RESUMO
BACKGROUND: It is not certain whether the blade geometry of videolaryngoscopes, either a hyperangulated or Macintosh shape, affects glottic view, success rate and/or tracheal intubation time in patients with expected difficult airways. We hypothesised that using a hyperangulated videolaryngoscope blade would visualise a higher percentage of glottic opening compared with a Macintosh videolaryngoscope blade in patients with expected difficult airways. METHODS: We conducted an open-label, patient-blinded, randomised controlled trial in adult patients scheduled to undergo elective ear, nose and throat or oral and maxillofacial surgery, who were anticipated to have a difficult airway. All airway operators were consultant anaesthetists. Patients were allocated randomly to tracheal intubation with either hyperangulated (C-MAC D-BLADE™) or Macintosh videolaryngoscope blades (C-MAC™). The primary outcome was the percentage of glottic opening. First attempt success was designated a key secondary outcome. RESULTS: We assessed 2540 adults scheduled for elective head and neck surgery for eligibility and included 182 patients with expected difficult airways undergoing orotracheal intubation. The percentage of glottic opening visualised, expressed as median (IQR [range]), was 89 (69-99 [0-100])% with hyperangulated videolaryngoscope blades and 54 (9-90 [0-100])% with Macintosh videolaryngoscope blades (p < 0.001). First-line hyperangulated videolaryngoscopy failed in one patient and Macintosh videolaryngoscopy in 12 patients (13%, p = 0.002). First attempt success rate was 97% with hyperangulated videolaryngoscope blades and 67% with Macintosh videolaryngoscope blades (p < 0.001). CONCLUSIONS: Glottic view and first attempt success rate were superior with hyperangulated videolaryngoscope blades compared with Macintosh videolaryngoscope blades when used by experienced anaesthetists in patients with difficult airways.
Assuntos
Manuseio das Vias Aéreas , Intubação Intratraqueal , Laringoscópios , Laringoscopia , Humanos , Laringoscopia/métodos , Laringoscopia/instrumentação , Masculino , Feminino , Pessoa de Meia-Idade , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Adulto , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/instrumentação , Idoso , Gravação em Vídeo , Glote , Desenho de Equipamento , Método Simples-Cego , Técnicas e Procedimentos Assistidos por VídeoRESUMO
This review aims to assess the published evidence on airway management with a supraglottic airway device (SGA) for general anaesthesia in patients requiring a caesarean section. Physiological changes during pregnancy can make airway management in parturients challenging. At the same time, pregnant patients are at risk of pulmonary aspiration due to hormonal and mechanical alterations. The standard airway management for parturients undergoing caesarean section is rapid sequence induction followed by tracheal intubation. Evidence exists that using second-generation SGA devices is well tolerated and effective in selected patients. In this review, we provide an overview of the existing evidence and provide an algorithm to make an evidence-based clinical decision on the use of SGA devices. An online literature search was performed in Medline, Embase, PubMed, Emcare, Cochrane Library and CINAHL. The search terms used were 'supraglottic airway', 'supraglottic airway device', 'supraglottic airway management', 'supraglottic tube', 'i-gel', laryngeal mask', 'laryngeal mask airway', 'LMA', 'SGA', 'Proseal', 'Supreme', 'obstetric surgery', 'obstetric operation', 'general anaesthesia', 'caesarean' or 'caesarean section', 'abdominal delivery'. Full-text articles in English, Dutch and French were included. Case reports and studies in which the surgery was not a caesarean section were excluded. The initial search yielded 815 results. Following screening, deduplication and removal of publications that were unrelated to the topic or did not fit the inclusion criteria, 13 manuscripts were included in our analysis. A total of 7722 patients were described in the articles included. In the majority of manuscripts, second-generation SGA devices were used. There were seven cases of failed insertion and a need for conversion to tracheal intubation; first-generation SGA devices were used in these cases. There were no cases of pulmonary aspiration, and only one case of gastric regurgitation was described. Growing evidence suggests that the use of second-generation SGA devices might be well tolerated as the primary method for securing the airway for caesarean sections requiring general anaesthesia, in selected patients with a low risk for aspiration and difficult intubation.
