A new model of endotracheal tube biofilm identifies combinations of matrix-degrading enzymes and antimicrobials able to eradicate biofilms of pathogens that cause ventilator-associated pneumonia.

Ventilator-associated pneumonia is defined as pneumonia that develops in a patient who has been on mechanical ventilation for more than 48 hours through an endotracheal tube. It is caused by biofilm formation on the indwelling tube, which introduces pathogenic microbes such as Pseudomonas aeruginosa, Klebsiella pneumoniae and Candida albicans into the patient's lower airways. Currently, there is a lack of accurate in vitro models of ventilator-associated pneumonia development. This greatly limits our understanding of how the in-host environment alters pathogen physiology and the efficacy of ventilator-associated pneumonia prevention or treatment strategies. Here, we showcase a reproducible model that simulates the biofilm formation of these pathogens in a host-mimicking environment and demonstrate that the biofilm matrix produced differs from that observed in standard laboratory growth medium. In our model, pathogens are grown on endotracheal tube segments in the presence of a novel synthetic ventilated airway mucus medium that simulates the in-host environment. Matrix-degrading enzymes and cryo-scanning electron microscopy were employed to characterize the system in terms of biofilm matrix composition and structure, as compared to standard laboratory growth medium. As seen in patients, the biofilms of ventilator-associated pneumonia pathogens in our model either required very high concentrations of antimicrobials for eradication or could not be eradicated. However, combining matrix-degrading enzymes with antimicrobials greatly improved the biofilm eradication of all pathogens. Our in vitro endotracheal tube model informs on fundamental microbiology in the ventilator-associated pneumonia context and has broad applicability as a screening platform for antibiofilm measures including the use of matrix-degrading enzymes as antimicrobial adjuvants.

The effects of laryngeal mask versus endotracheal tube on atelectasis after general anesthesia induction assessed by lung ultrasound: A randomized controlled trial.

STUDY OBJECTIVE: This study aims to evaluate the impact of Supreme™ laryngeal masks versus endotracheal tubes on atelectasis during general anesthesia using lung ultrasound (LUS), and provide evidence for respiratory management. DESIGN: A single-center, double-blind, randomized controlled trial was conducted. SETTING: The study was conducted in both the operating room and the post-anesthesia care unit, with follow-up assessments performed in the ward. PATIENTS: Enrollment included 180 cases undergoing non-laparoscopic surgeries in gynecology, urology, and orthopedic limb surgeries. INTERVENTIONS: Patients were randomly assigned 1:1 to the endotracheal intubation or laryngeal mask group. MEASUREMENTS: LUS scores were recorded across 12 lung regions at baseline, 15 min after airway establishment, at the end of surgery, and 30 min following airway removal. Outcome measures encompassed the oxygenation index, dynamic lung compliance, incidence of postoperative pulmonary complications, throat pain, and other postoperative complications assessed at 24 and 48 h postoperatively. The primary outcome focused on the LUS score in all 12 lung regions at 15 min after airway establishment. MAIN RESULTS: Intention-to-treat analysis of 177 subjects revealed endotracheal intubation led to significantly higher LUS scores at 15 min {P < 0.001, mean difference 4.15 ± 0.60, 95% CI [2.97, 5.33]}, end of surgery (P < 0.001, mean difference 3.37 ± 0.68, 95% CI [2.02, 4.72]), and 30 min post-removal (P < 0.001, mean difference 2.63 ± 0.48, 95% CI [1.68, 3.58]). No major complications occurred in the two groups. CONCLUSIONS: Compared to endotracheal intubation, laryngeal masks effectively reduce atelectasis formation and progression in gynecological, urological non-laparoscopic, and orthopedic limb surgeries. However, caution is warranted when generalizing these findings to surgeries with a higher risk of laryngeal mask leakage or obese patients. Additionally, the efficacy of laryngeal masks in reducing postoperative atelectasis remains uncertain when comprehensive monitoring of muscle relaxation and reversal therapy is employed.

Comparison of two different positions of an anaesthesiologist for ease of endotracheal intubation in adult patients: A randomised control trial.

