Herb pair of Ephedrae Herba-Armeniacae Semen Amarum alleviates airway injury in asthmatic rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Ephedrae Herba (EH, Ephedra sinica Stapf.) and Armeniacae Semen Amarum (ASA, Prunus armeniaca L. var. ansu Maxim.) have been used to treat asthma, cold, fever, and cough in China for thousands of years. AIM OF THE STUDY: In this study, we aimed to investigate the optimal ratio of EH and ASA compatibility (EAC) to reduce airway injury in asthmatic rats and its possible mechanism. METHODS: Rats were sensitized with a mixture of acetylcholine chloride and histamine bisphosphate 1 h before sensitization by intragastric administration of EAC or dexamethasone or saline for 7 days. Subsequently, the ultrastructure of rat airway epithelial tissue changes, apoptosis of the airway epithelial cells, and the expression of mRNA and protein of EGRF and Bcl-2 were detected. RESULTS: Transmission electron microscope: EAC (groups C and E) had the most prominent effect on repairing airway epithelial cells' ultrastructural changes in asthmatic rats. TUNEL: dexamethasone and EAC (groups B、C、E and F) inhibited the apoptosis of airway epithelial cells in asthmatic rats (P < 0.05). In situ hybridization: EAC (group E) inhibited the overexpression of EGFR and Bcl-2 mRNA (P < 0.05).Western Blotting: EAC (groups A、B、C、E and F) inhibited the upregulation of airway epithelial EGFR and Bcl-2 protein expression (P < 0.01). CONCLUSIONS: Our findings indicate that EAC can inhibit abnormal changes in airway epithelial structure and apoptosis of airway epithelial cells, thereby alleviating airway injury. In this study, the best combination of EH and ASA to alleviate airway epithelial injury in asthmatic rats was group E (EH: ASA = 8: 4.5).

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy.

BACKGROUND: There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort. METHODS: We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis. RESULTS: Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776). CONCLUSIONS: When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated.

BACKGROUND: Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. METHODS: Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. RESULTS: 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. CONCLUSION: Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

National estimations of airway foreign bodies in children in the United States, 2000 to 2009.

OBJECTIVE: Identify risk factors associated with airway foreign bodies in children in the United States and report observed trends over time. DATA SOURCE: KID database (2000-2009). METHODS: ICD-9-CM codes for airway foreign bodies were used to identify patients. Risk factors were used for univariate analysis and a multivariate model to identify any increased risk of mortality. These factors were then also trended over time. RESULTS: Children with airway foreign bodies demonstrate similar risk factors as previously reported, such as male gender, age less than five years and lack of private insurance. The weighted mortality rate for paediatric inpatients with airway foreign bodies was about 2.75%. Fortunately, the rate remained relatively unchanged from 2000 to 2009. Geographically, urban hospital settings appeared to be more affected. Increased risks of mortality were noted for older age, urban hospital setting and teaching hospital status. CONCLUSIONS: Our findings confirm previous findings and identified that the diagnosis of airway foreign bodies in children were associated with male gender, age <5 years, lack of private insurance and geographic location in an urban setting. Further investigation may be warranted to provide clarity on other factors found to have increased association with mortality for quality improvement.

Lesões pulmonares em suínos abatidos no matadouro Público Municipal de Esperança, Paraíba / Pulmonary lesions of slaughtered pigs at the municipal public slaughterhouse of Esperança, Paraíba

O objetivo do presente estudo foi avaliar as lesões macroscópicas e histológicas em pulmões de suínos abatidos no abatedouro público de Esperança, Paraíba. Foram inspecionados pulmões de 180 suínos entre julho e dezembro de 2013. Destes, 34 (18,8%) apresentaram lesões. Na análise anatomopatológica dos fragmentos coletados, 82,3% (28/34) exibiram lesões sugestivas de Pneumonia Enzoótica Suína (PES). Seis (17,7%) amostras apresentaram alterações causadas pela distribuição irregular de sangue. Casos sugestivos de PES crônica foram observados em 57,1% (16/28) dos fragmentos coletados. Em 42,9% (12/28) das amostras foram definidos como sugestivos de PES subaguda. Nenhum pulmão apresentou lesões sugestivas de PES aguda. A pesquisa demonstrou que lesões pulmonares em suínos são frequentemente detectadas no abatedouro de Esperança, Paraíba, sendo a maioria destas lesões sugestivas de PES.

