Pre-operative transnasal endoscopy as a predictor of difficult airway: A prospective cohort study.

BACKGROUND: Consequences of failed endotracheal intubation can be catastrophic and predicting difficulty is therefore a critical issue. There is no consensus on the best way to predict difficulty. OBJECTIVE: To evaluate the role of transnasal flexible endoscopic laryngoscopy (TFEL), a minimally invasive procedure, in the prediction of difficult intubation. DESIGN: Prospective cohort study. SETTING: San Raffaele Hospital, Milan, a tertiary university hospital. PATIENTS: One hundred and sixty nine adults scheduled for elective ear, nose and throat surgery under general anaesthesia with pre-operative TFEL. INTERVENTION: In addition to routine pre-operative evaluation by an anaesthesiologist, glottis exposure during TFEL was assessed with a scoring system similar to the modified Cormack-Lehane (MCL). MAIN OUTCOME MEASURES: The extent to which TFEL improves the prediction of difficult direct laryngoscopy, measured with the MCL score, and of difficult intubation, measured with the intubation difficulty scale score. RESULTS: When added to bedside evaluation, TFEL performed during tongue protrusion significantly (P = 0.005) improved the prediction of MCL. The area under the receiver operating characteristics curve was 0.75 [95% confidence interval (CI) 0.67 to 0.83] vs. 0.65 (95% CI 0.58 to 0.74). For the intubation difficulty scale (P = 0.049), the area under the receiver operating characteristics curve was 0.70 (95% CI 0.61 to 0.80) vs. 0.66 (95% CI 0.58 to 0.74). CONCLUSION: TFEL is a useful tool in predicting difficult intubation, improving predictability of routine bedside evaluation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02671877.

Feasibility, safety and efficacy of COVID-19 severe acute respiratory distress syndrome management without invasive mechanical ventilation.

BACKGROUND: COVID-19 acute respiratory distress syndrome (ARDS) is often managed with mechanical ventilation (MV), requiring sedation and paralysis, with associated risk of complications. There is limited evidence on the use of high flow nasal cannula (HFNC). We hypothesized that management of COVID-19 ARDS without MV is feasible. METHODS: Included were all adult patients diagnosed with COVID-19 ARDS, with PaO2/FiO2 ratio <100 at admission, and whose management was initially performed without MV. We evaluated need for intubation during ICU stay, mortality and hospital/ICU length of stay (LOS). RESULTS: Out of 118 patients, 41 were managed only with HFNC from hospital admission (and at least during first 24 hours in ICU) and had a PaO2/FiO2 ratio <100 (72.9±13.0). Twenty-nine out of 41 patients never required MV: 24 of them survived and were discharged home. Their median ICU LOS was 11 (7-17) days, and their hospital LOS was 29 (18-45) days. We identified PaO2/FiO2 ratio at ICU admission as the only significant predictor for need for MV during ICU stay. We also identified age, length of non-invasive respiratory support before ICU admission, mean value of PaO2/FiO2 ratio during first half and whole ICU stay as predictors of mortality. CONCLUSIONS: It is safe to monitor in ICU and use HFNC in patients affected by COVID-19 ARDS who initially present data suggesting an early need for intubation. The 41 patients admitted with a PaO2/FiO2 ratio <100 and initially treated only with HFNC show a 22% mortality that is in the lower range of what is reported in recent literature.