BACKGROUND AND AIMS: Maintaining the airway with a cuffed endotracheal tube (ETT) in the trachea remains one of the most essential anaesthesia skills. Many parameters were described to assess the difficulty of intubation in the preoperative period, but none allow the prediction of all difficult intubations. The correct posture of the anaesthesiologist is also an important factor for successful endotracheal intubation. The aim of this study was. This study aimed to compare the impact of two different positions of an anaesthesiologist (sitting vs. standing) at the time of endotracheal intubation. METHODS: One hundred ten American Society of Anaesthesiologists (ASA) Physical Status I/II patients, aged between 17 to 65 years, Mallampati grade I/II, mouth opening 39-70 mm, thyromental distance (TMD) 6-6.5 cm, and sternomental distance (SMD) >13 cm, scheduled for elective laparoscopic cholecystectomy, were recruited. Patients were divided into two groups; Group I consisted of patients who underwent endotracheal intubation by an anaesthesiologist in a sitting posture, while Group II encompassed patients who underwent endotracheal intubation by anaesthesiologists in a standing posture. Assessment parameters include ease of intubation (IDS score), intubation time, intubation success rate, number of attempts, grade of laryngoscopy (Cormack Lehane score, POGO score), and complications like tooth and soft tissue damage. RESULTS: The ease of intubation was higher in group I, 1(0-1), than in group II, 1(1-2) (p = 0.02), and there was a significant difference between the two groups. The Cormack Lehane grade (CL) was I/IIa/IIb/III in 19/23/13/0 in group I and I/IIa/IIb/III in 13/21/18/3 in group II. The first-attempt intubation success rate for groups I and II was 94.54 % and 92.72 % respectively. CONCLUSION: The sitting posture of an anaesthesiologist at the time of laryngoscopy provides a better intubating condition when compared with the standing posture. REGISTRATION: Clinical Trial Registry - India (CTRI) CTRI/2023/03/050371.

An intubation technique using hyperangulated video laryngoscopy and a DuCanto suction catheter preloaded with a bougie: A case report with a video demonstration.

Video laryngoscopy outperforms direct laryngoscopy for successful orotracheal intubation in the emergency department. When performing video laryngoscopy, emergency physicians may use a standard geometry blade or a hyperangulated blade. Hyperangulated video laryngoscopy is easier when using a rigid hyperangulated stylet instead of a standard malleable stylet. The angulation of the hyperangulated blade makes it difficult to use an endotracheal tube (ETT) introducer ("bougie"). We describe a case report using a DuCanto suction catheter (SSCOR) with a preloaded bougie to perform orotracheal intubation during hyperangulated video laryngoscopy. An adult patient presented to the emergency department in status epilepticus and was intubated for airway protection. Hyperangulated video laryngoscopy was performed with a LoPro S4 (GlideScope) blade; a DuCanto suction catheter was used to deliver a bougie through the vocal cords. The bougie was advanced down the trachea, and the DuCanto suction catheter was removed. The bougie successfully delivered a size 8.0 ETT. Visualization of the larynx with hyperangulated video laryngoscopy is usually easy, but ETT delivery into the trachea can be challenging. Rigid hyperangulated stylets were created to facilitate ETT delivery, but these stylets are expensive and often not available. Traditional teaching says that a bougie cannot be used while intubating with a hyperangulated blade. This case report describes a method to deliver a bougie via a DuCanto suction catheter during hyperangulated video laryngoscopy. It allows for the use of a bougie with a hyperangulated blade and offers a technique to perform hyperangulated video laryngoscopy without a rigid stylet.

Predicting dog tracheal diameter and length: A tool for improved intubation.

Objective: This study aims to develop formulas for estimating tracheal diameter and length in dogs using easily measurable anatomical parameters. Materials and Methods: The samples consisted of 20 dogs of various breeds, comprising 10 males and 10 females, sourced from cadavers. The measured parameters included occipital tuberosity to tail base (OT), eye angle to ear tragus, nose to ear tragus, inner vertical diameters (IVD), and tracheal length (TL). The study conducted correlation and linear regression analyses, and subsequently, the formulated models underwent validation using 16 live dogs. The results were compared to radiographic measurements. Results: Linear regression recommended formulas based on OT, resulting in IVD (mm) = 0.203 × OT - 3.724 (r2 = 0.608, p < 0.001) and TL (cm) = 0.346 × OT-3.773 (r2 = 0.837, p < 0.001). The predicted tracheal diameter and length from formulas were slightly smaller than radiographic measurements (IVD = 2.76 ± 1.85 mm, p < 0.0001 and TL = 2.07 ± 1.81 cm, p < 0.0001). Conclusion: These formulas offer a practical way to estimate tracheal dimensions in live dogs, facilitating the selection of suitable endotracheal tube sizes and insertion depth. Further studies with larger sample sizes and consistent measurement methods can enhance the accuracy of these findings.