The objective of the present study was to evaluate the macroscopic and histological lesions in the lungs of slaughtered pigs at the public slaughterhouse of Esperança, Paraíba. Lungs from 180 pigs were inspected between July and December 2013. Lesions were observed in 34 (18.8%) lungs. In the anatomopathological analysis of the collected fragments, 82.3% (28/34) presented suggestive lesions of Swine Enzootic Pneumonia (SEP). Six (17.7%) samples presented alterations caused by irregular blood distribution. Suggestive cases of chronic SEP were observed in 57.1% (16/28) of the collected fragments. In 42.9% (12/28) of the samples were defined as suggestive of subacute SEP. No lungs presented lesions suggestive of acute PES. The research showed that lung lesions in pigs are frequently detected in the Esperança, Paraíba slaughterhouse, with the majority of these lesions suggestive for SEP.

Protocol incorporating airway CT decreases negative bronchoscopy rates for suspected foreign bodies in pediatric patients.

BACKGROUND: Foreign body aspiration (FBA) is the 4th leading cause of death in children between the ages 1-5. Although direct laryngoscopy and bronchoscopy (DL&B) is the reference standard for diagnosis of pediatric airway foreign bodies, there is a high negative bronchoscopy rate, exposing patients to unnecessary operative and anesthetic risks and costs. METHODS: A clinical care protocol entailing the selective use of low-dose non-contrast airway computed tomography (CT) for children with an intermediate risk for FBA on the basis of clinical exam and chest radiography was implemented to decrease the negative DL&B rate. A retrospective review was conducted to compare negative bronchoscopy rates before and after implementation of the new protocol and the diagnostic performance characteristics of airway CT for airway foreign bodies were analyzed. RESULTS: After implementation of the airway FB clinical care protocol entailing selective airway CT, the overall negative bronchoscopy rate decreased from an institutional historical rate of 37% (54/145) to 17% (10/56) (p = .06). The overall sensitivity, specificity, and positive and negative predictive value of airway CT for FB was 91%, 100%, 100%, and 97% respectively. CONCLUSIONS: Low-dose non-contrast airway CT is highly sensitive and specific for airway foreign bodies, and its selective use in a clinical care protocol for children with suspected foreign body aspiration could greatly reduce the negative bronchoscopy rate, thereby decreasing operative risks and costs.

Predictors of complicated airway foreign body extraction.

OBJECTIVES: To evaluate outcomes of foreign body aspiration (FBA) and to investigate surgeon and hospital volume as risk factors for a complicated course. STUDY DESIGN: Retrospective case series. METHODS: Children with FBA in a multihospital network were identified from January 2005 to September 2015. Demographic information, surgeon, and hospital location were reviewed. Mean operative time and hospital length of stay were recorded. Cases requiring intensive care unit admission, hospital stay greater than 24 hours, need for more than one bronchoscopy, operative time greater than 1 hour, or death were considered "complicated." RESULTS: A total of 450 cases of airway foreign body extraction were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of 1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different surgeons at 11 different facilities. There were one to 24 surgeons for each facility, with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were considered complicated, including five (1.1%) deaths. Increased rates of complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency (P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association was found between surgeon type or facility as related to a complicated case. CONCLUSIONS: Unwitnessed aspiration events and abnormalities on chest radiograph may be associated with a more complicated course in children with FBA. This multihospital study identified a low number of procedures by many surgeons; however, surgeon and hospital volume did not significantly correlate with higher complication rates. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:490-495, 2018.

Low rate of positive bronchoscopy for suspected foreign body aspiration in infants.