Assuntos
Manuseio das Vias Aéreas , Algoritmos , Anestesia Geral , Anestesia Obstétrica , Cesárea , Intubação Intratraqueal , Máscaras Laríngeas , Humanos , Feminino , Gravidez , Anestesia Geral/métodos , Anestesia Geral/instrumentação , Anestesia Obstétrica/métodos , Anestesia Obstétrica/instrumentação , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/instrumentação , Intubação Intratraqueal/métodos , Intubação Intratraqueal/instrumentaçãoRESUMO
BACKGROUND: Atelectasis has been reported in 68 to 100% of children undergoing general anaesthesia, a phenomenon that persists into the recovery period. Children receiving recruitment manoeuvres have less atelectasis and fewer episodes of oxygen desaturation during emergence. The optimal type of recruitment manoeuvre is unclear and may be influenced by the airway device chosen. OBJECTIVE: We aimed to investigate the different effects on lung mechanics as assessed by the forced oscillation technique (FOT) utilising different recruitment strategies: repeated inflations vs. one sustained inflation and different airway devices, a supraglottic airway device vs. a cuffed tracheal tube. DESIGN: Pragmatic enrolment with randomisation to the recruitment strategy. SETTING: We conducted this single-centre trial between February 2020 and March 2022. PARTICIPANTS: Seventy healthy patients (53 boys) aged between 2 and 16âyears undergoing general anaesthesia were included. INTERVENTIONS: Forced oscillations (5âHz) were superimposed on the ventilator waveform using a customised system connected to the anaesthesia machine. Pressure and flow were measured at the inlet of the airway device and used to compute respiratory system resistance and reactance. Measurements were taken before and after recruitment, and again at the end of surgery. MAIN OUTCOME MEASURES: The primary endpoint measured is the change in respiratory reactance. RESULTS: Statistical analysis (linear model with recruitment strategy and airway device as factors) did not show any significant difference in resistance and reactance between before and after recruitment. Baseline reactance was the strongest predictor for a change in reactance after recruitment: prerecruitment Xrs decreased by mean (standard error) of 0.25 (0.068)âcmH 2 Oâsâl -1 per â1âcmH 2 O -1 âsâl -1 increase in baseline Xrs ( P â<â0.001). After correcting for baseline reactance, the change in reactance after recruitment was significantly lower for sustained inflation compared with repeated inflation by mean (standard error) 0.25 (0.101)âcmH 2 O ( P â=â0.0166). CONCLUSION: Although there was no significant difference between airway devices, this study demonstrated more effective recruitment via repeated inflations than sustained inflation in anaesthetised children. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12619001434189.
Assuntos
Anestesia Geral , Mecânica Respiratória , Humanos , Anestesia Geral/instrumentação , Anestesia Geral/métodos , Criança , Masculino , Feminino , Adolescente , Pré-Escolar , Mecânica Respiratória/fisiologia , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Pulmão/fisiologia , Atelectasia Pulmonar/prevenção & controle , Atelectasia Pulmonar/etiologia , Atelectasia Pulmonar/fisiopatologia , Respiração Artificial/instrumentação , Respiração Artificial/métodosRESUMO
OBJECTIVE: The i-gel supraglottic airway device (Intersurgical, Berkshire, UK) is commonly used in the United States and worldwide for prehospital airway management. Previous research has suggested that a sex-based method of size selection (4.0 for female patients and 5.0 for male patients) is superior to a weight-based method in patients undergoing elective anesthesia. Our objective was to compare a sex-based i-gel size selection strategy with a weight-based strategy using real-world prehospital data. METHODS: The ESO Data Collaborative 2018 to 2022 dataset was used. All initial i-gel insertion attempts in patients > 18 years of age were evaluated for inclusion. Insertion attempts were excluded if age, sex, weight, success, or device size was not documented. Logistic regression was used to compare the rate of insertion failure on the first attempt for the group placed in alignment with the weight-based but not sex-based method with the group placed in alignment with the sex-based but not weight-based method. RESULTS: After the application of the exclusion criteria, 39,867 initial i-gel insertion attempts were included. The overall rate of failure was 6.5% (2,585/39,867). The rate of unsuccessful i-gel placement was similar when i-gel devices were placed in alignment with a sex-based size selection method in comparison to i-gel placement in alignment with a weight-based selection strategy (6.0% vs. 6.4%). Logistic regression analysis did not reveal a significant difference between groups (odds ratio: 1.08; 95% confidence interval: 0.95-1.23). CONCLUSION: The use of a sex-based method of i-gel size selection may be equivalent with respect to the rate of unsuccessful i-gel placement on the first attempt in comparison to a weight-based method.
