Factors influencing the continuity of evidence-based practice in perioperative airway management for elderly patients with fractures:A qualitative study

BACKGROUND More and more evidence-based practices are emerging,but researchers mostly focus on short-term effects,resulting in evidence-based practices not being applied in the clinic in the long term.In this study,we took the evidence-based practice of perioperative airway management in elderly fracture patients as an example and adopted a descriptive phenomenological approach to understand the influencing factors of its sustainability to provide a reference basis for promoting the continuity of evidence-based practice in the clinic.AIM To explore factors influencing the persistence of evidence-based practice in perioperative airway management in elderly patients with fractures.METHODS This study was qualitative research.Nine nurses who implemented evidencebased practice in the orthopedic ward of a tertiary comprehensive hospital in Shanghai from September 2023 to October 2023 were selected using purposive sampling as research subjects.Semi-structured interviews were conducted with them,and the data were analyzed using the Colaizzi phenomenological analysis method based on the three dimensions and ten factors of the NHS sustainability model.RESULTS Three main themes and ten subthemes were identified:Process aspects(benefits to patients,benefits to nurses,lack of follow-up,complex processes);staff aspects(insufficient human resources,inadequate training and education,lack of leadership support);and organizational environment aspects(inadequate infrastructure,poor patient compliance,poor doctor cooperation).CONCLUSION Human resources,training and education,leadership support,infrastructure,and patient-physician collaboration are important factors influencing the sustainability of evidence-based practice for perioperative airway management in older patients with fractures.

Airway management of a patient with linear immunoglobulin A bullous dermatosis:A case report

BACKGROUND There is limited literature on managing the airway of patients with linear immunoglobulin A(IgA)bullous dermatosis,a rare mucocutaneous disorder that leads to the development of friable bullae.Careful clinical decision making is necessary when there is a risk of bleeding into the airway,and a multidisciplinary team approach may lead to decreased patient morbidity during these high-risk scenarios,especially when confronted with an unusual cause for bleeding.CASE SUMMARY A 45-year-old African American female presented to our ambulatory surgical center for right corneal transplantation due to corneal perforation after blunt trauma in the setting of cicatricial conjunctivitis and diffuse corneal neovascularization from linear IgA bullous dermatosis.The diagnosis of IgA dermatosis was recent,and the patient had been lost to follow-up.The severity of the disease and extent of airway involvement was unknown at the time of the surgery.Significant airway bleeding was noticed upon intubation and the otorhinolaryngology team had to be called to the operating room.The patient required transfer to the intensive care unit where a multidisciplinary team was involved in her case.The patient was extubated on postoperative day 4.CONCLUSION A multidisciplinary approach to treating this disease is the best course of action before a surgical procedure.In our case,key communication between the surgery,anesthesia,and dermatology teams led to the quick and safe treatment of our patient’s disease.Ambulatory surgery should not be considered for these cases unless they are in full remission and there is no mucous membrane involvement.

Research on the Application of Evidence-Based Quality Control Circle to Improve the Implementation Rate of Airway Management Measures in Adult Critically Ill Patients

Objective: To explore the effect of evidence-based quality control circle (QCC) in improving the implementation rate of airway management measures in adult critically ill patients. Methods: Based on the Joanna Briggs Institute (JBI) evidence-based health care model, the best evidence of airway management in adult critically ill patients was obtained and applied to the clinic. Results: The total implementation rate of airway management measures in adult critically ill patients increased from 23.62% before the implementation of quality control circle to 88.82%, and the pulmonary infection rate in critically ill patients decreased from 42.31% to 21.74%, with statistical significance between the two groups (P 0.05). Conclusion: Evidence-based quality control circle activities can standardize the practice standards of airway management in critically ill patients, reduce the occurrence of patients’ airway related complications, and improve clinical outcomes.

Aspiration as the first-choice procedure for airway management in an infant with large epiglottic cysts: A case report

