrong decision) (nine cases); job factors (e.g. task difficulty; staffing, time pressure) (eight cases); and person factors (e.g. tiredness, hunger, stress) (six cases). Protective factors, such as teamwork and communication, were also revealed. The post-report HFIT interview method identified relevant human factors and this approach merits further testing as part of the investigation of anaesthetic incidents.