Intravenous versus intracuff alkalinized lidocaine to prevent postoperative sore throat: a prospective randomized controlled trial.

Introduction: postoperative sore throat (POST) is a common complication after general anesthesia with endotracheal intubation caused by tracheal mucosal injury. Multiple techniques prevent postoperative sore throat (POST). Our study aimed to compare two techniques: intravenous and intracuff lidocaine versus placebo to prevent postoperative sore throat after general anesthesia with orotracheal intubation. Methods: we conducted a prospective double-blind, randomized controlled clinical trial involving patients, proposed for a scheduled surgery less than 240 minutes under general anesthesia with orotracheal intubation. Patients were divided into three groups: L group: infused with saline, cuff filled with alkalinized lidocaine. S group: Infused with 1.5 mg/kg of lidocaine, cuff filled with saline. T group: placebo: infused with saline, cuff filled with saline. Our primary outcome was the incidence of sore throat and their (visual analog scale) VAS score in the first 24 postoperative hours. Our secondary outcomes were the incidence of cough, dysphonia, dysphagia, and postoperative nausea and vomiting. Results: ninety patients were analyzed and divided into 3 groups of 30. The incidence of POST at the sixth postoperative hour, for placebo, the "L" group, and the "S" group, respectively, was 67%, 30%, and 47%. And at the 24th postoperative hours 67%, 13%, and 37%. Intravenous lidocaine reduced significantly the VAS of POST at the 24th hour (S: 6.80 ± 20.70; T: 20.67 ± 18.182; p= 0.02). Alkalinized lidocaine decreased significantly the VAS of POST in the sixth (L: 8.17 ± 22.761; T: 23 ± 21.838; p = 0.048) and the 24th postoperative hour (L: 6.33 ± 20.592; T: 20.67 ± 18.182; p= 0.019) with the lowest pain score. There was no statistically significant difference between the L and S groups at the 6 and 24 postoperative hours. Both lidocaine techniques reduced cough at emergence, with the superiority of alkalinized lidocaine (p=0.02). They decreased the incidence of cough, dysphonia, dysphagia, nausea, and vomiting compared to a placebo. Conclusion: intravenous and intracuff lidocaine allowed better control of postoperative sore throat.

Evaluating endotracheal tube length in very and extremely preterm infants.

OBJECTIVE: Our study objective was to evaluate changes in ETT tube depth throughout the initial intubation course in very and extremely preterm infants in order to evaluate the risk of outgrowing an endotracheal tube (ETT). METHODS: This was a retrospective cohort study of preterm infants born at <32 weeks of gestation who were admitted to the NICU between 2012 and 2021 and required intubation for mechanical ventilation. Infants who were intubated only for surfactant administration and those with airway malformations were excluded. Descriptive statistics were used to define the range of ETT depths at the time of extubation, stratified by gestational age (<28 weeks vs 28-32 weeks of gestation). Relative ETT depth was defined as the final depth minus the initial depth. RESULTS: Out of 496 infants, 140 patients met all criteria for inclusion. Descriptive analysis of extubation depths across the populations demonstrated median relative ETT depth of 0 cm for the 28-32-week gestational age group, and -0.25 cm for the <28-week gestational age group. The 95th percentile for both gestational age groups was a relative depth of 0.5 cm and the 99th percentile was 1.0-1.5 cm. CONCLUSION: The results of our study suggest that the vast majority of patients in the NICU are unlikely to "outgrow" ETT tube length which should be taken into account when deciding where to trim the ETT in order to minimize airway resistance.

The Complex Interplay of Variables in Extubation Decision-Making Following Pediatric Cardiac Surgery: A Narrative Review.

