Just-in-Time Video Laryngoscopy Versus Direct Laryngoscopy for Neonatal Intubation.

As neonatal endotracheal intubation (ETI) is a low-frequency, high-consequence event, it is essential that providers have access to resources to aid in ETI. We sought to determine the impact of video laryngoscopy (VL) with just-in-time training on intubation outcomes over direct laryngoscopy (DL) when performed by neonatal nurses. We conducted a prospective, randomized, crossover study with neonatal nurses employed at a level 2 neonatal intensive care unit (NICU). Nurses performed both DL and VL on a neonatal mannequin using a CMAC (Karl Storz Corp, Tuttlingen, Germany) either with the assistance of the screen (VL) or without (DL). Before performing the intubation, providers were given a just-in-time, brief education presentation and allowed to practice with the device. Each ETI attempt was reviewed to obtain the percentage of glottic opening (POGO) score, time to intubation (TTI, time from insertion of the blade into the mouth until the first breath was delivered), and time from blade insertion until the best POGO score. We enrolled 19 participants, with a median (interquartile range) of 20 (9-26) years of experience and having a median of 2 (1-3) intubations within the past year. None had used VL in the NICU previously. Median TTI did not differ between DL and VL: 19.9 (15.3-41.5) vs 20.3 (17.9-24.4) (P = 1). POGO scores and the number of attempts also did not differ between DL and VL. In our simulated setting, just-in-time VL training provided similar intubation outcomes compared with DL in ETI performed by neonatal nurses. Just-in-time VL education may be an alternative to traditional DL for neonatal intubations.

[Principles of larynx surgery and nurse surveillance]. / Principes de la chirurgie du larynx et surveillance infirmière.

Endoscopic transoral surgical techniques have developed, adapted to forms of early stage larynx cancer. A total laryngectomy remains the only treatment for patients suffering from an advanced stage cancer which is not receptive to organ preservation strategies. For all these patients, nurse surveillance combines technical and relational care.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway.

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

Awake intubation.

Securing the airway is a core skill in anaesthesia, the gold standard of which is tracheal intubation. Normally this is achieved after induction of anaesthesia. However, some circumstances demand an awake approach. Awake intubation can be achieved via several methods. Using the fibreoptic laryngoscope is the most widely used technique in the UK with minimal patient discomfort and a wide margin of safety. When compared with attempts at difficult direct laryngoscopy, awake fibreoptic intubation provides excellent cardiovascular stability when performed under good topical anaesthesia and conscious sedation. Understanding the equipment used as well as preparing the patient and being aware of potential pitfalls are important elements to performing a successful awake intubation.

Asystole during laryngoscopy of a patient with pleural and pericardial effusions: a case report.

A 53-year-old woman presented to the operating room for surgical correction of pericardial and pleural effusions. Her history included stage IV breast cancer, well-controlled hypertension, and diverticulitis. Although her baseline blood pressure, heart rate, and respirations were normal, she was short of breath with diminished breath sounds on the left side of the lungs and required oxygen, 2 L/min via nasal cannula. The nurse anesthesia student, under the direction of the Certified Registered Nurse Anesthetist (CRNA) and anesthesiologist, induced general anesthesia with etomidate, fentanyl, lidocaine, and succinylcholine. During placement of a double-lumen endotracheal tube, the patient became asystolic. The nurse anesthesia student immediately withdrew the laryngoscope, and the patient returned to normal sinus rhythm. A second attempt at laryngoscopy produced asystole as well. Again, the laryngoscope was withdrawn, and the patient returned to normal sinus rhythm. After resuming ventilation with 100% oxygen and administering atropine, 0.4 mg, the next intubation was successful, producing no untoward effects. Reintubation at the end of the case with a single lumen endotracheal tube was uneventful. The patient was transported to the intensive care unit and mechanically ventilated overnight. The next morning, she was extubated with no further anesthetic complications.

A comparison of preoperative airway assessment techniques: the modified Mallampati and the upper lip bite test.