Assuntos
Serviços Médicos de Emergência , Humanos , Masculino , Feminino , Serviços Médicos de Emergência/métodos , Pessoa de Meia-Idade , Adulto , Idoso , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/instrumentação , Máscaras Laríngeas , Intubação Intratraqueal/métodos , Intubação Intratraqueal/instrumentação , Fatores Sexuais , Estudos RetrospectivosRESUMO
Difficult airway management poses a great challenge for clinicians, especially if it is unanticipated. Numerous guidelines and a wide array of devices constitute the anesthesiologist's armamentarium for managing the airway. When the use of individual devices fails, the use of combination techniques is advised. We present a case of difficult intubation in a 50-year-old male patient scheduled for aortic valve replacement. He had no prior history of difficult airway management, and no abnormalities were detected on preoperative airway assessment. Body mass index was 29 kg/m2. After the separate use of direct laryngoscopy, videolaryngoscopy and a BONFILS intubation endoscope (BIE) had failed, we resorted to a combination technique, combining videolaryngoscopy and BIE. While the videolaryngoscope provided the space needed for BIE and visual guidance through copious secretions, the BIE served as a stylet for endotracheal tube guidance, leading to successful intubation. Since the technique requires costly equipment, experience in handling it and at least two operators, it is more appropriate as a rescue measure than an elective procedure. Given the potentially disastrous outcomes of failed intubation, mastering advanced airway management techniques remains of vital importance, and the combination technique is one of them.
Assuntos
Intubação Intratraqueal , Laringoscópios , Laringoscopia , Humanos , Masculino , Pessoa de Meia-Idade , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Laringoscopia/instrumentação , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/instrumentação , Técnicas e Procedimentos Assistidos por VídeoRESUMO
We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway management are published and revised regularly, uniform implementation of such guidelines are applied sporadically throughout the hospital and prehospital settings. The primary roles of an Airway Lead are to ensure supply, quality and storage of airway equipment, promote the use of current practice guidelines as well as the organisation of training and audits. Locally, the Airway Lead may chair a multi-disciplinary airway committee within their organisation; an Airway Lead Network enables Airway Leads to share common problems and solutions to promote optimal airway management on a national level. Support from governing bodies is an essential part of this structure.