BACKGROUND Epiglottic cysts is a rare but potentially lethal supraglottic airway pathology in infants due to the high risk of cannot intubation or cannot ventilation.Awake fiberoptic intubation appeared to be the safest technique,but it is very challenging in infants with large epiglottic cysts.Even it has the risk of airway loss.We report that cyst aspiration is an effective treatment as the first-choice procedure for airway management in an infant with large epiglottic cysts.CASE SUMMARY A 46-day-old male infant weighing 2.3 kg presented to the emergency room with difficulty feeding,worsening stridor,and progressive respiratory distress.Epiglottic cysts was diagnosed,but fibro bronchoscopy examination failed,as the fiberoptic bronchoscope was unable to cross the epiglottic cysts to the trachea.The infant was transferred to the operating room for emergency cystectomy under general anesthesia.Spontaneous respiration was maintained during anesthesia induction,and cyst aspiration was performed as the first procedure for airway management under video laryngoscopy considering that the preoperative fibro bronchoscopy examination failed.Then,the endotracheal tube was intubated successfully.Cystectomy was performed uneventfully,and the infant was safely transferred to the intensive care unit after surgery.The infant was extubated smoothly on the third postoperative day and discharged on the eighth day after surgery.On follow-up 1 year after the surgery,a normal airway was found by fibro bronchoscopy examination.CONCLUSION Epiglottic cyst aspiration can be considered the first procedure for airway management in infants with large epiglottic cysts.

Airway management training program for nurses via online course in COVID-19 preparedness

BACKGROUND Nursing officers are an integral component of any medical team.They participate in taking care of basic airway management and assist in advanced airway management,specifically amidst the current coronavirus disease 2019(COVID-19)pandemic.AIM To assess the efficacy of a standardized web-based training module for nurses in preparedness to fight against COVID-19.METHODS The training was held in three sessions of 1 h each,consisting of live audio-visual lectures,case scenarios,and skill demonstrations.The sequence of airway equipment,drug preparation,airway examination,and plans of airway management was demonstrated through mannequin-based video-clips.RESULTS Pre-and post-test scores as well as objective structured clinical examination scores were analyzed using Student’s t-test and the Likert scale was used for feedback assessment.It was found that the mean score out of the total score of 20 was 8.47±4.2 in the pre-test,while in the post-test it was 17.4±1.8(P value<0.001).The participants also felt self-reliant in executing the roles of airway assistant(63.3%)and drug assistant(74.3%).Fear of self-infection with COVID-19 was also high,as 66%of participants feared working with the patient’s airway.CONCLUSION Amidst this COVID-19 emergency,when the health care systems are being persistently challenged,training of nursing staff in the safe conduct of airway management can ensure delivery of life-saving treatment.

Prehospital difficult airway management:old things still work

To the Editor：Airway management is a crucial skill for emergency physician, who＇s often called to deal with difficult airways and requests for quick, simple and effective responses, as the many factors responsible for difficulties might be enhanced by emergency setting.[1] We now have many rescue devices as the LMA, I-gel, but they do not provide a definitive airway, and recent studies evaluating the use of the videolaryngoscopes in emergency show conflicting results.

Current state and influencing factors in airbag management among emergency department nurses:A multicenter study

BACKGROUND The emergency department(ED)plays a critical role in establishing artificial airways and implementing mechanical ventilation.Managing airbags in the ED presents a prime opportunity to mitigate the risk of ventilator-associated pneumonia.Nonetheless,existing research has largely overlooked the understanding,beliefs,and practical dimensions of airway airbag management among ED nurses,with a predominant focus on intensive care unit nurses.AIM To investigate the current status of ED nurses'knowledge,beliefs,and practical behaviors in airway airbag management and their influencing factors.METHODS A survey was conducted from July 10th to August 10th,2023,using convenience sampling on 520 ED nurses from 15 tertiary hospitals and 5 sary hospitals in Shanghai.Pathway analysis was utilized to analyze the influencing factors.RESULTS The scores for ED nurses'airway airbag management knowledge were 60.26±23.00,belief was 88.65±13.36,and behavior was 75.10±19.84.The main influencing factors of airbag management knowledge included participation in specialized nurse or mechanical ventilation training,department,and work experience in the department.Influencing factors of airbag management belief comprised knowledge,department,and participation in specialized nurse or mechanical ventilation training.Primary influencing factors of airbag management behavior included knowledge,belief,department,participation in specialized nurse or mechanical ventilation training,and professional title.The belief in airbag management among ED nurses acted as a partial mediator between knowledge and behavior,with a total effect value of 0.513,and an indirect effect of 0.085,constituting 16.6%of the total effect.CONCLUSION ED nurses exhibit a positive attitude toward airbag management with relatively standardized practices,yet there remains room for improvement in their knowledge levels.Nursing managers should implement interventions tailored to the characteristics of ED nurses'airbag management knowledge,beliefs,and practices to enhance their airbag management proficiency.