Pediatric cardiac surgery poses significant challenges in developing countries, where a considerable number of children require intervention for congenital heart disease (CHD). The utilization of endotracheal intubation and anesthesia is pivotal in conducting surgical or angiography procedures on patients with CHD exhibiting diverse anatomical and hemodynamic characteristics. The decision to extubate pediatric patients following cardiac surgery remains a crucial element of postoperative care. This article explores the complexities surrounding extubation decision-making in this population, emphasizing the critical role of surgical, physiological, and postoperative factors. Various preoperative and intraoperative factors influence the timing of extubation. Early extubation is increasingly prevalent, offering benefits like reduced length of stay and minimized drug exposure. Multidisciplinary collaboration and protocol-driven strategies contribute to improved extubation outcomes, emphasizing the need for a comprehensive approach in pediatric cardiac surgery. Future research can focus on the implementation and efficacy of standardized extubation procedures involving collaboration among healthcare experts.

Prevention of Oral Injuries during Endotracheal Intubation: Patients' and Anesthesiologists' Perspective.

OBJECTIVE: The aim was to design accessible, simple, inexpensive protection for teeth and soft tissues during ETI, compare damage occurrence with and without protection, and investigate post-ETI orofacial pain symptoms. MATERIALS AND METHODS: The selection procedure for adequate protection was carried out after which a reduced elastomer mouthguard was selected. Fifty patients were divided into 2 groups. In the first group, ETI was carried out using a mouthguard, while in the second group it was performed without it. The mouthguard was fabricated by anesthesiologists. After the ETI procedure, the patients and anesthesiologists were asked to complete a survey. RESULTS: No difference in intubation severity and time required for intubation between the two groups was present. Seven patients from the non-mouthguard group suffered injuries during the ETI procedure. No injuries were present in the mouthguard group. In 92% of cases anesthesiologists agreed that mouthguards should be used during ETI. However, most of them (96% of cases) agree that the mouthguard should be used only when there is an increased risk of tooth loss and/or tooth damage. There was a significant ETI effect on the emergence of new orofacial pain cases. CONCLUSION: The mouthguard adequately protected dental and soft tissues and did not affect the work of the anesthesiologist. A significantly higher number of patients experiencing temporomandibular joint and masticatory muscles pain after surgery indicates that ETI might be a risk factor for orofacial pain.

An in vitro technique to measure resistance to compression and kinking of endotracheal tubes.

Background: During intraoperative care, ventilatory parameters including peak inflating pressure (PIP) and exhaled tidal volumes are continuously monitored to assess changes in respiratory resistance and compliance. Changes in these parameters, such as an increase in PIP or a decrease in the exhaled tidal volume, may indicate various pathologic processes that may require immediate attention to prevent inadequate ventilation resulting in hypoxemia or hypercarbia. A kinked endotracheal tube (ETT) may mimic other pathologic processes including bronchospasm, mainstem intubation, or ventilator malfunction. As newer ETTs are developed, a key factor in their design should be resistance to kinking or occlusion due to patient positioning. Methods: The current project developed and describes the process for using a repeatable in vitro mechanical test to determine resistance to kinking by an ETT. Results: The mechanical testing procedure can be used to determine the compression force and distance required to kink an ETT under different conditions including temperature. The force required to induce devastating kink failure was lower during heated testing conditions. The addition of airflow through the ETTs during compression testing confirms the occurrence of airway obstruction at approximately the same time a mechanical kink is observed on the force-versus-distance curves. Conclusions: These procedures may be used to characterize and evaluate ETT designs under in vitro conditions mimicking those in the clinical practice.

Endotracheal tube cuff position in relationship to the walls of the trachea: A retrospective computed tomography-based analysis.