Assuntos
Manuseio das Vias Aéreas/normas , Segurança do Paciente , Guias de Prática Clínica como Assunto , Manuseio das Vias Aéreas/instrumentação , Hospitais , HumanosRESUMO
Different introducers are available to assist with tracheal intubation. Subtle differences in the design of introducers can have a marked effect on safety and performance. The Difficult Airway Society's Airway Device Evaluation Project Team proposal states that devices should only be purchased for which there is at least a case-control study on patients assessing airway devices. However, resources are not currently available to carry out a case-control study on all introducers available on the market. This study comprised a laboratory and manikin-based investigation to identify introducers that could be suitable for clinical investigation. We included six different introducers in laboratory-based assessments (design characteristics) and manikin-based assessments involving the participation of 30 anaesthetists. Each anaesthetist attempted placement in the manikin's trachea with each of the six introducers in a random order. Outcomes included first-time insertion success rate; insertion success rate; number of attempts; time to placement; and distance placed. Each anaesthetist also completed a questionnaire. First-time insertion success rate depended significantly on the introducer used (p = 0.0016) and varied from 47% (Armstrong and P3) to 77% (Intersurgical and Frova). Median time to placement (including oesophageal placement) varied from 10 s (Eschmann and Frova) to 20 s (P3) (p = 0.0025). Median time to successful placement in the trachea varied from 9 s (Frova) to 22 s (Armstrong) (p = 0.037). We found that the Armstrong and P3 devices were not as acceptable as other introducers and, without significant improvements to their design and characteristics, the use of these devices in studies on patients is questionable. The study protocol is suitable for differentiating between different introducers and could be used as a basis for assessing other types of devices.
Assuntos
Manuseio das Vias Aéreas/normas , Anestesistas/normas , Desenho de Equipamento/normas , Intubação Intratraqueal/normas , Manequins , Inquéritos e Questionários , Manuseio das Vias Aéreas/instrumentação , Competência Clínica/normas , Desenho de Equipamento/instrumentação , Humanos , Intubação Intratraqueal/instrumentação , Traqueia/anatomia & histologiaRESUMO
BACKGROUND: Endotracheal intubation (ETI) is still the gold standard of airway management, but in cases of sudden cardiac arrest in patients with suspected SARS-CoV-2 infection, ETI is associated with risks for both the patient and the medical personnel. We hypothesized that the Vie Scope® is more useful for endotracheal intubation of suspected or confirmed COVID-19 cardiac arrest patients than the conventional laryngoscope with Macintosh blade when operators are wearing personal protective equipment (PPE). METHODS: Study was designed as a prospective, multicenter, randomized clinical trial performed by Emergency Medical Services in Poland. Patients with suspected or confirmed COVID-19 diagnosis who needed cardiopulmonary resuscitation in prehospital setting were included. Patients under 18 years old or with criteria predictive of impossible intubation under direct laryngoscopy, were excluded. Patients were randomly allocated 1:1 to Vie Scope® versus direct laryngoscopy with a Macintosh blade. Study groups were compared on success of intubation attempts, time to intubation, glottis visualization and number of optimization maneuvers. RESULTS: We enrolled 90 out-of-hospital cardiac arrest (OHCA) patients, aged 43-92 years. Compared to the VieScope® laryngoscope, use of the Macintosh laryngoscope required longer times for tracheal intubation with an estimated mean difference of -48 s (95%CI confidence interval [CI], -60.23, -35.77; p < 0.001). Moreover VieScope® improved first attempt success rate, 93.3% vs. 51.1% respectively (odds ratio [OR] = 13.39; 95%CI: 3.62, 49.58; p < 0.001). CONCLUSIONS: The use of the Vie Scope® laryngoscope in OHCA patients improved the first attempt success rate, and reduced intubation time compared to Macintosh laryngoscope in paramedics wearing PPE for against aerosol generating procedures. TRIAL REGISTRATION: ClinicalTrials registration number NCT04365608.
Assuntos
Pessoal Técnico de Saúde/estatística & dados numéricos , Intubação Intratraqueal/instrumentação , Laringoscópios/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/estatística & dados numéricos , Pessoal Técnico de Saúde/normas , Feminino , Humanos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/estatística & dados numéricos , Laringoscópios/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Equipamento de Proteção Individual/efeitos adversos , Equipamento de Proteção Individual/normas , Equipamento de Proteção Individual/estatística & dados numéricos , Estudos Prospectivos , Ressuscitação/instrumentação , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricosRESUMO
BACKGROUND: We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes. METHODS: We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used. RESULTS: Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively). CONCLUSIONS: In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.
