Airway management is a skill necessary for healthcare providers who manage patients. Intubation is a skill that both anesthesiologists and intensivists use daily. We present a case of a neonate that developed signific...Airway management is a skill necessary for healthcare providers who manage patients. Intubation is a skill that both anesthesiologists and intensivists use daily. We present a case of a neonate that developed significant worsening stridor after a successful intubation for a hernia repair. After 4 intubation attempts, with easy visualization of the vocal cords and unsuccessful placement of the endotracheal tube, the patient was emergently brought to the operating room for evaluation.展开更多
BACKGROUND: Airway management in intensive care unit(ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy(DL) and ...BACKGROUND: Airway management in intensive care unit(ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy(DL) and that by using the video laryngoscopy(VL).METHODS: A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success. RESULTS: A total of 163 ICU patients underwent intubation during the study period(81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group(67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications(all P>0.05). CONCLUSION: Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.展开更多
Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The cha...Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.展开更多
BACKGROUND In anesthesia practice,orotracheal intubation remains the primary concern of the anesthesiologist.The introduction of video laryngoscopy(VL)has increased the success rate of orotracheal intubation;however,c...BACKGROUND In anesthesia practice,orotracheal intubation remains the primary concern of the anesthesiologist.The introduction of video laryngoscopy(VL)has increased the success rate of orotracheal intubation;however,conflicting results have been reported regarding the usefulness of the current technique with VL in clinical practice.AIM To describe a modification to improve intubation with VL,followed by evaluation of the practice in vivo.METHODS First,a mannequin trial was conducted with operators having different experience and background.Then,a retrospective analysis was performed for an>1-year period with patients who underwent general anesthesia with orotracheal intubation.The endotracheal tube used had been pre-formed with two curves.Stepwise intubation had been performed with direct eye vision,followed by screen assistance and rotation of the tube as needed to direct it toward the glottis.In the mannequin trial,the outcome measures were quantification of torque(force with angular acceleration during levering),need for external maneuvers,and time to intubate.In the clinical experience,orotracheal intubation used VL(pre-formed tube)or direct laryngoscopy(DL)at the anesthetist’s discretion and throat discomfort was reported by the patient.RESULTS In the mannequin trials using VL,there was less torque with the pre-formed tube than with a regular tube(8%and 65%,respectively).The first-pass rate was higher with the pre-formed tube(95%)than with a regular tube(81%).However,the time to intubate was longer with the pre-formed tube than with a regular tube(22 s and 12 s,respectively).In clinical practice,562 patients underwent surgery under general anesthesia with orotracheal intubation using either VL(n=244)or DL(n=318)at the discretion of the attending anesthetist.VL was specifically planned in 62 of the patients,due to anticipated difficulty.Second attempts by readjustment of the curve of the tube were significantly fewer with VL than with DL(10%vs 18%).Throat discomfort was reported by fewer patients who underwent VL than those who underwent DL(6%vs 24%).CONCLUSION Pre-formed endotracheal tube with stepwise insertion produces less torque,fewer external maneuvers and higher first-pass success rate during VL intubation.Further,prospective studies are warranted.展开更多
Purpose:As common clinical screening tests cannot effectively predict a difficult airway,and unanticipated difficult laryngoscopy remains a challenge for physicians.We herein used ultrasound to develop some point-of-c...Purpose:As common clinical screening tests cannot effectively predict a difficult airway,and unanticipated difficult laryngoscopy remains a challenge for physicians.We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy.Methods:This prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment.Patients under 18 years old,or with maxillofacial deformities or fractures,limited mouth opening,limited neck movement or history of neck surgery were excluded from the study.Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane(CL)scoring system.The measurements acquired comprised tongue width,the longitudinal cross-sectional area of the tongue,tongue volume,the mandible-hyoid bone distance,the hyoid boneglottis distance,the mandible-hyoid bone-glottis angle,the skin-thyrohyoid membrane distance,the glottis-superior edge of the thyroid cartilage distance(DGTC),the skin-hyoid bone distance,and the epiglottis midway-skin distance.ANOVA and Chi-square were used to compare differences between groups.Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram.R version 3.6.3 and SPSS version 26.0 were used for statistical analyses.Results:Difficult laryngoscopy was indicated in 49 patients(CL grade III-IV)and easy laryngoscopy in 453 patients(CL grade I-II).The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups(p<0.001).Difficult laryngoscopy was predicted by an area under the curve(AUC)of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5and by an AUC of 0.722 with a threshold DGTC of 1.22 cm.The longitudinal cross-sectional area of the tongue,tongue width,tongue volume,the mandible-hyoid distance,and the hyoid-glottis distance did not significantly differ between the groups.Conclusion:Difficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid boneglottis angle is smaller than 125.5or DGTC is larger than 1.22 cm.展开更多
