Comparación de máscaras laríngeas (I-gel Fastrach) para realización de intubación endotraqueal guiada con broncofibroscopio flexible / Comparison of I-gel Fastrach laryngeal masks in conducting flexible bronchofiberscope-guided

GOALS: Determine the success rate of guided intubation with a flexible bronchofibroscope (BFC) through supraglottic devices: I-gel or Fastrach, establish the degree of fibroscopic visualization and determine the insertion time of the laryngeal mask airway (LMA) and endotracheal intubation. METHODS: Experimental, prospective, comparative and randomized study of 60 ASA I-II-III patients, older than 18 years, undergoing elective surgeries that required general anesthesia and endotracheal intubation. After anesthetic induction, the assigned LMA was placed and intubation with BFC was performed through it. Both the success of laryngeal mask insertion and intubation were recorded, as well as the time (in seconds) equired for these procedures. The vision of the laryngeal structures was classified according to the Brimacombe Scale. RESULTS: The groups analyzed presented similar general characteristics. Insertion time of he LMA was significantly lower with I-gel than Fastrach (median 12 s vs 16 s. Respectively, p = 0.001). Also, in the intubation time BFC guided through the laryngeal mask, differences in favor of I-gel were found, with a median of 72 s. vs 89 s. (p = 0.001). Regarding the degree of glottic visualization with BFC, no statistically significant differences were found between both groups.CONCLUSIONS: Although both devices had the highest success rate (both in their placement and in intubation through them), with I-gel the intubation was performed quicker.

OBJETIVOS: Determinar la tasa de éxito de intubación guiada con broncofibroscopio flexible (BFC) a través de los dispositivos supraglóticos: I-gel o Fastrach, establecer el grado de visualización fibroscópica y determinar el tiempo de inserción de la máscara laríngea y de intubación endotraqueal. MATERIALES Y MÉTODOS: Estudio experimental, prospectivo, comparativo y aleatorizado de 60 pacientes ASA I- II ­III, mayores de 18 años, sometidos a cirugías electivas que requerían anestesia general e intubación endotraqueal. Luego de la inducción anestésica, se procedió a colocar la máscara laríngea asignada y se realizó la intubación con BFC a través de la misma. Tanto el éxito de inserción de máscara laríngea como de intubación fueron registrados, así como el tiempo (en segundos) requerido para dichos procedimientos. La visión de las estructuras laríngeas fue clasificada de acuerdo a Escala de Brimacombe. RESULTADOS: Los grupos analizados presentaron características generales similares. El tiempo de inserción de la ML fue significativamente menor con I-gel que con Fastrach (medianas: 12 s. vs 16 s. respectivamente, p = 0,001). También en el tiempo de intubación guiada con BFC a través de la máscara laríngea, se encontraron diferencias en favor de I-gel, con una mediana de 72 s. vs 89 s. (p = 0,001). Respecto al grado de visualización glótica con BFC, no se encontraron diferencias estadísticamente significativas entre ambos grupos. CONCLUSIONES: Aunque ambos dispositivos tuvieron la máxima tasa de éxito (tanto en su colocación como en la intubación a través de ellos), con I-gel se realizó la intubación de manera más rápida.

Manejo de vía aérea en pandemia. Caso clínico / Difficult airway during pandemia: Case report

We present a 38 years female patient with known difficult airway associated with an important anatomic deformation due to a tumoral removal back in 2014 (maxilectomy). This patient was scheduled for a new tumoral resection at the base of the skull, which was considered a potential regrowth of her maxilar sinus cancer, and because of that, the surgery admitted no delays. A multi-disciplinary approach is convenied and an AFOI with topical airway anesthesia and dexmedetomidine sedation is planned to secure the airway during surgery. The main Objective was to optimize the protective measures against SARS CoV2 transmission while securing spontaneous ventilation and patient collaboration during the procedure. To achieve this it was necessary a complex and multi-disciplinary teamwork between de intervening personal. Eventually the airway approach was successful and the surgery was carried out uneventfully. The patient was extubate and taken to the post anesthesia care unit with no recall nor sequel of the procedure.