Background: The use of cuffed endotracheal tubes (ETTs) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: The study included patients ranging in age from 1 month to 10 years who underwent neck and chest CT imaging that required general anesthesia and endotracheal intubation. The location of the ETT and of the cuff within the airway was determined from axial CT images at three levels (proximal, middle, and distal). Anatomical orientations were tabulated, and percent chances of each orientation were determined for the ETT and the cuff. Results: The study cohort included 42 patients ranging in age from 1 to 114 months. An ETT with a polyvinylchloride cuff was used in 24 patients, and an ETT with a polyurethane cuff was used in 18 patients. The ETT was located near the posterior wall of the trachea in approximately 24-38% of patients, being most likely to be centrally located at the proximal end and at its mid-portion. The middle part of the cuff was most likely to be positioned in the mid-portion of the trachea but tended to skew anteriorly at both the proximal and distal ends. Conclusion: This is the first study using CT imaging to identify the uniformity of cuff inflation within the trachea in children. With commonly used cuffed ETTs, cuff inflation and the final position of ETT cuff within the tracheal lumen were not uniform. Future investigations are needed to determine the reasons for this asymmetry and its clinical implications.

Effectiveness of intracuff alkalinized lidocaine associated with intravenous dexamethasone in reducing laryngotracheal morbidity in children undergoing general anesthesia for tonsillectomy: a randomized controlled trial.

BACKGROUND: Postoperative sore throat is one of the main postoperative complaints in patients undergoing tonsillectomy. As the primary outcome, we aimed to determine whether endotracheal tube cuffs filled with alkalinized lidocaine are associated with a lower incidence of postoperative sore throat and anesthesia emergence phenomena in children undergoing tonsillectomy or adenotonsillectomy. We also assessed the potential additional benefits of IV dexamethasone in reducing postoperative laryngotracheal morbidity. METHODS: This is a clinical prospective, randomized, controlled trial. Patients were randomly allocated to one of four groups, as follows: air - endotracheal tube cuff filled with air; air/dex - endotracheal tube cuff filled with air and intravenous dexamethasone; lido - endotracheal tube cuff filled with alkalinized lidocaine; and lido/dex - endotracheal tube cuff filled with alkalinized lidocaine and intravenous dexamethasone. Perioperative hemodynamic parameters and the incidence of postoperative nausea and vomiting, coughing and hoarseness were recorded. Postoperative sore throat was assessed in the postanesthetic care unit and 24 hours post tracheal extubation. RESULTS: In total, 154 children aged 4-12 years, ASA physical status I or II, undergoing general anesthesia for elective tonsillectomy and adenotonsillectomy, were assessed for postoperative sore throat in this study. The incidence of postoperative sore throat 24 hours after tracheal extubation was significantly lower in the lido/dex group compared to groups air and air/dex (p = 0.01). However, no additional reduction in these symptoms was observed from the intravenous administration of dexamethasone when comparing the lido and lido/dex groups. Similarly, there were no differences among groups regarding perioperative hemodynamic variables or postoperative nausea and vomiting, coughing, and hoarseness during the study period. CONCLUSION: Intracuff alkalinized lidocaine, associated with intravenous dexamethasone, might be effective in reducing sore throat 24 hours post-tonsillectomy or adenotonsillectomy in children when compared to the use of air as the cuff insufflation media.

A Randomised Control Study Comparing Ultrasonography with Standard Clinical Methods in Assessing Endotracheal Tube Tip Positioning.

Introduction: Airway ultrasound has been increasingly used in correct positioning of endotracheal tube. We hypothesize that a safe distance between endotracheal tube tip and carina can be achieved with the aid of ultrasound. Aim of the study: Our primary objective was to determine whether ultrasound guided visualisation of proximal end of endotracheal tube cuff is better when compared to conventional method in optimal positioning of tube tip. The secondary objective was to find the optimal endotracheal tube position at the level of incisors in adult Indian population. Materials and Methods: There were 25 patients each in the conventional group and the ultrasound group. Conventional method includes auscultation and end tidal capnography. In the ultrasound group the upper end of the endotracheal tube cuff was positioned with an intent to provide 4 cm distance from the tube tip to the carina. X ray was used in both groups for confirmation of tip position and comparison between the two groups. Further repositioning of the tube was done if indicated and the mean length of the tube at incisors was then measured. Results: After x ray confirmation, endotracheal tube repositioning was required in 24% of patients in the USG group and 40 % of patients in the conventional group. However, this result was not found to be statistically significant (p = 0.364). The endotracheal tube length at the level of teeth was 19.4 ± 1.35 cm among females and 20.95 ± 1.37 cm among males. Conclusions: Ultrasonography is a reliable method to determine ETT position in the trachea. There was no statistically significant difference when compared to the conventional method. The average length of ETT at the level of incisors was 19.5 cm for females and 21 cm for males.