OBJECTIVES: To describe our institution's low rate of positive bronchoscopy in infants suspected of inhaling a foreign body. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was performed of patients at a tertiary children's hospital with suspected inhalation of a foreign body. Charts were reviewed for demographic information, radiologic findings, operative reports, and respiratory viral panels were reviewed. RESULTS: Sixteen pediatric patients under 12 months of age were identified from 2008 to 2016 with a diagnosis of possible airway foreign body inhalation who underwent emergent bronchoscopy. Of these patients, only one was positive for a foreign body present in the airway. The remaining 15 children were found to have a negative direct laryngoscopy and bronchoscopy evaluation for a foreign body. Of these fifteen patients, 14 were found to have structural airway abnormalities and 7 tested positive for a respiratory viral infection. CONCLUSIONS: Our institution has a low rate of positive bronchoscopy for highly suspected foreign body inhalation in a group of patients less than 12 months of age. Patients presenting with respiratory distress, stridor, or other airway symptoms were often found to have an underlying airway abnormality or viral infection, which coupled with an unclear history, would increase the suspicion for an airway foreign body and subsequent decision to perform bronchoscopy. In stable patients, diagnostic evaluation for an underlying respiratory infection should be performed in these cases. LEVEL OF EVIDENCE: Case Series.

The multivariate analysis of indications of rigid bronchoscopy in suspected foreign body aspiration.

OBJECTIVE: Foreign body aspiration (FBA) could be a serious life-threatening condition in children. Patients usually underwent bronchoscopy with suspicious of FBA alone. In this study, we aimed to determine which patients need to go to bronchoscopy based on pre-operative findings. METHODS: Retrospective analysis of patients underwent bronchoscopy between 1999 and 2015 was performed. Clinical symptoms, witnessed aspiration event (WAE), physical examination findings (PEFs) and radiological findings (RFs) were analyzed by multivariate analysis to evaluate the indications of bronchoscopy. RESULTS: 431 patients (266M, 165F) underwent bronchoscopy with a median age of 2 years (7 months-16 years). A foreign body was detected in 68% of the patients. Univariate analysis demonstrated that wheeze was the sole distinctive clinical symptom for detection of FBA (p<0.001). The rates of positive WAE, PEFs and RFs were 83%, 71.7% and 36.9%, respectively. All of them were identified as independent predictive parameters in the detection of FBA by univariate analysis (p = 0.003&p<0.001&p = 0.015). Multivariate analysis was performed with considering the association between them. The rate of positive bronchoscopy was 91.3% in patients with positive WAE, PEFs and RFs together(84/92). In patients with a positive WAE alone who had not got PEFs and RFs, the rate of positive bronchoscopy was 34.2% (25/73). A foreign body was detected in 84% of the patients who had not got a WAE but positive PEFs and RFs together(21/25). Bronchial laceration was occurred in one patient during bronchoscopy. Pneumothorax was not seen in any of the other patients. The rate of mortality was 0.4% in the overall group (2 patients). CONCLUSION: The indications of bronchoscopy in suspected FBA are usually based on clinical suspicious. The definition of " suspicous" could be a WAE or positive PEFs and RFs. The association of these factors increase the rate of positive bronchoscopies. In the light of our study, the classical indication for suspected FBA is still valid as "suspicious requires bronchoscopy".

Retrieval of tracheobronchial foreign bodies by short flexible endoscopy in children.

OBJECTIVES: Flexible endoscopy (FE) is frequently used to diagnose tracheobronchial foreign bodies (TBFB). However, it is still controversial for retrieval of TBFB in pediatric field. This study aims at reporting and evaluating our experiences of using short-length FE with a non-invasive ventilation (NIV) technique and intensive care unit (ICU) support in retrieving pediatric TBFB. METHODS: A retrospective review of the hospital database and FE videos of pediatric patients aged less than 18 year-old who were diagnosed of TBFB and managed in our hospital over a 17-year period (1999-2015). The demographic data were collected and analyzed. A NIV technique of providing nasopharyngeal oxygen with intermittent nose closure and abdominal compression was routinely performed in procedural sedated patients throughout the whole FE procedures. RESULTS: Sixty-six consecutive patients with 76 TBFB were enrolled. Among them, 72 (94.7%) TBFB in 64 patients were successfully retrieved at the first attempt of FE immediately after the diagnosis was made. There were 13 iatrogenic TBFB in patients who already had coexisting airway problems. The median age was 16 months (range 1.5 months-17 years) and the median body weight was 10.5 kg (range 3.5-48.5 kg). Seventy (70/72, 97.2%) TBFB were retrieved by short-length FE and among them, 55 procedures (55/72, 76.4%) used FE with no working channel. No significant acute or late adverse effects were noted. The mean retrieval procedural time was 23.6 ± 15.1 min. CONCLUSION: Using short-length FE with this NIV technique, appropriate sedation and ICU support is a safe, simple and effective modality for the retrieval of TBFB immediately after confirming the diagnosis in pediatric patients.

