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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.

Patients receiving mechanical ventilation via orotracheal intubation (OTI-MV) in the ICU are often ordered to have nothing by mouth (‘nil per os’, NPO) which can lead to an intensified sensation of thirst. Although the issue of thirst has been acknowledged in clinical practice, there is limited research specifically addressing this population, particularly regarding the methods, frequency, and safe dosages of administration. The study, based on the Symptom Management Theory (SMT), formulates a thirst management strategy. It aims to evaluate the effects of different methods, temperatures, and doses, and the safety of a larger dose of 5 mL. A total of 84 participants were randomly assigned to one of three groups: Group A received a 1.6 mL injection of water at room temperature (20–26 °C), Group B received a 1.6 mL spray of cold water (2–6 °C), and Group C received a 5 mL spray of cold water (2–6 °C). Thirst symptoms were assessed using a total of 12 subjective and objective indicators, including the Thirst Intensity Scale, Thirst Distress Scale, Sleep Quality Scale, Oral Mucous Wetness Scale, Number of Additional Interventions, and Adverse Events. The improvement in thirst was greatest in Group C, followed by Group B, and then Group A. In terms of thirst distress, sleep quality, oral mucous wetness, and the number of additional interventions, the cold water spray had the better effect. There was no statistically significant difference in adverse events among the three groups. The spray method was superior to the injection method, cold water was more effective than room temperature water, and the 5 mL dosage outperformed the 1.6 mL. This dosage is considered safe. Thirst management based on SMT proves to be an effective strategy; the 5 mL cold water spray method is safe and effective, offering empirical support for clinical practice.

Background The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation. Methods In this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality. Results Of 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group ( p  = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively ( p  = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days ( p  = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group ( p  = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ. Conclusion The use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape. Trial registration ClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018

Failure to secure the airway is an important cause of morbidity and mortality during resuscitations. We compared the rate of successful intubation of the King Vision™ aBlade™ channeled and non-channeled video laryngoscopes, and McGRATH™ MAC video laryngoscope when used by junior doctors to intubate a simulated difficult airway in an out-of-hospital setting. 105 junior doctors were recruited in a crossover study to perform tracheal intubation with the three video laryngoscopes on a simulated difficult airway using the SimMan® 3G manikin. Primary outcome was the rate of successful intubations. Secondary outcomes were time-to-visualization, time-to-intubation and ease of use. Rates of successful intubations were higher for King Vision channeled and McGrath compared to the King Vision non-channeled (85.7% and 82.9% respectively versus 24.8%; p<0.001). Amongst the participants who had successful intubations, King Vision channeled and McGrath had shorter mean time-to-intubation compared to the King Vision non-channeled (41.3±20.3s and 38.5±18.7s respectively versus 53.8±23.8s, p<0.004;). There was no significant difference in the rate of successful intubation and mean time-to-intubation between King Vision channeled and McGrath. The King Vision channeled and McGrath video laryngoscopes demonstrated superior intubation success rates compared to King Vision non-channeled laryngoscope when used by junior doctors for intubating simulated difficult airway in an out-of-hospital setting. We postulated that the presence of a guidance channel in the King Vision channeled laryngoscope and the familiarity of the blade curvature and handling of the McGrath could have accounted for their improved intubation success rates.

Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited. To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit. We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding. A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008). Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

BackgroundWhen intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant’s weight. ETTs are frequently incorrectly positioned in newborns, most often inserted too far. Using the vocal cord guide (a mark at the distal end of the ETT) to guide insertion depth has been recommended.ObjectiveTo determine whether estimating ETT insertion depth using the vocal cord guide rather than weight results in more correctly positioned ETT tips.DesignSingle-centre randomised controlled trial.SettingLevel III neonatal intensive care unit (NICU) at a university maternity hospital (National Maternity Hospital, Dublin, Ireland).PatientsNewborn infants without congenital anomalies intubated in the NICU.InterventionsParticipants were randomised to have ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) +6] or vocal cord guide.Main outcome measureCorrect ETT position, that is, tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray as determined by one paediatric radiologist masked to group assignment.Results136 participants were randomised. The proportion of correctly positioned ETTs was similar in both groups (weight 30/69 (44%) vs vocal cord guide 27/67 (40%), p=0.731). Most incorrectly positioned ETT (69/79, 87%) were too low.ConclusionEstimating ETT insertion depth using the vocal cord guide did not result in more correctly positioned ETT tips.Trial registration numberISRCTN39654846.