Clinical experience of airway management and tracheal intubation under general anesthesia in patients with scar contracture of the neck

Background Because patients with scar contracture of the neck are at a high risk of loss of the airway control after anesthesia induction, awake intubation is usually recommended. This retrospective clinical study was designed to evaluate the possibility, safety and efficacy of airway management and tracheal intubation under general anesthesia in such patients. Methods This retrospective study included 1683 patients from January 1994 to December 2006 with scar contracture of the neck, aged 1.5--67.0 years, who were scheduled for elective plastic surgery under general anesthesia in Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. Based on the results of the preoperative airway assessment, the patients were classified into group 1 （including 1375 patients with the atlanto-occipital extension of 〉20° and the Mallampatti＇s grade I or II） and group 2 （containing 308 patients with the atlanto-occipital extension of 〈20° and the Mallampatti＇s grade III or IV. In group 1, the intravenous induction and maintenance of anesthesia and succinylcholine for muscle relaxation were used. The intubation was done using a modified Macintosh technique. In group 2, the total intravenous anesthesia （TIVA） or the sevoflurane inhalation anesthesia was chosen and the spontaneous breathing was reserved during anesthesia. The intubation was performed by a fiberoptic stylet laryngoscope （FOSL）. The number of intubation attempts, intubation time and relative complications were observed and recorded in all patients. Results In group 1, the intubation was accomplished during the first attempt in 1279 cases （93%） and the intubation time was 〈3 minutes in 1304 cases （95%）. In group 2, the intubation was completed by the first attempt in 114 patients （37%） and 123 patients had an intubation time of 〈3 minutes （40%）. Tracheal intubation was successful by the second or third attempt in 96 patients in group 1 and 156 patients in group 2. Thirty-eight patients required four or more attempts which only occurred in group 2. The incidence of traumatic complication was 2.6% and 9.7% with one intubation attempt in groups 1 and 2, respectively, 12.5% and 17.0% with multiple intubation attempts （one vs multiple attempts in both groups, P 〈0.001）. All nontrauamatic complications occurred in group 2 and laryngospasm and hypoxemia were more common in patients using the TIVA compared to those using the sevoflurane inhalational anesthesia （P 〈0.001）. Conclusions This study demonstrated that with a precise airway evaluation, an adequate preoperative preparation and a pre-planned failed intubation strategy, the anesthetist who was experienced in the difficult airway management could safely perform airway control and tracheal intubation under general anesthesia in patients with scar contracture of the neck. We believe that this technique may be very valuable for the management of a known difficult airway because it is comfortable for the patient and saves time for the anesthetist.

Current Evidences for the Use of UEscope in Airway Management

Objective：UEscope is a new angulated videolaryngoscope （VL）.This review aimed to describe the features of UEscope and provide clinical evidences regarding the efficacy and safety of this video device in adult tracheal intubation and its roles in airway management teaching.Data Sources：The Wan Fang Data,CNKI,PubMed,Embase,Cochrane Library,and Google Scholar were searched for relevant English and Chinese articles published up to January 15,2017,using the following keywords：＂HC video laryngoscope＂,＂UE videolaryngoscope＂,＂video laryngoscope＂,and ＂videolaryngoscopy＂.Study Selection：Human case reports,case series,observable studies,and randomized controlled clinical trials were included in our search.The results of these studies and their reference lists were cross-referenced to identify a common theme.Results：UEscope features the low-profile portable design,intermediate blade curvatures,all-angle adjustable monitor,effective anti-fog mechanisms,and built-in video recording function.During the past 5 years,there have been a number of clinical studies assessing the application and roles of UEscope in airway management and education.As compared with direct laryngoscope,UEscope improves laryngeal visualization,decreases intubation time （IT）,and increases intubation success rate in adult patients with normal and difficult airways.These findings are somewhat different from the previous results regarding the other angulated VLs;they can provide an improved laryngeal view,but no conclusive benefits with regard to IT and intubation success rate.Furthermore,UEscope has extensively been used for intubation teaching and shown a number of advantages.Conclusions：UEscope can be used as a primary intubation tool and may provide more benefits than other VLs in patients with normal and difficult airways.However,more studies with large sample are still needed to address some open questions about clinical performance of this new VL.

How to Initiate and Perform Simulation-based Airway Management Training More Effectively and Efficiently in China？

INTRODUCTION While airway management is a fundamental skill set for many healthcare professionals, the difficult airway management has long been recognized as one of the most challenging tasks facing healthcare providers.As yet, failure to properly manage airway conditions remains a significant source of patients＆#39; morbidity and mortality.[1] To avoid or reduce medical errors and improve patient safety and outcomes, training for healthcare providers for airway management skills is essential.