Comparison of supraglottic airway device and endotracheal tube in former preterm infants receiving general anesthesia: a randomized controlled trial.

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT.

A Comparative Study Between Intravenous Esmolol and Oral Clonidine in Attenuating Hyperdynamic Cardiovascular Response to Laryngoscopy and Endotracheal Intubation.

Background In today's era of anesthesia, balanced anesthesia is the main basis of patient care and pain management. Of all the medications given during general anesthesia, premedication, induction agents, and muscle relaxants play a major role in keeping the hemodynamics properly under control. When laryngoscopy is performed to intubate, a pain stimulus will be generated, leading to a rise in blood pressure and heart rate. This stimulus can be avoided without any complications if appropriate premedication is given to the patient at the appropriate dosage. In this research, we compare the influence of injection esmolol and oral clonidine during the time of induction as premedications to suppress the hemodynamic response. Material and methods In a prospective randomized controlled trial, 90 patients were divided into three groups: Group E (esmolol) received 2 mg/kg IV esmolol diluted in 0.9% NS two minutes pre-anesthesia; Group C (clonidine) received oral clonidine 4 mcg/kg 90 minutes pre-anesthesia; and Group P (placebo) received IV normal saline and oral water. Blood pressure, heart rate, and mean arterial pressure were measured at baseline and seven subsequent time points. Results The study compared systolic blood pressure (SBP), mean arterial pressure (MAP), and diastolic blood pressure (DBP) changes over seven minutes in three groups, clonidine (Group C), placebo (Group P), and esmolol (Group E). At one minute, Group E showed a consistent MAP decrease from 95.21 mmHg to 85.92 mmHg, while Group C and Group P exhibited fluctuating trends. DBP decreased across all groups, with Group P ending highest (77.7 mmHg) and Group C lowest (66.8 mmHg). Group E's SBP decreased steadily from 126.2 mmHg to 118.0 mmHg, Group C decreased from 128 mmHg to 116.1 mmHg, and Group P showed more erratic fluctuations in SBP, DBP, and MAP. Conclusion These findings suggest that intravenous esmolol shows a good hemodynamic response having superior control over heart rate and getting the pressure under control quickly without major drop compared with the clonidine and placebo groups.

Alternative Hybrid Technique of Intubation Using C-MAC and Yankauer Suction Catheter: Case of A Floppy Supraglottic Mass.

Supraglottic masses can be an anaesthesiologist's nightmare due to the difficult airway scenario and bleeding risk during airway manipulation. Awake fibreoptic intubation is the primary method to secure the airway in such cases. However, most practising anaesthesiologists are not experts at handling the fibreoptic scope, especially in cases with a floppy supraglottic mass where it becomes difficult to displace the mask with the thin flexible bronchoscope. A hybrid technique of intubation in supraglottic masses using Bonfils rigid scope and C-MAC is often described but frequently not available. Here we describe a case of an elderly patient in their 80s presenting with a floppy supraglottic mass where an awake fibreoptic bronchoscope failed to secure the airway. Without access to a rigid Bonfils scope, we intuitively used a C-MAC to visualize the larynx and a yankauer suction catheter to displace the mass and perform a bougie-guided endotracheal intubation.

Acute Laryngeal Injury in Patients Undergoing Airway Screening at a Long-Term Acute Care Hospital.

