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In this randomized trial, the use of video laryngoscopy in critically ill patients undergoing intubation in the ED or ICU resulted in a higher incidence of successful intubation on the first attempt than direct laryngoscopy.

Intubation in neonates is challenging, and repeated attempts are associated with adverse events. Among neonates undergoing urgent intubation, video laryngoscopy resulted in more successful first attempts than direct laryngoscopy.

Among critically ill adults undergoing tracheal intubation, hypoxemia increases the risk of cardiac arrest and death. The effect of preoxygenation with noninvasive ventilation, as compared with preoxygenation with an oxygen mask, on the incidence of hypoxemia during tracheal intubation is uncertain. In a multicenter, randomized trial conducted at 24 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults (age, ≥18 years) undergoing tracheal intubation to receive preoxygenation with either noninvasive ventilation or an oxygen mask. The primary outcome was hypoxemia during intubation, defined by an oxygen saturation of less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation. Among the 1301 patients enrolled, hypoxemia occurred in 57 of 624 patients (9.1%) in the noninvasive-ventilation group and in 118 of 637 patients (18.5%) in the oxygen-mask group (difference, -9.4 percentage points; 95% confidence interval [CI], -13.2 to -5.6; P<0.001). Cardiac arrest occurred in 1 patient (0.2%) in the noninvasive-ventilation group and in 7 patients (1.1%) in the oxygen-mask group (difference, -0.9 percentage points; 95% CI, -1.8 to -0.1). Aspiration occurred in 6 patients (0.9%) in the noninvasive-ventilation group and in 9 patients (1.4%) in the oxygen-mask group (difference, -0.4 percentage points; 95% CI, -1.6 to 0.7). Among critically ill adults undergoing tracheal intubation, preoxygenation with noninvasive ventilation resulted in a lower incidence of hypoxemia during intubation than preoxygenation with an oxygen mask. (Funded by the U.S. Department of Defense; PREOXI ClinicalTrials.gov number, NCT05267652.).

Hypoxemia during tracheal intubation may increase the risk of cardiac arrest and death. In this multicenter trial, adults undergoing tracheal intubation were randomly assigned to receive bag-mask ventilation during the interval between induction and laryngoscopy or no ventilation. Bag-mask ventilation increased oxygen saturation as compared with no ventilation.

Purpose High-flow nasal cannula oxygen (HFNC) has the potential to provide apnoeic oxygenation. We decided to assess in a proof-of-concept study whether the addition of HFNC to non-invasive ventilation (NIV) could reduce oxygen desaturation during intubation, compared with NIV alone for preoxygenation, in severely hypoxaemic intensive care unit (ICU) patients with respiratory failure. Methods We conducted a randomised, controlled, single-centre trial with assessor-blinded outcome assessment in patients admitted to the ICU. Hypoxaemic patients requiring orotracheal intubation for respiratory failure were randomised to receive preoxygenation using HFNC [flow = 60 L/min, fraction of inspired oxygen (FiO 2 ) = 100 %] combined with NIV (pressure support = 10 cmH 2 O, positive end-expiratory pressure = 5 cmH 2 O, FiO 2  = 100 %) in the intervention group or NIV alone in the reference group prior to intubation. The primary outcome was the lowest oxygen saturation (SpO 2 ) during the intubation procedure. Secondary outcomes were intubation-related complications and ICU mortality. Results Between July 2015 and February 2016, we randomly assigned 25 and 24 patients to the intervention and reference groups, respectively. In both groups the main reasons for respiratory failure were pneumonia and ARDS. During the intubation procedure, the lowest SpO 2 values were significantly higher in the intervention group than in the reference group [100 (95–100) % vs. 96 (92–99) %, p  = 0.029]. After exclusion of two patients from analysis for protocol violation, no (0 %) patients in the intervention group and five (21 %) patients in the reference group had SpO 2 below 80 % ( p  = 0.050). We recorded no significant difference between the groups in intubation-related complications or ICU mortality. Conclusions A novel strategy for preoxygenation in hypoxaemic patients, adding HFNC for apnoeic oxygenation to NIV prior to orotracheal intubation, may be more effective in reducing the severity of oxygen desaturation than the reference method using NIV alone.