Assuntos
Extubação/métodos , Manuseio das Vias Aéreas , Anestesia Geral/métodos , Hipóxia/prevenção & controle , Intubação Intratraqueal/métodos , Cuidados Pós-Operatórios/métodos , Adulto , Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Anestesiologia , Estudos de Coortes , Feminino , Humanos , Hipóxia/etiologia , Laringoscopia , Masculino , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Fármacos Neuromusculares não Despolarizantes/uso terapêutico , Estudos Retrospectivos , Risco , Adulto JovemRESUMO
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and the difficult airway is perhaps the anesthesiologists' quintessential concern. OSA and the difficult airway share certain similar anatomical, morphological, and physiological features. Individual studies and systematic reviews of retrospective, case-control, and large database studies have shown a likely association between patients with OSA and the difficult airway; OSA patients have a 3- to 4-fold higher risk of difficult intubation, difficult mask ventilation, or a combination of both. The presence of OSA should initiate proactive perioperative management in anticipation of a difficult airway. Prudent intraoperative management comprises the use of regional anesthesia where possible and considering an awake intubation technique where there is the presence of notable difficult airway predictors and risk of rapid desaturation following induction of general anesthesia. Familiarity with difficult airway algorithms, cautious extubation, and appropriate postoperative monitoring of patients with OSA are necessary to mitigate perioperative risks.
Assuntos
Manuseio das Vias Aéreas , Anestesia , Pulmão/fisiopatologia , Respiração , Apneia Obstrutiva do Sono/fisiopatologia , Sono , Procedimentos Cirúrgicos Operatórios , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/instrumentação , Anestesia/efeitos adversos , Tomada de Decisão Clínica , Humanos , Intubação Intratraqueal , Máscaras Laríngeas , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Respiração Artificial , Medição de Risco , Fatores de Risco , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/diagnóstico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Patients with obstructive sleep apnea syndrome (OSAS) experience excessive daytime sleepiness and insomnia and they are at risk of developing cardiovascular disease and stroke. Continuous positive airway pressure therapy could improve symptoms and decrease these risks; however, adherence is problematic. Although the oral appliance is another therapeutic option, patient satisfaction is limited and the effect of the nasal airway stent - a new device - remains unclear. OBJECTIVES: The aim of this study was to evaluate the effect of NAS therapy in patients with mild-to-moderate OSAS in a prospective, single-arm, interventional pilot study. METHOD: Patients with mild/moderate sleep apnea (n = 71; Apnea-Hypopnea Index [AHI], 5-20 events/h on polysomnography) were recruited. Sleep-associated events were measured using a portable device (WatchPAT200) pre- and immediately post-treatment and at 1 month follow-up. AHI (including supine and non-supine AHI), Oxygen Desaturation Index (ODI), Respiratory Disturbance Index (RDI), percutaneous oxygen saturation, heart rate, and snore volume were evaluated. Symptoms were assessed using the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Hospital Anxiety and Depression Scale. RESULTS: NAS use significantly improved AHI, supine AHI, RD, ODI, and snore volume compared to pre-intervention (r = 0.44, 0.48, 0.3, 0.42, and 0.34; p < 0.001, p < 0.001, p = 0.011, p < 0.001, and p = 0.048, respectively). Additionally, 25 and 10% of patients showed complete and partial response for AHI, respectively; these improvements remained significant 1 month later. Pittsburgh Sleep Quality Index scores improved from 6.0 to 5.3 (r = 0.46, p = 0.022). CONCLUSIONS: NAS therapy reduced severity and snoring in patients with mild-to-moderate OSAS. Approximately 30% of patients did not tolerate NAS due to side effects.
