Comparison of blind and endoscopic-guided orotracheal intubation on laryngeal and tracheal damage in domestic rabbits (Oryctolagus cuniculus).

OBJECTIVE: To compare blind and endoscopic-guided techniques for orotracheal intubation in rabbits and the number of intubation attempts with laryngeal/tracheal damage. STUDY DESIGN: Prospective, randomized experimental study. ANIMALS: A total of 24 healthy, intact female New Zealand White rabbits, weighing 2.2 ± 0.2 kg (mean ± standard deviation). METHODS: Rabbits were randomly assigned to blind (group B) or endoscopic-guided (group E) orotracheal intubation with a 2.0 mm internal diameter uncuffed tube. Intramuscular (IM) alfaxalone (7 mg kg-1), hydromorphone (0.1 mg kg-1) and dexmedetomidine (0.005 mg kg-1) were administered, and additional IM alfaxalone (3-5 mg kg-1) and dexmedetomidine (0.025 mg kg-1) were administered to rabbits with strong jaw tone. An intubation attempt was defined as the advancement of the endotracheal tube from the incisors to the laryngeal entrance. Tracheal intubation was confirmed via capnography and anesthesia was maintained with isoflurane for 2 hours. Following euthanasia, laryngeal and tracheal tissues were submitted for histopathology. Quality of anesthesia for orotracheal intubation, intubation procedure and tissue damage were numerically scored. Data were analyzed using Poisson regression, Spearman's correlation, t test, mixed anova, Mann-Whitney U test, Friedman and Chi square tests as appropriate. RESULTS: Median (range) intubation attempts were 2 (1-8) and 1 (1-3) for groups B and E, respectively. More rabbits in group E (91.6%) required additional alfaxalone and dexmedetomidine than in group B (16.7%). Median (range) cumulative histopathology scores were 6 (3-10) and 6 (2-9) for groups B and E, respectively. Scores were highest in the cranial trachea, but there was no difference between groups and no correlation between laryngeal/tracheal damage and the number of intubation attempts. CONCLUSIONS AND CLINICAL RELEVANCE: Both orotracheal intubation techniques were associated with laryngeal/tracheal damage. Although blind orotracheal intubation was associated with a higher number of attempts, the tissue damage was similar between groups.

Timing and Outcomes of Noninvasive Ventilation in 307 ARDS COVID-19 Patients: An Observational Study in an Italian Third Level COVID-19 Hospital.

Background and Objectives: Background: Coronavirus disease 2019 (COVID-19) is a novel cause of Acute Respiratory Distress Syndrome (ARDS). Noninvasive ventilation (NIV) is widely used in patients with ARDS across several etiologies. Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, its use has grown significantly in hospital wards. However, there is a lack of evidence to support the efficacy of NIV in patients with COVID-19 ARDS. Materials and Methods: We conducted an observational cohort study including adult ARDS COVID-19 patients admitted in a third level COVID-center in Rome, Italy. The study analyzed the rate of NIV failure defined by the occurrence of orotracheal intubation and/or death within 28 days from starting NIV, its effectiveness, and the associated relative risk of death. The factors associated with the outcomes were identified through logistic regression analysis. Results: During the study period, a total of 942 COVID-19 patients were admitted to our hospital, of which 307 (32.5%) presented with ARDS at hospitalization. During hospitalization 224 (23.8%) were treated with NIV. NIV failure occurred in 84 (37.5%) patients. At 28 days from starting NIV, moderate and severe ARDS had five-fold and twenty-fold independent increased risk of NIV failure (adjusted odds ratio, aOR = 5.01, 95% CI 2.08−12.09, and 19.95, 95% CI 5.31−74.94), respectively, compared to patients with mild ARDS. A total of 128 patients (13.5%) were admitted to the Intensive Care Unit (ICU). At 28-day from ICU admission, intubated COVID-19 patients treated with early NIV had 40% lower mortality (aOR 0.60, 95% CI 0.25−1.46, p = 0.010) compared with patients that underwent orotracheal intubation without prior NIV. Conclusions: These findings show that NIV failure was independently correlated with the severity category of COVID-19 ARDS. The start of NIV in COVID-19 patients with mild ARDS (P/F > 200 mmHg) appears to increase NIV effectiveness and reduce the risk of orotracheal intubation and/or death. Moreover, early NIV (P/F > 200 mmHg) treatment seems to reduce the risk of ICU mortality at 28 days from ICU admission.

Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions.

Background and Aims: Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children. Material and Methods: This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups. Results: The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours. Conclusion: The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Effects of head positions on awake fiberoptic bronchoscope oral intubation: a randomized controlled trial.

BACKGROUND: There are many factors affecting the success rate of awake orotracheal intubation via fiberoptic bronchoscope. We performed this study was to investigate the effects of head positions on awake Fiberoptic bronchoscope oral intubation. METHODS: Seventy-five adult patients, received general anaesthesia were included in this study. After written informed consent, these patients were undergoing awake orotracheal intubation via fiberoptic-bronchoscope and according to the head position, the patients were randomized allocated to neutral position group (NP group), sniffing position group (SP group) or extension position group (EP group). After sedation the patients were intubated by an experienced anesthesiologist. The time to view the vocal cords, the percentage of glottic opening scores (POGO), the time to insert the tracheal tube into trachea and the visual analog scale (VAS) scores for ease experienced of passing the tracheal tube through glottis, the hemodynamic changes and the adverse events after surgery were recorded. RESULTS: The time to view the vocal cords was significantly shorter and the POGO scores was significantly higher in the EP group compared with the other two groups (P < 0.05); The SpO2 in the EP group was higher than NP group at before intubation and higher than SP group and NP group at immediate after intubation (P < 0.05); The time to insert the tracheal tube into trachea, the VAS scores for passing the tracheal tube through glottis, the coughing scores had no significant differences among groups (P > 0.05). There were also no significant differences regard to the incidence of postoperative complications, mean arterial pressure and heart rate among the groups (P > 0.05). CONCLUSIONS: The head at extension position had a best view of glottic opening than neutral position or sniffing position during awake Fiberoptic bronchoscope oral intubation, so extension position was recommended as the starting head position for awake Fiberoptic bronchoscope oral intubation. TRIAL REGISTRATION: Clinical Trials.gov. no. NCT02792855. Registered at https://register.clinicaltrials.gov on 23 september 2017.

Determination of reliable lung function parameters in intubated mice.

BACKGROUND: Animal models and, in particular, mice models, are important tools to investigate the pathogenesis of respiratory diseases and to test potential new therapeutic drugs. Lung function measurement is a key step in such investigation. In mice, it is usually performed using forced oscillation technique (FOT), negative pressure-driven forced expiratory (NPFE) and pressure-volume (PV) curve maneuvers. However, these techniques require a tracheostomy, which therefore only allows end-point measurements. Orotracheal intubation has been reported to be feasible and to give reproducible lung function measurements, but the agreement between intubation and tracheostomy generated-data remains to be tested. METHODS: Using the Flexivent system, we measured lung function parameters (in particular, forced vital capacity (FVC), forced expiratory volume in the first 0.1 s (FEV0.1), compliance (Crs) of the respiratory system, compliance (C) measured using PV loop and an estimate of inspiratory capacity (A)) in healthy intubated BALB/cJ mice and C57BL/6 J mice and compared the results with similar measurements performed in the same mice subsequently tracheostomized after intubation, by means of paired comparison method, correlation and Bland-Altman analysis. The feasibility of repetitive lung function measurements by intubation was also tested. RESULTS: We identified parameters that are accurately evaluated in intubated animals (i.e., FVC, FEV0.1, Crs, C and A in BALB/cJ and FVC, FEV0.1, and A in C57BL/6 J). Repetitive lung function measurements were obtained in C57BL/6 J mice. CONCLUSION: This subset of lung function parameters in orotracheally intubated mice is reliable, thereby allowing relevant longitudinal studies.