Visual laryngoscope, as the most commonly used tracheal intubation tool in clinical practice, has a high intubation success rate and is quick to learn, but there are risks of over flexion of the neck, tooth loss, etc. The visual stylet helps to make up for these shortcomings. This study aimed to compare the effects of the visual stylet and visual laryngoscope on transoral single lumen tracheal intubation in non-difficult airways. The primary outcome was intubation time, and secondary outcomes included glottic exposure time, first success rates, hemodynamic indices, intubation-related complications. A total of 148 patients were included, with 75 in the visual stylet (VS) group and 73 in the visual laryngoscope (VL) group. The intubation time in the VS group was 35 (11) seconds, significantly shorter than the 41 (9) seconds in the VL group ( P  < 0.001). Immediately post-intubation, the MAP in the VS group was 80 (20.5) mmHg, lower than 87 (23) mmHg in the VL group ( P  < 0.01). Intubation-related complications are also lower in VS group compared to VL group. Other outcomes don’t have significant difference. Our study has demonstrated that the visual stylet significantly reduces intubation time and provides more stable hemodynamics. For patients with limited mouth opening, shorter thyromental distance, or higher Cormack-Lehane grades, the visual stylet may potentially be a better choice compared to video laryngoscopy for tracheal intubation. Trial registration China Clinical Trial Registry (ChiCTR2100051812) (05/10/2021).

In this randomized, controlled trial involving neonates in two Australian tertiary neonatal intensive care units, nasal high-flow therapy during neonatal endotracheal intubation increased the likelihood of successful intubation on the first attempt without physiological instability.

Background Out-of-hospital cardiac arrest remains a major challenge due to its high incidence and low survival rates. In recent decades, research has focused on the performance of chest compressions and improvements in early defibrillation, while the optimal ventilation strategy remains unclear. Despite the lack of monitoring systems, manual bag-valve-device ventilation is still common. Given the potential impact of both the applied volumes and the ventilation pressures on hemodynamics and resuscitation efforts, the present study investigated the effects of various airway devices on the target parameters of ventilation therapy during manual intra-arrest ventilation. Methods Thiel-embalmed human cadavers were included in a standardized resuscitation scenario. Ventilation was performed in a randomized order using various airway devices (tracheal tube (ET), supraglottic airway devices (SGA): laryngeal mask airway, laryngeal tube, i-gel ® laryngeal mask) and manual bag-valve-device ventilation. Chest compressions were performed via Corpuls-CPR. Ideal (Vt ideal ), expiratory (Vt e ) and inspiratory (Vt i ) tidal volumes; leakage volume (V leak ); and peak (P peak ) and mean (P mean ) pressures were recorded. The primary efficacy endpoint was the difference between Vt ideal and Vt e (∆Vt). Results Eleven cadavers were included (mean age at the time of death: 84 ± 3.7 years, male = 7 [63.6%]). During ventilation with ET, the following mean values were measured: ΔVt, 142.2 ± 125.5 ml; Vt e, 245.1 ± 91.2 ml; V leak, 17.9 ± 15.3%; P mean, 4.0 ± 1.5 mbar; and P peak, 47.7 ± 14.9 mbar. During ventilation with SGA, however, the mean values were ΔVt, 202.0 ± 153.1 ml; Vt e, 183.8 ± 122.1 ml; V leak, 39.0 ± 23.5%; P mean, 3.1 ± 1.0 mbar; and P peak, 39.0 ± 10.0 mbar. Comparison of the two groups revealed lower ΔVt values (regression coefficient [RC] = –61.07 ml, 95% confidence interval [95% CI] = [–93.58;–28.55], p = 0.0003) and V leak values (RC = –20.98%, 95% CI = [–26.63;–15.33], p<0.0001), but higher Vt e values (RC = 61.14 ml, 95% CI = [28.63;93.65], p = 0.0003), P mean values (RC = 0.90 mbar, 95% CI = [0.59;1.21], p<0.0001), and P peak values (RC = 11.46 mbar, 95% CI = [8.65;14.26], p<0.0001) in the ET group. There was no evidence for differences in ΔVt among the cadavers in the SGA group. Conclusion The ∆Vt was lower in the ET group than the SGA group, whereas there was no evidence for differences in ∆Vt among the devices in the SGA group. Trial registration clinicaltrials.gov; Unique identifier: NCT06306898, Registration date: 5 March 2024.