Background: Unpredictable difficult laryngoscopy (DL) remains a challenge for anesthesiologists, especially when difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be p...Background: Unpredictable difficult laryngoscopy (DL) remains a challenge for anesthesiologists, especially when difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common airway assessment methods only perform superficial screening. Thus, the deep laryngopharyngeal anatomy may not be evaluated. Ultrasound-based airway assessment has been recently proposed as a useful, simple, and non-invasive bedside tool as an adjunct to clinical methods, which may facilitate identification of DL. The present study aimed to determine the correlation between ultrasound-measured indicators and DL. Methods: Patients undergoing elective surgery under general anesthesia with tracheal intubation were enrolled. Ultrasonic airway assessments were performed before anesthesia induction. Ultrasound diagnostic indicators included the thickness and width of the base of the tongue, the angle between the epiglottis and glottis, the length of the thyrohyoid membrane, and the thickness of the lateral pharyngeal wall. A score of ≥3 in the Modified Cormack-Lehane Scoring System was used as a standard of DL and was also applied to divide patients into DL and non-DL groups. The area under the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic ability of various diagnostic indicators. Results: A total of 499 patients were enrolled into non-DL and DL groups comprising 452 (452/499, 90.6%) and 47 (47/499, 9.4%) patients, respectively. One ultrasonic diagnoses indicator correlated with DL, namely, the angle between the epiglottis and glottis. When the angle between the epiglottis and glottis was 50°, the area under the ROC curve was maximum (0.902), and the best sensitivity (81%) and specificity (89%) were achieved. Conclusions: Airway ultrasounds should be considered to identify DL. The ultrasonic angle measured between the epiglottis and glottis is highly associated with DL, which may occur when the angle is less than 50°. Clinical trial registration:展开更多
Objectives: To evaluate the diagnostic accuracy of flexible fiberoptic examinations of the larynx recorded onto smartphones. Methods: Prospective, blinded study of inpatients requiring laryngoscopy. A live exam was pe...Objectives: To evaluate the diagnostic accuracy of flexible fiberoptic examinations of the larynx recorded onto smartphones. Methods: Prospective, blinded study of inpatients requiring laryngoscopy. A live exam was per-formed, then a smartphone was attached to the endoscope using a novel coupling device and the same examination was recorded. The live and recorded exams were evaluated by two lar-yngologists, each blinded to the findings of the other. Results: Eighteen subjects were evaluated. Evaluation of airway patency was identical (Kappa = 1.0 [1, 1]). Evaluation of vocal cord motion was identical for 14 subjects: 9 normal, 3 paretic, 2 paralytic (Kappa = 0.69 [0.38, 1]). Conclusion: There is high correlation between laryngeal diagnoses using live flexible fiberoptic laryngoscopy and recordings using a coupling device to transfer the recordings on to smart-phones. Critical findings such as airway patency and vocal fold motion showed the highest cor-relation.展开更多
The use of SponTaneous Respiration using IntraVEnous anesthesia and High-flow nasal oxygen (STRIVE-Hi) in laryngeal surgery has become more widely reported. This method eliminates the endotracheal tube as a fuel for a...The use of SponTaneous Respiration using IntraVEnous anesthesia and High-flow nasal oxygen (STRIVE-Hi) in laryngeal surgery has become more widely reported. This method eliminates the endotracheal tube as a fuel for a potential fire. However, little has been published on its use in the pediatric population. Our case report describes its use in a 2-year-old undergoing micro-direct laryngoscopy with CO<sub>2</sub> assisted supraglottoplasty and rigid bronchoscopy for airway obstruction from congenital laryngomalacia. The STRIVE-Hi technique was modified for the pediatric patient by using a lower flow through the nasal cannula (4 L). No major changes in SpO<sub>2</sub> were detected during the 30-minute procedure. With back up airway safety equipment in place, STRIVE is proving to be a safe technique with major advantages when used in this unique scenario.展开更多
文摘Airway management is a skill necessary for healthcare providers who manage patients. Intubation is a skill that both anesthesiologists and intensivists use daily. We present a case of a neonate that developed significant worsening stridor after a successful intubation for a hernia repair. After 4 intubation attempts, with easy visualization of the vocal cords and unsuccessful placement of the endotracheal tube, the patient was emergently brought to the operating room for evaluation.