Anesthetic considerations for patients with acute cervical spinal cord injury

Anesthesiologists work to prevent or minimize secondary injury of the nervous system and improve the outcome of medical procedures.To this end,anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan.Anesthesiologists should conduct careful physical examinations of patients and consider neuroprotection at preoperative interviews,consider cervical spinal cord movement and compression during airway management,and suggest awake fiberoptic bronchoscope intubation for stable patients and direct laryngoscopy with manual in-line immobilization in emergency situations.During induction,anesthesiologists should avoid hypotension and depolarizing muscle relaxants.Mean artery pressure should be maintained within 85–90 mmHg（1 mmHg = 0.133 kPa; vasoactive drug selection and fluid management）.Normal arterial carbon dioxide pressure and normal blood glucose levels should be maintained.Intraoperative neurophysiological monitoring is a useful option.Anesthesiologists should be attentive to postoperative respiratory insufficiency（carefully considering postoperative extubation）,thrombus,and infection.In conclusion,anesthesiologists should carefully plan the treatment of patients with acute cervical spinal cord injuries to protect the nervous system and improve patient outcome.

咽后间隙结节性甲状腺肿致喉梗阻1例

1临床资料患者,男,81岁,因“发现左颈部包块1年,发作性呼吸困难3个月”于2020-07-17入院。患者1年前左颈部出现包块,并呈进行性增大,未予特殊诊治。3个月前开始出现呼吸困难,伴有进食不畅,仅能半流质饮食,症状呈进行性加重,就诊于我院。查体可见患者神志清楚,平静状态下有轻度喉喘鸣,左颈部可见分叶状实性肿物,喉气管受压右移。颈部CT提示左颈部肿物,上起悬雍垂游离缘水平,下至胸骨柄水平(图1A)。喉镜检查提示咽侧及咽后壁隆起,堵塞声门入口。

Advances in clinical studies of cardiopulmonary resuscitation

BACKGROUND: The survival rate of patients after cardiac arrest(CA) remains lower since 2010 International Consensus on Cardiopulmonary Resuscitation(CPR) and Emergency Cardiovascular Care(ECC) was published. In clinical trials, the methods and techniques for CPR have been overly described. This article gives an overview of the progress in methods and techniques for CPR in the past years.DATA SOURCES: Original articles about cardiac arrest and CPR from MEDLINE(PubM ed) and relevant journals were searched, and most of them were clinical randomized controlled trials(RCTs).RESULTS: Forty-two articles on methods and techniques of CPR were reviewed, including chest compression and conventional CPR, chest compression depth and speed, defibrillation strategies and priority, mechanical and manual chest compression, advanced airway management, impedance threshold device(ITD) and active compression-decompression(ACD) CPR, epinephrine use, and therapeutic hypothermia. The results of studies and related issues described in the international guidelines had been testifi ed.CONCLUSIONS: Although large multicenter studies on CPR are still difficult to carry out, progress has been made in the past 4 years in the methods and techniques of CPR. The results of this review provide evidences for updating the 2015 international guidelines.

Large lingual heterotopic gastrointestinal cyst in a newborn:A case report

BACKGROUND Heterotopic gastrointestinal cysts have gastrointestinal epithelium in the cyst wall and rarely occur in the oral cavity.Most are found in the neonatal period.However,heterotopic gastrointestinal cysts that are diagnosed as a congenital tongue cyst by routine ultrasonography are extremely rare.CASE SUMMARY A 12-day-old female presented with swelling of the anterior tongue.The obstetrician had detected significant tongue swelling on fetal ultrasonography in the 35 th gestational week.The female was born by cesarean delivery at gestational week 39.She soon became dyspneic,and the cyst was aspirated.After the aspiration,her breathing recovered and she started breastfeeding.The cyst was excised under general anesthesia on the 67 th day.Histopathologic examination showed that that cyst wall consisted of a lining of columnar gastrointestinal-type epithelium and pseudostratified ciliated epithelium.The patient restarted breastfeeding 3 h after surgery.The postoperative course was uneventful.CONCLUSION Airway distress and feeding difficulty were successfully avoided by cyst aspiration,and surgical resection was performed with no perioperative complications.

Expert consensus on difficult airway assessment

Background:Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room(OR)and non-operation room sites.There are no guidelines or expert consensus focused on the assessment of the difficult airway before,so this expert consensus is developed to provide guidance for airway assessment,making this process more standardized and accurate to reduce airway-related complications and improve safety.Methods:Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology(CSA)met to discuss the first draft and then this was sent to 15 international experts for review,comment,and approval.The Grading of Recommendations,Assessment,Development and Evaluation(GRADE)is used to determine the level of evidence and grade the strength of recommendations.The recommendations were revised through a three-round Delphi survey from experts.Results:This expert consensus provides a comprehensive approach to airway assessment based on the medical history,physical examination,comprehensive scores,imaging,and new developments including transnasal endoscopy,virtual laryngoscopy,and 3D printing.In addition,this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.Conclusions:This consensus applies to anesthesiologists,critical care,and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