Presentamos un caso de una paciente de 38 años con predictores de vía aérea dificultosa anticipada, asociada a importante alteración anatómica secundaria a maxilectomía, por patología tumoral, en el año 2014. Actualmente, se sometió a resección tumoral de base de cráneo, considerada una patología no diferible (tiempo sensible) en el contexto de pandemia por COVID-19. Decidimos aplicar un plan de manejo multidisciplinario e intubación orotraqueal vigil mediante fibrobroncoscopia asociada a sedación superficial con dexmedetomidina y anestesia tópica. El objetivo principal fue maximizar las medidas de seguridad, manteniendo la ventilación espontánea y colaboración de la paciente durante el procedimiento. Finalmente, resultó exitoso, siendo la paciente extubada en el quirófano pasando luego a la Unidad de Recuperación Postanestésica, sin manifestar recuerdos ni secuelas del procedimiento realizado para concluir su postoperatorio en sala común.

Application of fiber Raman endoscopic probe in the diagnosis of gastric cancer / 南方医科大学学报

OBJECTIVE@#To develop a fiber Raman endoscopic probe that can be integrated in a gastroscope and evaluate its value in the diagnosis of gastric cancer.@*METHODS@#The Raman spectra of gastric cancer tissues and normal tissues were obtained using the fiber Raman endoscopic probe and confocal microRaman spectroscopy. After preprocessing with smoothing, baseline elimination and normalization, the spectroscopic data were analyzed by the principle component analyses combined with stechiometry. Based on the pathological results, the diagnostic accuracy, sensitiveness and specificity of Raman spectroscopy combined with stechiometry were evaluated.@*RESULTS@#The fiber Raman endoscopic probe and microRaman spectroscopy revealed significantly different Raman spectra between gastric cancer tissues and normal tissues. The diagnostic accuracy, sensitiveness and specificity of the fiber Raman endoscopic probe was 80.56%, 88.89%, and 84.72% for gastric cancer, respectively.@*CONCLUSIONS@#The fiber Raman endoscopic probe combined with stechiometry provides an effective modality for the diagnosis of gastric cancer and can well distinguish gastric cancer tissue from normal gastric tissues.

Fibreoptic intubation in airway management: a review article

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.

Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome / Intubação traqueal difícil com fibra óptica em bebê de um mês de idade com síndrome de Treacher Collins

Abstract Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al. Case report: An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5 mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15 mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15 mm adapter was reattached to the tracheal tube. Conclusion: The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome.

Resumo Os recém-nascidos e crianças pequenas com malformação craniofacial podem ser muito difíceis ou impossíveis de ventilar por máscara ou de intubar. Gostaríamos de relatar a intubação com fibra óptica de um bebê com síndrome de Treacher Collins usando a técnica descrita por Ellis et al. Relato de caso: Uma criança de um mês de idade com síndrome de Treacher Collins foi programada para cirurgia mandibular sob anestesia geral endotraqueal. A laringoscopia direta para intubação oral não revelou a glote. A intubação com fibra óptica usando as abordagens nasal e oral por meio de máscara laríngea de tamanho 1,5 foi tentada, mas ambas as abordagens falharam porque o fibroscópio portando um tubo sem balonete de 3,5 mm ficou preso no interior da cavidade nasal ou dentro da máscara laríngea, respectivamente. Portanto, a máscara laríngea foi mantida no lugar e a técnica de intubação com fibra óptica descrito por Ellis et al. foi planejada: o tubo traqueal com o adaptador de 15 mm removido foi colocado proximalmente sobre o fibroscópio; o fibroscópio foi avançado na traquéia sob visualização em tela devídeo; a máscara laríngea foi removida, deixando o fibroscópio no lugar; o tubo traqueal foi passado completamente através da máscara laríngea e avançado para baixo sobre o fibroscópiona traquéia; o fibroscópio foi removido e o adaptador de 15 mm foi recolocado no tubo traqueal. Conclusão: O método de intubação com fibra óptica através de uma máscara laríngea descrito por Ellis et al. pode ser usado com sucesso em bebês com síndrome de Treacher Collins.