Evaluation of glottic view through Air-Q Intubating Laryngeal Airway in the supine and lateral position and assessing it as a conduit for blind endotracheal intubation in children in the supine position.

INTRODUCTION: We assessed the feasibility of blind orotracheal intubation in children using the Air-QILA as a conduit in supine position and the glottic view grading by fiberoptic bronchoscope (FOB) through it both in supine and lateral positions. METHODS: After ethical approval and consent, 60 children were enrolled in the study. In the operating room, after attaching standard monitors to all children, anesthesia was induced with sevoflurane (2-8%) in oxygen (100%). Once the children became sedated, an i.v. access was established and injection glycopyrrolate (10 µg · kg(-1)), fentanyl (2 µg · kg(-1)), and atracurium (0.5 mg · kg(-1)) were administered. After 3 min, the Air-QILA was placed in supine position and glottic view was assessed by using FOB, in supine and right lateral decubitus position. In all children, gradings of glottic view in two different positions were noted. After that all children were turned supine, and orotracheal intubation was done blindly through the Air-QILA. The success rate, insertion time of the Air-QILA, and endotracheal intubation were noted. RESULTS: The Air-QILA placement was successful in 57 children in first attempt and three children required second attempt. However, blind endotracheal intubations through the Air-QILA were successful in 38 children in first attempt and 12 children required second attempt. In the remaining 10 children, where blind endotracheal intubation through the Air-QILA remained unsuccessful, conventional laryngoscopy was performed. In supine and lateral positions, Grade 1 glottic view was seen in 41 and 38 of total 60 patients, respectively. Turning of all children from supine to lateral decubitus position resulted in the deterioration of grading of glottic view in eight children and improvement in two children (P = 0.001). CONCLUSION: The Air-QILA is an easy to place supraglottic airway device with excellent airway seal and low airway morbidity. It may be useful as a conduit for blind orotracheal intubation in supine position and can be used as an effective alternative to FOB in low resource settings.

Attenuation of hemodynamic response to laryngoscopy and orotracheal intubation using intravenous clonidine.

BACKGROUND AND AIMS: Alpha-2 agonists are being increasingly used as adjuncts in general anesthesia and the present study was carried out to study the effect of clonidine as an adjuvant to low dose fentanyl in attenuating the hemodynamic response to laryngoscopy and orotracheal intubation. MATERIALS AND METHODS: Ninety female patients belonging to American Society of Anesthesiologists (ASA) physical status I, II, and III in age group 25-65 years, body mass index (BMI) 21-26 kg/m(2), and diagnosed as carcinoma breast scheduled for breast surgery were included in this Prospective, randomized, placebo-controlled study. One-way analysis of variance (ANOVA), paired t-test, and chi-square test was applied where deemed appropriate. P-value at or below the level of 0.05 was considered as statistically significant. RESULTS: Intravenous (IV) clonidine 1.0 µg kg(-1) and clonidine 2.0 µg kg(-1) significantly attenuated the hyperdynamic response to laryngoscopy and intubation. Clonidine 2.0 µg kg(-1) was associated with adverse effects like hypotension at the time of induction and postoperative sedation which was not observed with clonidine 1.0 µg kg(-1). CONCLUSIONS: A single intravenous low dose clonidine (1.0 µg kg(-1)) when combined with low dose fentanyl (2 µg kg(-1)) is a practical, pharmacological and safe method with minimal side effects to attenuate the hyperdynamic response to laryngoscopy and intubation.

Vigilant Fiberoptic Orotracheal Intubation in a Patient With Severe Craniofacial Trauma During the Last Morocco Earthquake.