BACKGROUND/OBJECTIVES: Acute laryngeal injury (ALgI) is an identified complication of prolonged intubation. Its evolution into mature stenosis and factors affecting decannulation are unclear. This retrospective review aims to characterize the incidence and characteristics of ALgI development and decannulation. METHODS: Retrospective study of post-intubated patients with a tracheostomy seen for screening evaluation at a single long-term acute care hospital (LTACH) from 2019 to 2022. RESULTS: Patients were followed for an average of 115 days after extubation. Forty-nine of 119 adult patients had ALgI. Those with ALgI were more likely female (61% vs. 35.7%, p = 0.006) with higher body mass index (BMI; 32.9 vs. 28.1, p = 0.03) and lower height (166 vs. 171.1 cm, p = 0.01). Decannulation rates in patients with ALgI were 69.4% compared to 84.3% in patients without ALgI (p = 0.053). Patients with ALgI were scoped more quickly post-extubation (28.8 vs. 36.6 days, p = 0.04), but time to decannulation did not differ (66.6 vs. 81.2 days, p = 0.74). Lower CCI (4.03 vs 6.93) and lack of tobacco use (41.2% vs 73.3%) were associated with successful decannulation (p = 0.038, p = 0.0008). Patients with ALgI treated conservatively (observation or medical management) were decannulated up to 71 days post-extubation. Further decannulations only occurred with surgical intervention. CONCLUSIONS: Female gender, higher BMI, and shorter height are associated with ALgI among patients undergoing a LTACH screening evaluation. CCI and tobacco have a negative association with decannulation success. Among the ALgI cohort, no patient treated conservatively was decannulated after 71 days. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Comparing characteristics and outcomes of in-hospital cardiac arrest during the early and late COVID-19 pandemic at an academic institution in Saudi Arabia.

BACKGROUND: The COVID-19 pandemic has introduced major changes in the resuscitation practices of cardiac arrest victims. AIM: We aimed to compare the characteristics and outcomes of patients who sustained in-hospital cardiac arrest (IHCA) during the early COVID-19 pandemic period (2020) with those during the late COVID-19 pandemic period (2021). METHODS: This was a retrospective review of adult patients sustaining IHCA at a single academic centre. We compared characteristics and outcomes of IHCA for 5 months in 2020 with those experiencing IHCA for 5 months in 2021. RESULTS: Patients sustaining IHCA during the early COVID-19 pandemic period had higher rates of delayed epinephrine administration of more than 5 min (13.4% vs. 1.9%; p < 0.01), more frequent delays in the initiation of chest compressions (55.6% vs. 17.9%; p < 0.01), and were intubated less often (23.0% vs. 59.3%; p < 0.01). In terms of outcomes, both return of spontaneous circulation (35.8% vs. 51.2%; p < 0.01) and survival to hospital discharge rates (13.9% vs. 30.2%; p < 0.01) were lower during the early COVID-19 pandemic period. CONCLUSIONS: The early COVID-19 pandemic period was associated with delays in epinephrine administration and chest compression initiation for IHCA. Moreover, both return of spontaneous circulation and survival to hospital discharge were lower during the early COVID-19 pandemic period.

The level of discomfort during the use of different circuits of the mechanical ventilator.

Objectives: Endotracheal tube (ETT) intubation is a life-saving procedure in patients with respiratory failure. However, the presence of an ETT can cause significant discomfort. A tracheostomy tube is used to administer a mechanical ventilator, resulting in a more stable airway and fewer serious injuries. Noninvasive ventilators (NIPPVs) administer ventilation through masks and must be tightly fixed to the face. ETT, tracheostomy, and NIPPV are the most common methods of ventilator maintenance. However, these interventions often cause discomfort to patients. This study aimed to compare discomfort associated with ETT, tracheostomy, and NIPPV. Materials and Methods: Forty-nine conscious patients with postextubation NIPPV and eight conscious patients who underwent postextubation tracheotomy were evaluated for discomfort. A questionnaire survey on discomfort was performed before and after NIPPV or tracheostomy. These patients reported their level of discomfort on a visual analog scale. Results: The levels of sore throat, nasal pain, body pain, activity limitation, respiratory discomfort, oral discomfort, difficulty coughing sputum, worry about respiratory tube disconnection, back pain, anxiety, worry about long-term admission, sleep disturbance, and general discomfort during ETT intubation were higher than during tracheostomy or NIPPV (all P < 0.05). The mean level of discomfort was approximately 5-6 points (moderate) in patients with ETT and 2-3 points (mild) in patients with NIPPV or tracheostomy. Conclusion: The level of discomfort was higher in patients who underwent ETT intubation than in those who underwent NIPPV or tracheostomy. However, the level of discomfort was similar between the patients with NIPPV and those who underwent tracheostomy.

Case of tracheal rupture after endotracheal intubation: clinical risk management and medico-legal considerations.

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different. Case description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax. Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.