Airway

Techniques and complications of awake fibre-optic intubation

A survey of Difficult Airway Society members sheds light on awake fibre optic intubation practices.

Most respondents (48%) had performed less than 5 within the last 2 years. Some (10%) had not performed any during this period.

Remifentanil was the most common sedative with local topicalisation and spray-as-you-go local anesthesia.

Complications did not differ between techniques, and included desaturation, multiple attempts or failed intubation.

The low numbers are a cause for concern in this still core technique and expert guidelines are awaited.

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Checking mask ventilation before neuromuscular block

The outdated and misguided notion of there being safety in checking mask ventilation before giving the muscle relaxant persists as shown in this Swedish survey.

“The most common reason for checking mask ventilation was “to gather information about the airway,” while the reason for not using was mostly “that muscle relaxation often improves mask ventilation.”

The latter has been shown to be the case. In any event the difficult airway is already lost after Propofol. Airway guidelines need to incorporate this knowledge in guidelines.

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Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy

The decline is Succinylcholine use has been expedited by the arrival of Sugammadex. Succinylcholine is often still preferred where the risk of aspiration is deemed higher.

This study compared rapid sequence induction (RSI) with modified rapid sequence induction (mRSI) in infants.

The conclusion found mRSI acceptable practice: “In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.”

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

This study assessed the value of commonly used predictors of fitness for extubation in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.

Their conclusions:

“Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.”

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

This retrospective study is cause for concern in Pediatric and Neonatal Anesthesia.

In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies with a 35% hypoxia incidence, and 9% bradycardia incidence.

Multiple laryngoscopies were associated with hypoxia and while this population has airway challenges, there is a need to do better with training and equipment.

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis

This latest malpractice analysis still leaves concern for the outcomes in difficult tracheal intubation, showing outcomes still remain poor. Death is still a not uncommon occurrence.

The authors summarize: “Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.”

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Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials

All modern guidelines are in agreement with daily interruption of sedation in the ICU and spontaneous breathing trials but weaning strategies can differ.

This study found: “a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials.”

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Cannula based cricothyrotomy

Most experts have shifted to the scalpel technique with bougie for emergency front of neck airway (eFONA).

This high fidelity lab simulation however showed a lesser chance of failure with a cannula based technique and using a Rapid‐O2® cricothyroidotomy insufflation device.

With proper training the authors suggest that there is still a strong case for using a cannula based technique. Much anatomical distortion and difficulty has often been reported with locating the cricothyroid membrane especially in the obese as well as misplacement of the tube.

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i-gel® insertion and cricothyroid membrane identification

This small study examined cricothyroid membrane identification in adult females, whose anatomy is less pronounced than males. They concluded:

“The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy”.

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