The purpose of this study was to compare the preoperative anesthetic airway evaluation methods of the modified Mallamapti test (MMT) and upper lip bite test (ULBT) with the direct laryngoscopic views obtained during tracheal intubation. Positive relationships were predicted for the MMT and ULBT with direct laryngoscopic view and between the MMT and ULBT. We assessed 50 patients' airways preoperatively by MMT and ULBT. Intraoperatively, laryngoscopic views were graded on the Cormack and Lehane scale. Descriptive statistics and correlations were computed. There was no relationship between the MMT and the ULBT and the Cormack and Lehane scale. There was a significant relationship between the ULBT and the Cormack and Lehane scale (r = 0.512; P <.001 ). The ULBT was superior to the MMT in every measure in this study: sensitivity (55% vs 11%), specificity (97% vs 75%), positive predictive value (83% vs 9%), and accuracy (90% vs 64%). The findings of this study support those of a previous study of the ULBT. Because of the ease of the ULBT and the promising results of this small study, we recommend further research with a larger, more diverse sample.

Esophageal nasogastric tube misplacement in an infant following laser supraglottoplasty.

Nasogastric (NG) tube misplacement continues to be one of the most common problems associated with enteral tube feedings. Current methods of testing appropriate NG tube placement are ineffective in detecting tube misplacement in a clinically significant number of infants and children. This case study describes an NG tube misplacement into the esophagus in an infant following laser supraglottoplasty; the misplacement was detected on a radiograph obtained as part of a study protocol. Other testing methods used failed to detect the tube misplacement, which could have led to aspiration pneumonia or other complications if the radiograph had not shown the misplacement.

CPT coding for upper airway endoscopies.

The Spring issue (Rudy, 2005) of ORL-Head and Neck Nursing presented a broad review of endoscopic procedures for evaluation and management of upper airway problems. Zarnitz (2005) briefly addressed billing for the most commonly performed upper airway endoscopies in that issue. This paper presents, in detail, the coding for a wider range of upper airway endoscopies performed in the office setting, along with how to report them to third-party payors.

Guidelines for performing fiberoptic flexible nasal endoscopy and nasopharyngolaryngoscopy on adults.

This article presents guidelines for performing two diagnostic skilled examinations; adult fiberoptic flexible nasal endoscopy and nasopharyngolaryngoscopy. These guidelines help to address the paucity of nursing literature on this subject. These procedures previously have been the unique purview of otolaryngologists, but now are being performed by nurse practitioners in otolaryngology specialty practice, as well as by other healthcare providers. All healthcare providers are accountable for seeking appropriate learning resources and clinical supervision in acquiring new procedural skills after graduation and licensure. This article guides learners in acquiring upper airway endoscopy skills, and describes one nurse practitioner's path to gaining institutional sanction for expanding her scope of practice.

AANA journal course: update for nurse anesthetists--beyond the laryngoscope: advanced techniques for difficult airway management.

Airway catastrophes have been identified as the leading cause of injury and death during anesthesia. Proper management of a patient with a technically difficult airway commences with problem recognition. Physical limitations to mask ventilation and endotracheal intubation may be accurately identified by thorough observation. All patients should be examined for oral structure visibility, size of mandibular space, and ability to assume "sniffing" position. Patients with compromised airways should have patency secured while remaining awake by direct laryngoscopy, nasotracheal intubation, fiberoptic endoscopy, retrograde intubation, or possibly tracheostomy. Partial or complete airway obstruction requires immediate recognition and intervention. Repeated, unsuccessful attempts at endotracheal intubation should be avoided, as these may lead to laryngeal edema or hemorrhage which may critically compromise airway maintenance. Prudent options may include awakening the patient, proceeding with mask ventilation, or performing semi-elective tracheostomy. Emergency airway access may be achieved with a tracheoesophageal airway, esophageal tracheal combitube, laryngeal mask airway, digital intubation, or obtained surgically by transtracheal jet ventilation or tracheostomy. Reduction of airway-related morbidity and mortality is best achieved with an understanding of airway anatomy, common causes and prompt recognition of compromise, and alternative techniques of establishing patency and ventilation.