Assuntos
Manuseio das Vias Aéreas , Apneia Obstrutiva do Sono , Ronco , Stents , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Distúrbios do Sono por Sonolência Excessiva/diagnóstico , Distúrbios do Sono por Sonolência Excessiva/etiologia , Distúrbios do Sono por Sonolência Excessiva/terapia , Feminino , Determinação da Frequência Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Consumo de Oxigênio , Projetos Piloto , Polissonografia/métodos , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Apneia Obstrutiva do Sono/terapia , Distúrbios do Início e da Manutenção do Sono/diagnóstico , Distúrbios do Início e da Manutenção do Sono/etiologia , Distúrbios do Início e da Manutenção do Sono/terapia , Qualidade do Sono , Ronco/diagnóstico , Ronco/etiologia , Ronco/terapia , Resultado do TratamentoRESUMO
Endoscopic optical coherence tomography of large airways poses unique challenges. A hybrid lens is described that consists of a section of coreless fiber and graded index fiber (GIF), followed by a ball lens section. This design produces low numerical aperture beams better suited for large airway imaging. The performance of this lens is compared against conventional GIF and ball lens designs. Forward- and side-viewing probes were modeled, fabricated, and tested. The impact of a sheath on the beam profile was also investigated. Probes with working distances larger than 10 mm and depth-of-focus exceeding 12 mm are demonstrated with the proposed design.
Assuntos
Endoscopia/instrumentação , Lentes , Fibras Ópticas , Tomografia de Coerência Óptica/instrumentação , Manuseio das Vias Aéreas/instrumentação , Desenho de Equipamento , Humanos , Distribuição Normal , RefratometriaRESUMO
BACKGROUND: VieScope is a new type of laryngoscope, with a straight, transparent and illuminated blade, allowing for direct line of sight towards the larynx. In addition, VieScope is disposed of after single patient use, which can avoid cross-contaminations of contagious material. This has gained importance especially when treating patients with highly contagious infectious diseases, such as during the SARS-CoV2 pandemic. In this context, VieScope has not been evaluated yet in a clinical study. MATERIAL AND METHODS: This study compared intubation with VieScope to video-laryngoscopy (GlideScope) in normal and difficult airway in a standardized airway manikin in a randomized controlled simulation trial. Thirty-five medical specialists were asked to perform endotracheal intubation in full personal protective equipment (PPE). Primary endpoint was correct tube position. First-pass rate (i.e., success rate at the first attempt), time until intubation and time until first correct ventilation were registered as secondary endpoints. RESULTS: For correct tracheal tube placement, there was no significant difference between VieScope and GlideScope in normal and difficult airway conditions. VieScope had over 91% fist-pass success rate in normal airway setting. VieScope had a comparable success rate to GlideScope in difficult airway, but had a significantly longer time until intubation and time until ventilation. CONCLUSION: VieScope and GlideScope had high success rates in normal as well as in difficult airway. There was no unrecognized esophageal intubation in either group. Overall time for intubation was longer in the VieScope group, though in an acceptable range given in literature. Results from this simulation study suggest that VieScope may be an acceptable alternative for tracheal intubation in full PPE. TRIAL REGISTRATION: The study was registered at the German Clinical Trials Register www.drks.de (Registration date: 09/11/2020; TrialID: DRKS00023406 ).
Assuntos
Manuseio das Vias Aéreas/métodos , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Equipamento de Proteção Individual , Adulto , Manuseio das Vias Aéreas/instrumentação , Equipamentos Descartáveis , Desenho de Equipamento , Feminino , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Intubação Intratraqueal/instrumentação , Laringoscopia/instrumentação , Masculino , Manequins , Pessoa de Meia-Idade , Fatores de Tempo , Gravação em VídeoRESUMO
OBJECTIVES: The objective of this study was to compare paediatric emergency airway management strategies in the simulation lab and operating room environments. METHODS: This was a two-part cluster cross-over randomised trial including simulation lab and operating room environments conducted between January 2017 and June 2018 in Portland, Oregon, USA. In simulated infant cardiac arrests, paramedic students placed an endotracheal tube, an i-gel or a laryngeal mask airway in random order. In the operating room, paramedic students placed a laryngeal mask airway or i-gel device in random order in sequential patients. The primary outcome for both portions of the study was time to ventilation. In the operating room portion, we also evaluated leak pressures and average initial tidal volumes. RESULTS: There were 58 paramedic students who participated in the simulation lab and 22 who participated in the operating room study. The mean time to airway placement in the simulation lab was 48.5 s for the i-gel, 68.9 s for the laryngeal mask and 129.5 s for the endotracheal tube. In the operating room, mean time to i-gel placement was 34.3 s with 45.2 s for the laryngeal mask. In multivariable analysis of the simulation study, the laryngeal mask and i-gel were significantly faster than the endotracheal tube, and the i-gel was faster than the laryngeal mask. In the operating room, there was no significant difference in time to placement, leak pressure and average volume of the first five breaths between the i-gel and laryngeal mask. CONCLUSIONS: We found that paramedic students were able to place supraglottic devices rapidly with high success rates in simulation lab and operating room environments. Supraglottic devices, particularly the i-gel, were rated as easy to use. The i-gel may be easiest to use since it lacks an inflable cuff and requires fewer steps to place.