Endotracheal intubation is the gold standard for airway management. Supraglottic airway devices (SADs) are useful in airway abnormalities. SAD blind intubation enables airway management with better ventilation and a reduced risk of gastric content aspiration. The aim was to compare various SADs in blind intubation performed by inexperienced physicians in several pediatric airway scenarios. One hundred sixteen physicians with no previous experience with SAD performed blind endotracheal intubations with (1) iGEL, (2) Air-Q intubating laryngeal airway, and (3) Ambu AuraGain disposable laryngeal mask in a pediatric manikin in three airway scenarios: (A) normal airway without chest compressions, (B) normal airway with continuous chest compressions with the CORPULS CPR system, and (C) difficult airway with continuous chest compressions with the CORPULS CPR system. Intubation tube with 5.0 internal diameter was used for all blind intubation attempts. First intubation success rate, median time to SAD placement, time to endotracheal intubation with SAD, and ease to perform the intubation were investigated in this study. All these parameters were better or non-inferior for iGEL in all investigated scenarios.Conclusion: Our manikin study demonstrated that iGEL was the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios.What is Known:• For pediatric resuscitation, bag-mask ventilation is the first-line method for airway control and ventilation.• Endotracheal intubation is considered by many scientific societies the gold standard for airway management.• Supraglottic airway devices are particularly useful when bag-mask ventilation is difficult or impossible but can be also used for blind intubation.What is New:• The iGEL laryngeal mask turns out the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios.• It may be a reasonable first emergency blind intubation technique for inexperienced physicians in pediatric patients in normal airway with and without continuous chest compressions, as well as in difficult airway with continuous chest compressions.

Background The video laryngoscope is recommended for intubating difficult airways. The present study aimed to determine whether the video laryngoscope can further improve intubation success rates compared with the direct laryngoscope in patients with non-difficult airways. Methods In total, 360 patients scheduled for elective abdominal surgeries were randomly assigned to undergo intubation using either a video laryngoscope ( n  = 179) or a direct laryngoscope ( n  = 181). The following parameters were measured: mouth opening; thyromental distance; sternomental distance; shape angle of the tracheal catheter; and glottic exposure grade. Results The percentage of patients with level I-II of total glottic exposure in the video laryngoscope group was 100% versus 63.5% in the direct laryngoscope group ( P  < 0.001). The one-attempt success rate of intubation was 96.1% using a video laryngoscope versus 90.1% using a direct laryngoscope ( P  = 0.024). The intubation success rate using a video laryngoscope was 100% versus 94.5% using a direct laryngoscope ( P  = 0.004). Immediate oropharyngeal injury occurred in 5.1% of patients intubated using a direct laryngoscope versus 1.1% using a video laryngoscope ( P  = 0.033). On postoperative day 1, obvious hoarseness was exhibited by 7.9% of patients intubated using a direct laryngoscope versus 2.8% using a video laryngoscope ( P  = 0.035). The grade of glottic exposure and catheter shape angle were independent risk factors for tracheal intubation failure. Thyromental distance, shape angle, glottic exposure time, and surgical position were independent risk factors for postoperative complications. Thyromental distance and glottic exposure time were independent risk factors for complications lasting > 2 days. Conclusions Intubation using a video laryngoscope yielded significantly higher intubation success rates and significantly fewer postoperative complications than direct laryngoscopy in patients with non-difficult airways. Trial registration Chinese Clinical Trial Registry. No: ChiCTR-IOR-16009023 . Prospective registration.

The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014-June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = -10.3%, 95% confidence interval (CI), -14.8% to -5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = -10.7%, 95% CI, -17.3% to -4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = -21.4%, 95% CI, -27.0% to -16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33]. FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.

Background Postoperative sore throat (POST) is a common problem following endotracheal (ET) intubation during general anesthesia. The objective was to compare the incidence and severity of POST during routine intubation with Glidescope (GL) and Macintosh laryngoscope (MCL). Methods One hundred forty adult patients ASA I and II with normal airway, scheduled to undergo elective surgery under GA requiring ET intubation were enrolled in this prospective randomized study and were randomly divided in two groups, GL and MCL. Incidence and severity of POST was evaluated at 0, 6, 12 and 24 h after surgery. Results At 0 h, the incidence of POST was more in MCL than GL ( n  = 41 v.s n  = 22, P  = 0.001), and also at 6 h after surgery ( n  = 37 v.s n  = 23, P  = 0.017). Severity of POST was more at 0, 6 and 12 h after surgery in MCL ( P  < 0.001, P  = 0.001, P  = 0.004 respectively). Conclusions Routine use of GL for ET tube placement results in reduction in the incidence and severity of POST compared to MCL. Trial regisration ClinicalTrials.gov NCT02848365 . Retrospectively Registered (Date of registration: July, 2016).