Accidental esophageal intubation via a large type C congenital tracheoesophageal fistula:A case report

BACKGROUND Tracheoesophageal fistula(TEF)is a congenital anomaly characterized by interruptions in esophageal continuity with or without fistulous communication to the trachea.Anesthetic management during TEF repair is challenging because of the difficulty of perioperative airway management.It is important to determine the appropriate position of the endotracheal tube(ETT)for proper ventilation and to prevent excessive gastric dilatation.Therefore,the tip of the ETT should be placed immediately below the fistula and above the carina.CASE SUMMARY A full-term,one-day-old,2.4 kg,50 cm male neonate was diagnosed with TEF type C.During induction,an ETT was inserted using video laryngoscope and advanced deeply to ensure that the tip passed over the fistula,according to known strategies.The passage of the ETT through the vocal cords was confirmed via video laryngoscope.However,after inflating the ETT cuff,breath sounds were not heard on bilateral lung auscultation.Instead,gastric sounds were heard.Considering that a large fistula(approximately 6.60 mm×4.54 mm)located 10.2mm above the carina was confirmed on preoperative tracheal computed tomography,the possibility of unintentional esophageal intubation was highly suspected.Therefore,we decided to uncuff and withdraw the ETT carefully for repositioning,while monitoring auscultation and end-tidal CO2 simultaneously.At a certain point(9.5 cm from the lip),clear breath sounds and proper end-tidal CO_(2) readings were suddenly achieved,and adequate ventilation was possible.CONCLUSION Preanesthetic anatomical evaluation with imaging studies in TEF is necessary to minimize complications related to airway management.

Submental tracheal intubation for resection of recurrent giant pituitary tumor:a case report

Airway management in the patients who receive transmaxillary approach for resection of giant pituitary tumor presents a clinical challenge to the anesthesiologists. Oral or nasal route for tracheal intubation can interfere with surgical procedures. This report describes submental tracheal intubation for airway management in a patient who underwent resection of recurrent giant pituitary tumor via transmaxillary approach. Submental tracheal intubation is an adaptable and safe alternative technology for airway management during operation.

Digital Intubation without Stylet: Myth or Reality? Case Report

Digital intubation was discovered as one of the first methods to face a difficult airway without direct laryngoscopy. From the very beginning, this technique has been surrounded by much controversy, mainly because it required to be performed by an expert. Nowadays, it remains a useful technique when treating patients with difficult airways, so it is of utmost importance all personnel involved with airway management must know and perfect this technique when scenarios where conventional laryngoscopy or rescue devices for difficult airway are not available or contraindicated. The present work’s main objective is to suggest digital intubation as a safe and effective technique for the management of patients with difficult airways when there are no other devices available. The authors present a successful case of digital intubation on a patient with a difficult airway, demonstrating this technique is useful when performed by expert practitioners and when there is no other equipment available.

A quantitative study of airway ultrasound in predicting difficult laryngoscopy:A prospective study

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.

Safety of removal of ProSeal laryngeal mask airway in children in the supine versus lateral position in a deep plane of anesthesia:A randomized controlled trial

Importance:When a ProSeal laryngeal mask airway(PLMA)is removed with the child in a deep plane of anesthesia,the upper airway muscle tone and protective upper airway reflexes may be obtunded.Objective:To determine whether the supine or lateral position is safer for the removal of a PLMA in deeply anesthetized children by comparing the incidence of upper airway complications.Methods:This randomized single-blind comparative trial was conducted at a tertiary care hospital between January 2020 and September 2020.Forty children of the American Society of Anesthesiologists class I/II of ages 1–12 years age undergoing surgery under general anesthesia with PLMA used as the definitive airway device were recruited.Patients were randomly allocated to lateral group or supine group for PLMA removal in a deep plane of anesthesia in the lateral or supine position.The primary outcome was the number of patients experiencing one or more upper airway complications and the secondary outcomes were incidence of individual respiratory adverse effects and of severe airway complications.Results:The incidence of airway complications was 30%in the supine group and 20%in the lateral group(P=0.6641).Incidence of laryngospasm,immediate stridor,and excessive secretions were similar.Early stridor and oxygen desaturation were higher in the supine group(P=0.0374,P=0.0183 respectively).Interpretation:The overall incidence of upper airway complications was similar with the removal of a PLMA in the supine or lateral position in deeply anesthetized children.The incidence of oxygen desaturation and stridor were higher with PLMA removal in the supine as compared to the lateral position.