[INJURY PREVENTION WHILE ENSURING THE AIRWAY DURING SURGERY IN THE NOSE AND SINUSES.]

THE AIM: A comparative analysis of the injuries of upper airways flexible reinforced laryngeal mask and endotracheal intubation by examining the stress response reaction of the cardiovascular system, as well as the frequency and variety of complications. Blood pressure, heart rate, glucose and cortisol, and complications of airway management in children were analyzed. METHODS: The influence of the method of airway management with surgery in nose and sinuses in children in the stress response, hemodynamics, injuries of the airway were studied. The study included 140 patients aged 3 to 17 years. RESULTS: LMA FlexibleTMhas a minimal negative impact on the hemodynamics. Stress response is less pronounced when installing laryngeal mask than with tracheal intubation, which manifests itself in less cortisol concentration of 3.7%, 11.4% glucose. After removing the flexible reinforced laryngeal mask less than after extubation occurs: cough by 21%, 10% hoarseness, and sore throat by 26%. CONCLUSION: The use of the laryngeal mask airway during surgery in the nose and paranasal sinuses safer and less trau- matic manipulation compared with tracheal intubation.

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes.

BACKGROUND: Airway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported. METHODS: The KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x). RESULTS: 11,793 patients, ages 0-17, were found to have an airway FB. Of patients admitted for airway FB 21.2 % required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5 %. Location of the airway FB was dependent on age (p < 0.01). Use of mechanical ventilation was dependent on the location of the airway FB (p < 0.01) and being transferred from another hospital (OR 2.59, p < 0.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (p < 0.01), use of a ventilator during hospitalization (OR 24.4, p < 0.01), and transfer from another hospital (OR 2.11, p < 0.01). CONCLUSIONS: The in-hospital mortality rate for airway foreign bodies is 2.5 %. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

[The effect and injury to the airways of different sputum aspiration pressure in a rat model of mucus hypersecretion].

OBJECTIVE: To explore the optimal pressure of sputum aspiration to ensure the effectiveness and safety of clinical operation. METHODS: We established a rabbit model of airway mucus hypersecretion by aerosol acrolein inhalation, and the animals were divided into 4 groups randomly with different sputum aspiration pressure as follows: group A -75 mmHg (1 mmHg=0.133 kPa), group B -150 mmHg, group C -225 mmHg, group D -300 mmHg. Sputum aspiration efficiency and tracheal mucosal damage degree were evaluated by sputum volume, oxygen saturation changes, the pathological sections of tracheal mucosa and the expressions of IL-1ß and TNF-α in airway secretion. RESULTS: The sputum suction volume of group A, B, C, D were (2.72±0.24), (4.81±0.32), (5.03±0.37) and (6.29±0.51) ml, respectively, which was significantly higher in group D, but lower in group A, as compared to other groups (P<0.05). There were no significant differences between B and C groups. The maximal SpO2 decrease of C and D groups [(18.1±5.2)% and(32.4±8.4)%]were significantly higher than those in A and B groups [(4.4±1.7)% and (6.3±2.9)%], and group D was significantly more than group C, and the difference was statistically significant (P<0.05). There were no significant differences between A and B groups. HE staining of tracheal mucosa in C and D groups showed that the inflammatory cell infiltration and mucosal damage were more serious than A and B groups, but the airway mucosal damage of group A was the least. CONCLUSION: The pressure of -150 mmHg was more effective with high oxygen saturation and less airway injury, which may be suitable for clinical sputum aspiration.

Civilian Airway Trauma: A Single-Institution Experience.