文摘BACKGROUND: Airway management in intensive care unit(ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy(DL) and that by using the video laryngoscopy(VL).METHODS: A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success. RESULTS: A total of 163 ICU patients underwent intubation during the study period(81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group(67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications(all P>0.05). CONCLUSION: Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.
文摘Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.
基金the Ethics and Research Committee of University Hospital Sharjah,No.UHS-HERC-014-30072019.
文摘BACKGROUND In anesthesia practice,orotracheal intubation remains the primary concern of the anesthesiologist.The introduction of video laryngoscopy(VL)has increased the success rate of orotracheal intubation;however,conflicting results have been reported regarding the usefulness of the current technique with VL in clinical practice.AIM To describe a modification to improve intubation with VL,followed by evaluation of the practice in vivo.METHODS First,a mannequin trial was conducted with operators having different experience and background.Then,a retrospective analysis was performed for an>1-year period with patients who underwent general anesthesia with orotracheal intubation.The endotracheal tube used had been pre-formed with two curves.Stepwise intubation had been performed with direct eye vision,followed by screen assistance and rotation of the tube as needed to direct it toward the glottis.In the mannequin trial,the outcome measures were quantification of torque(force with angular acceleration during levering),need for external maneuvers,and time to intubate.In the clinical experience,orotracheal intubation used VL(pre-formed tube)or direct laryngoscopy(DL)at the anesthetist’s discretion and throat discomfort was reported by the patient.RESULTS In the mannequin trials using VL,there was less torque with the pre-formed tube than with a regular tube(8%and 65%,respectively).The first-pass rate was higher with the pre-formed tube(95%)than with a regular tube(81%).However,the time to intubate was longer with the pre-formed tube than with a regular tube(22 s and 12 s,respectively).In clinical practice,562 patients underwent surgery under general anesthesia with orotracheal intubation using either VL(n=244)or DL(n=318)at the discretion of the attending anesthetist.VL was specifically planned in 62 of the patients,due to anticipated difficulty.Second attempts by readjustment of the curve of the tube were significantly fewer with VL than with DL(10%vs 18%).Throat discomfort was reported by fewer patients who underwent VL than those who underwent DL(6%vs 24%).CONCLUSION Pre-formed endotracheal tube with stepwise insertion produces less torque,fewer external maneuvers and higher first-pass success rate during VL intubation.Further,prospective studies are warranted.
基金This research was supported by the Special Project of Technological Innovation and Application Development of Chongqing,China(Grant NO.cstc2019jscx-msxmX0248).
文摘Purpose:As common clinical screening tests cannot effectively predict a difficult airway,and unanticipated difficult laryngoscopy remains a challenge for physicians.We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy.Methods:This prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment.Patients under 18 years old,or with maxillofacial deformities or fractures,limited mouth opening,limited neck movement or history of neck surgery were excluded from the study.Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane(CL)scoring system.The measurements acquired comprised tongue width,the longitudinal cross-sectional area of the tongue,tongue volume,the mandible-hyoid bone distance,the hyoid boneglottis distance,the mandible-hyoid bone-glottis angle,the skin-thyrohyoid membrane distance,the glottis-superior edge of the thyroid cartilage distance(DGTC),the skin-hyoid bone distance,and the epiglottis midway-skin distance.ANOVA and Chi-square were used to compare differences between groups.Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram.R version 3.6.3 and SPSS version 26.0 were used for statistical analyses.Results:Difficult laryngoscopy was indicated in 49 patients(CL grade III-IV)and easy laryngoscopy in 453 patients(CL grade I-II).The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups(p<0.001).Difficult laryngoscopy was predicted by an area under the curve(AUC)of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5and by an AUC of 0.722 with a threshold DGTC of 1.22 cm.The longitudinal cross-sectional area of the tongue,tongue width,tongue volume,the mandible-hyoid distance,and the hyoid-glottis distance did not significantly differ between the groups.Conclusion:Difficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid boneglottis angle is smaller than 125.5or DGTC is larger than 1.22 cm.