Maxillofacial trauma is prevalent, particularly among the young population, often stemming from assaults, road accidents, or sports-related mishaps. Traditional intubation methods for managing these injuries can be challenging, especially with occluso-facial fractures requiring intermaxillary blocking for dental articulation restoration. Effective management requires interdisciplinary collaboration between emergency physicians, anesthetists, and maxillofacial surgeons. Proficiency in techniques like the vigilant fiberoptic approach should be emphasized through specialized training courses. This collaborative approach ensures the best possible strategy for managing difficult airways, with input from all stakeholders including patients, students, and practitioners. In this case, we successfully conducted a rapid-sequence awake fiberoptic oral intubation on a trauma patient, during the last earthquake that hit Morocco, with severe craniofacial injuries and an unstable skull. The patient, a 40-year-old woman, presented with complex facial fractures, including hemi lefort III on the right and hemi lefort II on the left, along with minimal subarachnoid hemorrhage and frontal pneumocephalus. Due to the patient's compromised airway from diffuse facial bleeding and low oxygen saturation, we opted for awake fiberoptic intubation once immediate life-threatening issues were addressed. This approach allowed us to maintain the patient's spontaneous respirations and navigate around unstable craniofacial structures. The procedure was performed with meticulous care, considering the patient's unstable skull, and was successful without complications. Post-intubation, the patient was extubated, and her recovery was uneventful.

Awake Videolaryngoscopy for Intubation in Patients With Laryngeal Cancer: A Case Series.

Total laryngectomy is the gold standard surgical approach for laryngeal cancer and is generally conducted under general anesthesia. Orotracheal intubation remains a very delicate step in the general anesthesia process. In otolaryngology (ENT) surgery, it remains considered the preferred method of anesthesia for many surgical procedures. A significant challenge in oncological ENT surgery is the difficulty associated with orotracheal intubation, due to a number of reasons that can lead to failure of orotracheal intubation. To mitigate this risk, experts recommend proceeding with orotracheal intubation with the patient awake and breathing spontaneously. In this case series, we report four patients with supraglottic tumors of the larynx who underwent total laryngectomy surgery under general anesthesia, during which they underwent orotracheal intubation while awake and spontaneous breathing, under no sedative drugs of any kind, in order to avoid complications of orotracheal intubation failure and respiratory apnea due to bleeding tumor masses that engaged the supraglottic space.

Tracheostomy before and during COVID-19 pandemic.

BACKGROUND: The aim of the study was to provide insight into the influence of the COVID-19 on the frequency and characteristics of urgent and emergent tracheostomies (TS), comparing data collected both before and during the pandemic. Our two hypotheses were that during COVID-19, more TS were performed in the emergent setting and that during COVID-19 more TS were performed under general anaesthesia. PATIENTS AND METHODS: The research was retrospective. The study period included the two years before and after the COVID-19 outbreak in Slovenia. Forty-one patients in each period met the inclusion criteria. Their medical charts were reviewed. The anamnestic, clinical, surgical and anaesthesiological data were collected. The two groups of patients from corresponding time periods were statistically compared. RESULTS: Predominantly men required the surgical resolution of acute upper airway obstruction (76% of patients). The causes for acute respiratory distress included head and neck cancer (62%), infections (20%), vocal cord paralysis (16%), and stenosis (2%). There were no statistically significant differences either in the (emergent/urgent) setting of TS or in the type of anaesthesia used. Both hypotheses were rejected. A statistically significant rise in use of the C-MAC laryngoscope during COVID-19 (from 3% to 15%) was reported. CONCLUSIONS: The outbreak of COVID-19 did not have a statistically significant effect on the frequency of performing emergent and urgent tracheostomies nor on the use of general or local anaesthesia. It did, however, require a change of intubation technique. Consequently, a significant rise in the use of the C-MAC laryngoscope was noted.

Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Post-extubation dysphagia (PED) emerges as a frequent complication following endotracheal intubation within the intensive care unit (ICU). PED has been strongly linked to adverse outcomes, including aspiration, pneumonia, malnutrition, heightened mortality rates, and prolonged hospitalization, resulting in escalated healthcare expenditures. Nevertheless, the reported incidence of PED varies substantially across the existing body of literature. Therefore, the principal objective of this review was to provide a comprehensive estimate of PED incidence in ICU patients undergoing orotracheal intubation. METHODS: We searched Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science, Technology Journal Database (VIP), and SinoMed databases from inception to August 2023. Two reviewers independently screened studies and extracted data. Subsequently, a random-effects model was employed for meta-statistical analysis utilizing the "meta prop" command within Stata SE version 15.0 to ascertain the incidence of PED. In addition, we performed subgroup analyses and meta-regression to elucidate potential sources of heterogeneity among the included studies. RESULTS: Of 4144 studies, 30 studies were included in this review. The overall pooled incidence of PED was 36% (95% confidence interval [CI] 29-44%). Subgroup analyses unveiled that the pooled incidence of PED, stratified by assessment time (≤ 3 h, 4-6 h, ≤ 24 h, and ≤ 48 h), was as follows: 31.0% (95% CI 8.0-59.0%), 28% (95% CI 22.0-35.0%), 41% (95% CI 33.0-49.0%), and 49.0% (95% CI 34.0-63.0%), respectively. When sample size was 100 < N ≤ 300, the PED incidence was more close to the overall PED incidence. Meta-regression analysis highlighted that sample size, assessment time and mean intubation time constituted the source of heterogeneity among the included studies. CONCLUSION: The incidence of PED was high among ICU patients who underwent orotracheal intubation. ICU professionals should raise awareness about PED. In the meantime, it is important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED.

Tapia's Syndrome: A Comprehensive Analysis of a Rare Intensive Care-Associated Complication.

Tapia's syndrome is a rare complication of airway manipulation, involving the simultaneous paralysis of the hypoglossal nerve and the recurrent laryngeal nerve. The etiological mechanism is commonly attributed to compression or stretching during airway manipulation. An efficient recognition of this condition is pivotal for a comprehensive multidisciplinary approach and optimized recovery time. The presence of persistent dysphagia and dysphonia, coupled with observable deviation or restriction of tongue movement, not only after oral endotracheal intubation for surgical interventions with general anesthesia but also after a prolonged orotracheal intubation period in the intensive care, should heighten the suspicion of this syndrome. This report details a case of Tapia's syndrome emerging as a complication of airway manipulation and prolonged intubation in the intensive care unit.

[Non-invasive ventilation in acute respiratory failure of oncology-hematology patients: What are its current benefits and limitations?] / Ventilation non invasive dans l'insuffisance respiratoire aiguë des patients d'onco-hématologie : quelle place en 2023 ?

Acute respiratory failure (ARF) is a leading cause, along with sepsis, of admission to the intensive care unit (ICU) of patients with active cancer. Presenting variable clinical severity, ARF in onco-hematological patients has differing etiologies, primarily represented by possibly opportunistic acute infectious pneumonia (de novo hypoxemic ARF), and decompensation in chronic cardiac or respiratory diseases (e.g., acute pulmonary edema or exacerbated chronic obstructive pulmonary disease). In these patients, orotracheal intubation is associated with a doubled risk of in-hospital mortality. Consequently, over the last three decades, numerous researchers have attempted to demonstrate and pinpoint the precise role of non-invasive ventilation (NIV) in the specific context of ARF in onco-hematological patients. While the benefits of NIV in the management of acute pulmonary edema or alveolar hypoventilation (hypercapnic ARF) are well-demonstrated, its positioning in de novo hypoxemic ARF is debatable, and has recently been called into question. In the early 2000s, based on randomized controlled trials, NIV was recommended as first-line treatment, one reason being that it allowed significantly reduced use of orotracheal intubation. In the latest randomized studies, however, the benefits of NIV in terms of survival orotracheal intubation have not been observed; as a result, it is no longer recommended in the management of de novo hypoxemic ARF in onco-haematological patients.