BACKGROUND: Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. The objective of this study is to determine the clinical characteristics and outcomes for patients with airway injury. METHODS: From 1974 to 2014, a prospectively entered trauma database at a Level 1 trauma center was accessed to identify patients with injuries to the larynx, cervical trachea, or thoracic airway. Hospital charts were reviewed to obtain data on demographics, presentation, injury management, in-hospital and long-term morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality and long-term vocal cord morbidity. Data are expressed as N (%). RESULTS: One hundred and twenty patients were included (median injury severity score: 19 [interquartile range: 10-27]). There were 65 (54 %) blunt and 55 (46 %) penetrating injuries, with 90 (75 %) suffering multiple injuries. Sixteen (13 %) patients died from associated injuries (7: in ER; 9: after admission). Injuries were located in the cervical airway [101 (84 %)], thoracic airway [21 (18 %)], or both [2 (2 %)]. Eighty-six (72 %) patients were managed surgically. Predictors of in-hospital mortality included hemodynamic instability (OR 6.54, 95 % CI 1.11-37.14), GCS < 8 upon presentation (OR 4.35, 95 % CI 3.24-5.41), and head trauma (OR 4.10, 95 % CI 1.91-6.30). Fracture of cricoid or thyroid cartilages was a strong predictor of long-term vocal cord injury (OR 3.93, 95 % CI 1.25-12.59). CONCLUSIONS: Airway trauma remains a major challenge for early diagnosis, airway control, and management of both acute life-threatening injury and long-term morbidity.

Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm.

OBJECTIVES: To determine the specific CT findings of penetrating neck wound profile predicting aerodigestive injuries, diagnostic performance of CTA and to propose a modified selective management algorithm to reduce nontherapeutic invasive procedures. METHODS: We retrospectively evaluated CTAs of 102 patients to determine the presence of various CT signs. "Trajectory"-based signs included trajectory of the wound extending into the aerodigestive tract and trajectory violating the deep neck spaces. "Conventional" signs included transcervical injury; wall defect; air or blood in the deep neck spaces; irregular or thickened aerodigestive tract; and active mucosal bleeding. RESULTS: Trajectory of the wound extending into the aerodigestive tract (sensitivity 76 %, specificity 97 %) and trajectory of the wound violating the suprahyoid deep neck spaces or the infrahyoid visceral space (sensitivity 97 %, specificity 55 %) were the best predictors of injury on regression analysis. The most specific "conventional" CT signs were "wall defect" and "active mucosal bleed", but had very low sensitivity. The sensitivity of CTA for detecting an injury ranged from 89.5 % to 92 %, specificity ranged from 62.5 % to 89 %. CONCLUSION: CTA can be a useful technique in detecting aerodigestive injury. Our proposed management algorithm can exclude an injury with high degree of confidence (sensitivity 97 %). KEY POINTS: • Trajectory-based CT signs predict aerodigestive injury after penetrating neck trauma. • Surgery should be considered when trajectory extends into the infra-arytenoid aerodigestive tract. • Endoscopy or exploration should be considered when trajectory violates deep neck spaces. • This modified approach can decrease negative explorations and invasive diagnostic procedures.

Pneumomediastinum following blunt trauma: Worth an exhaustive workup?