Background Patients with acute hypoxemic respiratory failure are at risk for life-threatening complications during endotracheal intubation. Preoxygenation might help reduce the risk of hypoxemia and intubation-related complications. This network meta-analysis summarizes the efficacy and safety of preoxygenation methods in adult patients with acute hypoxemic respiratory failure. Methods We searched PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2019 for randomized controlled trials (RCT) that studied the use of conventional oxygen therapy (COT), high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and HFNC and NIV as preoxygenation before intubation in patients with acute hypoxemic respiratory failure. Citations’ screening, study selection, data extraction, and risk of bias assessment were independently performed by two authors. The primary outcome was the lowest SpO 2 during the intubation procedure. Results We included 7 RCTs (959 patients). Patients preoxygenated with NIV had significantly less desaturation than patients treated with COT (mean difference, MD 5.53, 95% CI 2.71, 8.34) and HFNC (MD 3.58, 95% CI 0.59, 6.57). Both NIV (odds ratio, OR 0.43, 95% CI 0.21, 0.87) and HFNC (OR 0.49, 95% CI 0.28, 0.88) resulted in a lower risk of intubation-related complications than COT. There were no significant mortality differences among the use of NIV, HFNC, COT, and HFNC and NIV during preoxygenation. Conclusions In adult patients with acute hypoxemic respiratory failure, NIV is a safe and probably the most effective preoxygenation method.

Purpose Preoxygenation with high-flow therapy by nasal cannulae (HFNC) is now widespread in the intensive care unit (ICU). However, no large randomized study has assessed its relevance in non-severely hypoxemic patients. In a randomized controlled trial (PROTRACH study), we aimed to evaluate preoxygenation with HFNC vs. standard bag-valve mask oxygenation (SMO) in non-severely hypoxemic patients during rapid sequence intubation (RSI) in the ICU. Methods Randomized controlled trial including non-severely hypoxemic patients requiring intubation in the ICU. Patients received preoxygenation by HFNC or SMO during RSI. HFNC was maintained throughout the intubation procedure whereas SMO was removed to perform laryngoscopy. The primary outcome was the lowest pulse oximetry (SpO 2 ) throughout the intubation procedure. Secondary outcomes included drop in SpO 2 , adverse events related to intubation, and outcome in the ICU. Results A total of 192 patients were randomized. In the intent-to-treat analysis, 184 patients (HFNC n  = 95; SMO n  = 89), the median [IQR] lowest SpO 2 was 100% [97; 100] for HFNC and 99% [95; 100] for the SMO group ( P  = 0.30). Mild desaturation below 95% was more frequent with SMO (23%) than with HFNC (12%) (RR 0.51, 95% CI 0.26–0.99, P  = 0.045). There were fewer adverse events in the HFNC group (6%) than in the SMO group (19%) (RR 0.31, 95% CI 0.13–0.76, P  = 0.007), including fewer severe adverse events, respectively 6 (6%) and 14 (16%) with HFNC and SMO (RR 0.38, 95% CI 0.15–0.95, P  = 0.03). Conclusions Compared with SMO, preoxygenation with HFNC in the ICU did not improve the lowest SpO 2 during intubation in the non-severely hypoxemic patients but led to a reduction in intubation-related adverse events. Trial registration Clinical trial Submission: 7 March 2016. Registry name: Benefits of high-flow nasal cannulae oxygen for preoxygenation during intubation in non-severely hypoxemic patients: the PROTRACH study. Clinicaltrials.gov identifier: NCT02700321. Eudra CT: 2015-A00145-44. CPP: 15/13-975 (Comité de protection des personnes de Rennes). URL registry: https://clinicaltrials.gov/ct2/show/record/NCT02700321 .