Clinical application and evaluation of a new type of tracheal catheter fixation belt.

AIM: To evaluate a new fixation band for tracheal catheter in intensive care unit. DESIGN: A cross-sectional study. METHODS: A total of 90 patients admitted to the ICU between August 2018-February 2019 were enrolled in the study. Patients were randomly divided into experimental group and control group (N = 45/per each group). 3 M strong adhesive tape and a new tracheal catheter fixation band were applied to patients in two groups, respectively. The fixation effect, incidence of mucosal pressure injury and nursing cost were evaluated. RESULTS: Forty-three patients from the experimental group and 42 patients from the control group participated in this study. Mild, moderate and severe catheter dislocation happened in 2, 0, 0 cases in the experimental group, and 6, 3 and 2 cases in the control group, respectively; the difference was statistically significant. The rates of mucosal pressure injury were 4.7% and 21.4%, which was significantly different, and the experiment group had a lower average daily nursing cost related to tracheal intubation. CONCLUSIONS: The new tracheal catheter fixation band, which allows for accurate fixation, is simple to operate, may reduce the incidence of mucosal pressure injury, decrease the nursing cost and improve the patients' comfort in clinical practice.

McGrath® versus Macintosh laryngoscopes on hemodynamic response to intubation in elderly patients: a randomized clinical trial.

Introduction: laryngoscopy and tracheal intubation induce catecholaminergic release. Our study aimed to evaluate the hemodynamic impact of orotracheal intubation by McGrath® compared to the Macintosh laryngoscope in the elderly. Methods: we conducted a prospective randomized clinical trial that included elderly patients proposed for a scheduled surgery under general anesthesia with orotracheal intubation and divided into 2 groups: patients who were intubated using the McGrath® (group V) and patients who were intubated using the Macintosh direct laryngoscope (group M). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MAP), were recorded before induction of anesthesia (baseline), and at 1 min, 3 min, and 5 min after intubation. Our outcomes were the increase of SBP (∆ SBP), MAP (∆ MAP), and HR (∆ HR) between the two groups, during the 5 minutes following the start of the orotracheal intubation, intubation time and the incidence of its related complications. Results: sixty patients were included and randomized into 2 groups of 30. The average age of our sample was 70±6 years with a sex ratio of 1.22. Most of the patients were operated on for orthopedic, urologic, or abdominal surgery. There were no statistically significant differences between the two groups in terms of demographic characteristics and the duration of anesthesia (p> 0.05). The intubation time was significantly increased in group M (p≤0.001). There was a significant difference in SBP, MAP, and HR values at 1 min after orotracheal intubation compared with the baseline values in Group V(P<0,05) and Group M (p < 0.05). There was a significant increase in the first minute after tracheal intubation in terms of SBP (151±42 vs 134.5±26 mmHg, p=0.012), MAP (114±4 vs 102±17 mmHg, p=0.015), DBP (89±32 vs 84±16 mmHg, p=0.01), and HR (99.5±10 vs 94.5±2 b/min, p=0.008) when group M was compared to group V. The ∆SBP was significantly different between group M (∆SBP = 36.2±23.5mmHg) and group V (∆SBP= 30.77±21.6mmHg) (p = 0.005). There were 4 ventricular arrhythmias in group M versus zero in group V (p <0.0001). The postoperative sore throat was significantly decreased in group M vs V (p=0.036). Conclusion: the McGrath® videolaryngoscope decreased the hemodynamic fluctuations due to endotracheal intubation in elderly patients.

Anti-Toothbreaker: A Novel Low-Budget Device Enabling Contactless Dental Protection and a Forbidden Technique during Direct Laryngoscopy for Endotracheal Intubation.

