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.

Disinfection byproducts in chlorinated or brominated swimming pools and spas: Role of brominated DBPs and association with mutagenicity

Although the health benefits of swimming are well-documented, health effects such as asthma and bladder cancer are linked to disinfection by-products(DBPs) in pool water. DBPs are formed from the reaction of disinfectants such as chlorine(Cl) or bromine(Br) with organics in the water. Our previous study(Daiber et al., Environ. Sci. Technol. 50, 6652;2016) found correlations between the concentrations of classes of DBPs and the mutagenic potencies of waters from chlorinated or brominated swimming pools and spas. We extended this study by identifying significantly different concentrations of 21 individual DBPs in brominated or chlorinated pool and spa waters as well as identifying which DBPs and additional DBP classes were most associated with the mutagenicity of these waters. Using data from our previous study, we found that among 21 DBPs analyzed in 21 pool and spa waters, the concentration of bromoacetic acid was significantly higher in Brwaters versus Cl-waters, whereas the concentration of trichloroacetic acid was significantly higher in Cl-waters. Five Br-DBPs(tribromomethane, dibromochloroacetic acid, dibromoacetonitrile, bromoacetic acid, and tribromoacetic acid) had significantly higher concentrations in Br-spa versus Cl-spa waters. Cl-pools had significantly higher concentrations of ClDBPs(trichloroacetaldehyde, trichloromethane, dichloroacetic acid, and chloroacetic acid), whereas Br-pools had significantly higher concentrations of Br-DBPs(tribromomethane, dibromoacetic acid, dibromoacetonitrile, and tribromoacetic acid). The concentrations of the sum of all 4 trihalomethanes, all 11 Br-DBPs, and all 5 nitrogen-containing DBPs were each significantly higher in brominated than in chlorinated pools and spas. The 8 Br-DBPs were the only DBPs whose individual concentrations were significantly correlated with the mutagenic potencies of the pool and spa waters. These results, along with those from our earlier study, highlight the importance of Br-DBPs in the mutagenicity of these recreational waters.