Assuntos
Manuseio das Vias Aéreas/instrumentação , Pessoal Técnico de Saúde/educação , Parada Cardíaca/terapia , Salas Cirúrgicas , Treinamento por Simulação , Criança , Estudos Cross-Over , Feminino , Humanos , Intubação Intratraqueal/métodos , Máscaras Laríngeas , Masculino , ManequinsRESUMO
BACKGROUND: Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion. METHODS: All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD's. RESULTS: Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients. CONCLUSIONS: Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.
Assuntos
Manuseio das Vias Aéreas/instrumentação , Intubação Intratraqueal/instrumentação , Parada Cardíaca Extra-Hospitalar , Adulto , Humanos , Noruega , Parada Cardíaca Extra-Hospitalar/terapia , Estudos ProspectivosRESUMO
Although 1st and 2nd generation supraglottic airway devices (SADs) have many desirable features, they are nevertheless inserted in a similar 'blind' way as their 1st generation predecessors. Clinicians mostly still rely entirely on subjective indirect assessments to estimate correct placement which supposedly ensures a tight seal. Malpositioning and potential airway compromise occurs in more than half of placements. Vision-guided insertion can improve placement. In this article we propose the development of a 3rd generation supraglottic airway device, equipped with cameras and fiberoptic illumination, to visualise insertion of the device, enable immediate manoeuvres to optimise SAD position, verify whether correct 1st and 2nd seals are achieved and check whether size selected is appropriate. We do not provide technical details of such a '3rd generation' device, but rather present a theoretical analysis of its desirable properties, which are essential to overcome the remaining limitations of current 1st and 2nd generation devices. We also recommend that this further milestone improvement, i.e. ability to place the SAD accurately under direct vision, be eligible for the moniker '3rd generation'. Blind insertion of SADs should become the exception and we anticipate, as in other domains such as central venous cannulation and nerve block insertions, vision-guided placement becoming the gold standard.
Assuntos
Manuseio das Vias Aéreas/instrumentação , Desenho de Equipamento , Glote , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Manuseio das Vias Aéreas/tendências , Tecnologia de Fibra Óptica , Humanos , Intubação Intratraqueal/tendências , Visão OcularRESUMO
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.