BACKGROUND: Iatrogenic dental injury is the most common complication of conventional laryngoscopy during orotracheal intubation. The main cause is unintended pressure and leverage forces from the hard metal blade of the laryngoscope. The aim of this pilot study was to introduce and test a novel, reusable low-budget device not only providing contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enabling, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis. METHODS: A constructed prototype for intrahospital usage was evaluated by seven participants on a simulation manikin for airway management. Endotracheal intubation was performed with and without the device using a conventional Macintosh laryngoscope (blade size 4) and a 7.5 mm endotracheal tube (Teleflex Medical GmbH, Fellbach, Germany). Necessary time and success of first pass were determined. Degree of visualization of the glottis with and without the device was stated by the participants according to the Cormack and Lehane (CL) classification system and the Percentage of Glottic Opening (POGO) scoring system. In addition, subjective physical effort, feeling of safety regarding successful intubation, and risk for dental injury were queried on a numeric scale between 1 and 10. RESULTS: All participants except one stated that the intubation procedure was easier with usage of the device than without it. On average, this was subjectively perceived as being approximately 42% (range, 15-65%) easier. In addition, time to first pass success, as well as degree of glottis visualization, subjective physical effort, and feeling of safety regarding risk for dental injury, were clearly better with usage of the device. Concerning feeling of safety regarding successful intubation, there was only a minor advantage. No difference in first pass success rate and number of total attempts could be observed. CONCLUSION: The Anti-Toothbreaker is a novel, reusable low-budget device which might not only provide contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enables, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis. Future human cadaveric studies are needed to investigate whether these advantages also prove themselves there.

Comparison Of Chula Formula With Standard 21/23 Rule For Estimation Of Orotracheal Tube Depth In Intubated Adult Patients: A Sindh Institute Of Urology And Transplantation Experience.

BACKGROUND: The proper estimation of depth of the orotracheal tube (OTT) in intubated patients is difficult. Several methods have been developed for proper estimation of the depth of OTT. The purpose of this study was to compare two commonly used formulae (21/23 rule and Chula formula) for proper estimation of depth of OTT in our Pakistani population. METHODS: In this randomized interventional study, we included 74 adult patients. The study was conducted in the Intensive care unit of a tertiary care hospital in Karachi, Pakistan, from October 2021 to April 2022. Patients were intubated using either the 21/23 rule (OTT was fixed at 21 cm in females and 23 cm in males from the right incisor) or the Chula formula (OTT was fixed at the right incisor according to the height based formula, {(height in cm/10)+4}). The distance between the carina and the OTT tip was measured using the digital chest x-ray with a PACS software. RESULTS: A total of 74 patients were intubated in which 32 were intubated using 21/23 rule and 42 were intubated using the Chula formula. Four female patients in 21/23 rule group encountered unsafe distance between the carina and the tip of the OTT (i.e., <2 cm) while no such complications were reported in Chula formula group (p-value 0.031). CONCLUSIONS: Chula formula was safe method for OTT placement in our study. Further studies with larger sample size are needed to assess the safety and efficacy of Chula formula for Pakistani Population.

Antimicrobial oral lavage reduces the SARS-CoV-2 load in intubated patients: randomized clinical trial.

Background: The oral cavity can be a reservoir for SARS-CoV-2 and may play a crucial role in the viral transmission in the hospital environment. Objective: To investigate whether an oral hygiene protocol with chlorhexidine (CHX) used alone and in combination with hydrogen peroxide (HP) in the intensive care unit was effective in reducing the SARS-CoV-2 viral load in the oral cavity. Methods: SARS-CoV-2 viral load was measured on oral fluid samples collected from patients undergoing orotracheal intubation. The study sample was randomly in: CHX group (n = 19) - oral rinse using only 0.12% CHX solution; HP+CHX group (n = 24) - oral rinse with 1.5% HP and 0.12% CHX. The samples were collected before the interventions (T0), immediately (T1), 30 minutes (T2) and 60 minutes (T3) after the procedure. Results: A significant viral load reduction was observed at T1 (mean ± SD:-0.57 ± 0.19 log10;-73.2%;p = 0.022) in the HP+CHX group. No statistically significant differences between any time points were observed in the CHX group. Conclusion: The HP+CHX oral rinses significantly reduced the SARS-CoV-2 viral load in the oral fluid immediately after the procedure. The CHX oral rinse alone did not result in any significant viral load reductions.