基金This study was supported by a grant from the National Natural Science Foundation of China (No. 81370112).
文摘Background: Unpredictable difficult laryngoscopy (DL) remains a challenge for anesthesiologists, especially when difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common airway assessment methods only perform superficial screening. Thus, the deep laryngopharyngeal anatomy may not be evaluated. Ultrasound-based airway assessment has been recently proposed as a useful, simple, and non-invasive bedside tool as an adjunct to clinical methods, which may facilitate identification of DL. The present study aimed to determine the correlation between ultrasound-measured indicators and DL. Methods: Patients undergoing elective surgery under general anesthesia with tracheal intubation were enrolled. Ultrasonic airway assessments were performed before anesthesia induction. Ultrasound diagnostic indicators included the thickness and width of the base of the tongue, the angle between the epiglottis and glottis, the length of the thyrohyoid membrane, and the thickness of the lateral pharyngeal wall. A score of ≥3 in the Modified Cormack-Lehane Scoring System was used as a standard of DL and was also applied to divide patients into DL and non-DL groups. The area under the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic ability of various diagnostic indicators. Results: A total of 499 patients were enrolled into non-DL and DL groups comprising 452 (452/499, 90.6%) and 47 (47/499, 9.4%) patients, respectively. One ultrasonic diagnoses indicator correlated with DL, namely, the angle between the epiglottis and glottis. When the angle between the epiglottis and glottis was 50°, the area under the ROC curve was maximum (0.902), and the best sensitivity (81%) and specificity (89%) were achieved. Conclusions: Airway ultrasounds should be considered to identify DL. The ultrasonic angle measured between the epiglottis and glottis is highly associated with DL, which may occur when the angle is less than 50°. Clinical trial registration:
文摘Objectives: To evaluate the diagnostic accuracy of flexible fiberoptic examinations of the larynx recorded onto smartphones. Methods: Prospective, blinded study of inpatients requiring laryngoscopy. A live exam was per-formed, then a smartphone was attached to the endoscope using a novel coupling device and the same examination was recorded. The live and recorded exams were evaluated by two lar-yngologists, each blinded to the findings of the other. Results: Eighteen subjects were evaluated. Evaluation of airway patency was identical (Kappa = 1.0 [1, 1]). Evaluation of vocal cord motion was identical for 14 subjects: 9 normal, 3 paretic, 2 paralytic (Kappa = 0.69 [0.38, 1]). Conclusion: There is high correlation between laryngeal diagnoses using live flexible fiberoptic laryngoscopy and recordings using a coupling device to transfer the recordings on to smart-phones. Critical findings such as airway patency and vocal fold motion showed the highest cor-relation.
文摘The use of SponTaneous Respiration using IntraVEnous anesthesia and High-flow nasal oxygen (STRIVE-Hi) in laryngeal surgery has become more widely reported. This method eliminates the endotracheal tube as a fuel for a potential fire. However, little has been published on its use in the pediatric population. Our case report describes its use in a 2-year-old undergoing micro-direct laryngoscopy with CO<sub>2</sub> assisted supraglottoplasty and rigid bronchoscopy for airway obstruction from congenital laryngomalacia. The STRIVE-Hi technique was modified for the pediatric patient by using a lower flow through the nasal cannula (4 L). No major changes in SpO<sub>2</sub> were detected during the 30-minute procedure. With back up airway safety equipment in place, STRIVE is proving to be a safe technique with major advantages when used in this unique scenario.