Assuntos
Manuseio das Vias Aéreas/instrumentação , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/psicologia , Emergências , Humanos , Laringe , Pescoço , TraqueiaRESUMO
Exposure of healthcare providers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a significant safety concern during the coronavirus disease 2019 (COVID-19) pandemic, requiring contact/droplet/airborne precautions. Because of global shortages, limited availability of personal protective equipment (PPE) has motivated the development of barrier-enclosure systems, such as aerosol boxes, plastic drapes, and similar protective systems. We examined the available evidence and scientific publications about barrier-enclosure systems for airway management in suspected/confirmed COVID-19 patients. MEDLINE/Embase/Google Scholar databases (from December 1, 2019 to May 27, 2020) were searched for all articles on barrier enclosures for airway management in COVID-19, including references and websites. All sources were reviewed by a panel of experts using a Delphi method with a modified nominal group technique. Fifty-two articles were reviewed for their results and level of evidence regarding barrier device feasibility, advantages, protection against droplets and aerosols, effectiveness, safety, ergonomics, and cleaning/disposal. The majority of analysed papers were expert opinions, small case series, technical descriptions, small-sample simulation studies, and pre-print proofs. The use of barrier-enclosure devices adds to the complexity of airway procedures with potential adverse consequences, especially during airway emergencies. Concerns include limitations on the ability to perform airway interventions and the aid that can be delivered by an assistant, patient injuries, compromise of PPE integrity, lack of evidence for added protection of healthcare providers (including secondary aerosolisation upon barrier removal), and lack of cleaning standards. Enclosure barriers for airway management are no substitute for adequate PPE, and their use should be avoided until adequate validation studies can be reported.
Assuntos
Aerossóis , Manuseio das Vias Aéreas/instrumentação , Infecções por Coronavirus/terapia , Isolamento de Pacientes/instrumentação , Pneumonia Viral/terapia , Manuseio das Vias Aéreas/métodos , COVID-19 , Humanos , Controle de Infecções , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias , Isolamento de Pacientes/métodos , Equipamento de Proteção IndividualRESUMO
BACKGROUND: Age-related changes in upper airway anatomy may affect the overall performance of supraglottic airways significantly. The clinical performance of the i-gel and the self-pressurized air-Q intubating laryngeal airways with noninflatable cuffs for elderly populations remains unknown, unlike in children. Thus, we performed a prospective, randomized comparison of these 2 supraglottic airways in elderly patients undergoing general anesthesia. METHODS: We recruited 100 patients, 65-90 years of age, who were scheduled for elective surgery under general anesthesia with muscle relaxation. The enrolled patients were allocated to the i-gel or self-pressurized air-Q group. We assessed oropharyngeal leak pressure as the primary outcome and fiberoptic view after placement and fixation of the airway and at 10 minutes after the initial assessment. The fiberoptic view was scored using a 5-point scale as follows: vocal cords not visible; vocal cords and anterior epiglottis visible, >50% visual obstruction of epiglottis to vocal cords; vocal cords and anterior epiglottis visible, <50% visual obstruction of epiglottis to vocal cords; vocal cords and posterior epiglottis visible; and vocal cords visible. We also investigated success rate and ease of insertion, insertion time, and manipulations during insertion as insertion variables, complications during maintenance and emergence periods, and postoperative pharyngolaryngeal complications including sore throat, dysphagia, and dysphonia. RESULTS: After assessing for eligibility, 48 patients were allocated to each group. Oropharyngeal leak pressures were significantly higher in the i-gel group than in the self-pressurized air-Q group (P < .001) at the 2 measurement points. The raw mean difference at initial assessment and the median difference after 10 minutes were 5.5 cm H2O (95% confidence interval, 3.3-7.6 cm H2O) and 5.0 (95% confidence interval, 2.0-7.0 cm H2O), respectively. The initial scores of fiberoptic view were similar in the 2 groups. However, the self-pressurized air-Q supraglottic airway provided a significantly improved fiberoptic view at 10 minutes after initial assessment (P = .030). We found no statistically significant differences in insertion variables and complications between the 2 groups. CONCLUSIONS: The i-gel provided better sealing function than the self-pressurized air-Q supraglottic airway according to the high oropharyngeal leak pressures in elderly patients during general anesthesia. The self-pressurized air-Q supraglottic airway had improved fiberoptic views in elderly patients during general anesthesia.
Assuntos
Manuseio das Vias Aéreas/normas , Anestesia Geral/normas , Intubação Intratraqueal/normas , Máscaras Laríngeas/normas , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/instrumentação , Anestesia Geral/instrumentação , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Masculino , Estudos ProspectivosRESUMO
BACKGROUND: The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA). METHODS: Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI. RESULTS: Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001). CONCLUSIONS: Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.