Effects of lidocaine and esmolol on hemodynamic response to tracheal intubation: a randomized clinical trial.

INTRODUCTION AND OBJECTIVES: Although lidocaine is widely used to prevent cardiovascular changes resulting from laryngoscopy and orotracheal intubation, it is still unclear whether there are more efficacious drugs. This study aimed to compare the beta-blocker esmolol with lidocaine regarding the effects on hemodynamic response after orotracheal intubation. METHODS: The study has a prospective, randomized, double-blind, superiority design, and assessed 69 participants between 18 and 70 years of age, ASA I-II, scheduled for elective or emergency surgery under general anesthesia with orotracheal intubation. Participants were randomly allocated to receive 1.5 mg.kg-1 esmolol bolus followed by 0.1 mg.kg-1.min-1 esmolol infusion (n = 34) or 1.5 mg.kg-1 lidocaine bolus followed by 1.5 mg.kg-1.h-1 lidocaine infusion (n = 35). We recorded changes in heart rate, arterial blood pressure and incidence of adverse events. RESULTS: Post-intubation tachycardia episodes were significantly less frequent in the esmolol group (5.9% vs. 34.3%; Relative Risk (RR) 0.17; 95% Confidence Interval (95% CI) 0.04-0.71; Number Needed to Treat (NNT) 3.5; p = 0.015. After orotracheal intubation, mean heart rate was significantly lower in the esmolol group (74.5 vs. 84.5, p = 0.006). Similar results were observed in the subsequent 3 and 6 minutes (75.9 vs. 83.9, p = 0.023 and 74.6 vs. 83.0, p = 0.013, respectively). CONCLUSION: Esmolol was a safe and more effective intervention to reduce incidence of tachycardia and control heart rate immediately after tracheal intubation when compared to lidocaine.

[Balloon catheter inflation with alkalinized lidocaine reduces post-operative laryngeal pain: a prospective, randomized controlled clinical trial]. / L'inflation du ballonnet de la sonde d'intubation par la lidocaïne alcalinisée réduit les douleurs laryngées post-opératoires: essai clinique prospectif contrôlé randomisé.

Introduction: post-operative laryngeal pain (POLP) is frequent and embarrassing. The purpose of this study is to assess the efficacy of endotracheal tube balloon (ETB) inflation with alkalinized lidocaine in the prevention of the POLP. Methods: we conducted a prospective, single-center, double-blind, randomized study including patients undergoing general anesthesia with tracheal intubation (OTI) with an expected duration of less than 240 min. Patients were divided into two equivalent groups: lidocaine (GL) group: patients with ETB inflated with alkaline lidocaine and the control group (GT): patients whose ETB was inflated with normal saline solution. The primary endpoint was the incidence of POLP in the first 24 hours after surgery and the secondary endpoint was the incidence of cough, dysphonia and postoperative vomiting, postoperative nausea and vomiting (PONV) in the first 24 hours after surgery. Statistical analysis was carried out using SPSS software version 25. The difference was considered significant when p< 0.05. Results: the study included 60 patients randomized into 2 groups of 30 patients each. Both groups were comparable with regard to their demographic and anesthetic criteria. ETB inflation with alkalinized lidocaine reduced the incidence of POLP, cough, dysphonia and PONV. No cases of balloon rupture or lidocaine toxicity were reported. Conclusion: ETB inflation with alkaline lidocaine prevents POLP.