BACKGROUND: Incidental pneumomediastinum is a common radiologic finding following blunt thoracic injury; however, the clinical significance of pneumomediastinum on screening imaging is poorly defined (Curr Probl Surg. 2004;41(3):211-380; Injury. 2010;41(1):40-43). The purpose of this study was to define the incidence of aerodigestive injuries in patients with pneumomediastinum after blunt thoracic and neck injury. METHODS: After institutional review board approval was obtained, a retrospective review was performed of all patients admitted to Los Angeles County + University of Southern California Medical Center with blunt neck and/or thoracic injuries between January 2007 and December 2012. All patients with pneumomediastinum on radiologic investigation were included. Data accrued included demographics, admission clinical data, injury severity patterns, incidence of aerodigestive injuries, operative findings, morbidity, mortality, as well as intensive care unit and hospital lengths of stay. RESULTS: A total of 9,946 patients were included in the study. The predominant mechanism was motor vehicle collision (49%), disproportionately male (76%). Overall, 258 patients (2.6%) had a pneumomediastinum: 65 (25%) and 193 (75%) were diagnosed on a chest x-ray or on a computed tomography (CT) scan, respectively. A total of 21 patients (8.1%) had an aerodigestive workup with bronchoscopy, esophagram, and/or esophagoscopy. Overall, four aerodigestive lesions (1.6%) were diagnosed. Three tracheobronchial injuries were identified on CT scan, and one esophageal injury was diagnosed on an esophagram. Two tracheobronchial injuries required surgery, while the remaining cases were managed nonoperatively. The overall mortality in this cohort was 10.9%. CONCLUSION: Isolated findings of pneumomediastinum on screening chest x-ray or CT following blunt trauma is a poor predictor of an aerodigestive injury. Highly selective workup in this clinical setting is warranted. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Adverse airway events in parturient compared with non-parturient patients. Is there a difference? Results from a quality management project.

AIM: The fear of airway problems often leads to prolonged attempts to obtain neuroaxial (spinal anesthesia or epidural anesthesia) anesthesia in obstetric anesthesia. The aim of this institutional quality management study was to revisit existing anesthesia care in the obstetric department, focusing on the frequency of delayed or failed neuroaxial anesthesia as well as the risk of airway problems in parturient and non-obstetric patients. METHODS: The clinical records from 8 consecutive years (2005-2013) were analyzed retrospectively. Cases of cesarean delivery with general anesthesia were analyzed and compared with an age-matched group of female patients undergoing non-obstetric abdominal or gynecological surgery with rapid sequence induction. Poor laryngeal visualization (Cormack-Lehane grade III or IV) and failed intubation were recorded. RESULTS: The records of 6393 cesarean deliveries including 851 with general anesthesia were analyzed. In 175 cases insufficient or delayed onset of regional anesthesia led to requirement for general anesthesia. The rate of poor laryngoscopic view in parturient women undergoing cesarean delivery was 14/851, and 4/814 in the reference group (P = 0.023). Failed intubation occurred in three patients undergoing cesarean delivery (0.4%) and in one non-obstetric patient (0.1%; P = 0.339). CONCLUSION: The rate of failed intubations in patients undergoing cesarean delivery may be equivalent to non-obstetric patients. In time-challenging cesarean deliveries, delay of conversion from non-successful neuroaxial anesthesia to general anesthesia in order to avoid adverse airway events does not appear to be justified.

Intubation with VivaSight or conventional left-sided double-lumen tubes: a randomized trial.

INTRODUCTION: Double-lumen endotracheal tubes (DLTs), which are commonly used for single-lung ventilation during surgery, are difficult to insert. In addition, they often move during surgical lung manipulation which can cause life-threatening complications. Flexible bronchoscopy is used routinely to establish and confirm proper DLT placement. The newly designed VivaSight DLT has an integrated camera, allowing continuous visualization of its position in the trachea. We hypothesized that the time to intubation using the VivaSight DLT would be faster than with a conventional DLT. METHODS: We enrolled 40 adults scheduled for thoracic surgery. Patients were randomized to conventional DLT (n = 20) or VivaSight DLT (n = 20). Time to intubation was our primary outcome. Secondary outcomes were insertion success without flexible bronchoscopy, frequency of tube displacement, ease of insertion, quality of lung collapse, postoperative complaints, and airway injuries. RESULTS: Time [mean (SD)] to successful intubation was significantly faster with the VivaSight DLT [63 (58) sec] compared with the conventional DLT [97 (84) sec; P = 0.03]. The VivaSight DLTs were correctly inserted during all attempts. When malpositioning of the VivaSight DLT occurred, it was easily remedied, even in the lateral position. The devices were comparable with respect to postoperative coughing, hoarseness, and sore throat. Airway injuries tended to be more common with the VivaSight DLT, although this study was underpowered for airway injuries. CONCLUSION: The VivaSight DLT camera allowed faster insertion and facilitated initial positioning. It also confirmed proper tube positioning intraoperatively and facilitated repositioning when necessary. This trial was registered at clinicaltrials.gov: NCT01807676.