Efficacy of early treatment via fiber bronchoscope in children with Mycoplasma pneumoniae pneumonia complicated by airway mucus obstruction / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To study the efficacy of early treatment via fiber bronchoscope in children with Mycoplasma pneumoniae pneumonia (MPP) complicated by airway mucus obstruction.</p><p><b>METHODS</b>According to the time from admission to the treatment via fiber bronchoscope, the children with MPP who were found to have airway mucus obstruction under a fiber bronchoscope were randomly divided into early intervention group (≤3 days; n=40) and late intervention group (>3 days; n=56). The two groups were compared in terms of clinical data and imaging recovery.The children were followed for 1-3 months.</p><p><b>RESULTS</b>Of the 96 children, 38 were found to have the formation of plastic bronchial tree, among whom 10 were in the early intervention group and 28 were in the late intervention group (P=0.01). Compared with the late intervention group, the early intervention group had a shorter duration of fever, length of hospital stay, and time to the recovery of white blood cell count and C-reactive protein (P<0.05), as well as a higher atelectasis resolution rate (P<0.05). Compared with the late intervention group, the early intervention group had a higher percentage of children with a ≥ 60% absorbed area of pulmonary consolidation at discharge. After 3 months of follow-up, the early intervention group had a higher percentage of children with a ≥ 90% absorbed area of pulmonary consolidation than the late intervention group (80% vs 55%; P=0.01), and the early intervention group had a lower incidence rate of atelectasis than the late intervention group (P<0.05).</p><p><b>CONCLUSIONS</b>Early treatment via fiber bronchoscope can shorten the course of the disease and reduce complications and sequelae in MPP children with airway mucus obstruction.</p>

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation / Uma comparação de vários dispositivos supraglóticos para intubação traqueal guiada por fibra óptica

Abstract Background: Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. Methods: With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p < 0.05). Results: Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. Conclusion: None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical assisted intubation compared to other devices.

Resumo Justificativa: A intubação guiada por fibra óptica (IGFO) através de dispositivo supraglótico (DSG) tem sido descrita como um procedimento seguro e fácil para o manejo de via aérea difícil. No entanto, a visibilização da abertura da glote é essencial para a IGFO. Vários DSGs diferentes estão comercialmente disponíveis e podem oferecer diferentes condições para a IGFO. O objetivo deste estudo foi comparar a melhor visão obtida da abertura da glote com o uso de diferentes DSGs. Métodos: Com a aprovação do Comitê de Ética local, 52 pacientes adultos submetidos à anestesia eletiva foram randomicamente designados para um dos DSGs: tubo laríngeo (TL), máscara laríngea (ML) I-Gel, ML Unique, ML Supreme, ML AuraOnce. Após a indução padronizada da anestesia, o DSG foi colocado de acordo com as recomendações do fabricante. Após ventilação bem-sucedida, a posição do DSG em relação à abertura da glote foi examinada com um endoscópio flexível. Uma abertura da glote total ou parcialmente visível foi considerada como adequada para a IGFO. A adequação para a IGFO foi comparada entre os grupos (teste-H, teste-U; p < 0,05). Resultados: Os dados demográficos não foram diferentes entre os grupos. A colocação do DSG e a ventilação adequada foram bem-sucedidas em todas as tentativas. A visão da glote adequada para a IGFO diferiu entre os dispositivos, variou de 40% para o TL, 66% para a ML Supreme, 70% para a ML I-Gel e 90% para ambas as máscaras laríngeas Unique e AuraOnce. Conclusão: Nenhum dos DSG usados ofereceu uma visão total ou parcial da glote em todos os casos. Porém, as máscaras laríngeas Unique e AuraOnce pareceram mais adequadas para a IGFO em comparação com os outros dispositivos.

Awake fiberoptic intubation in a patient with known difficult airway due to huge thyroid goiter

Thyroid enlargement or goiter has been considered a risk factor for difficulty in airway management during anaesthesia and surgery. Moderate to huge size along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter with compression symptoms and patient cannot be intubated by conventional direct laryngoscopy at a district hospital a week ago. CT scan revealed extension of mass into superior mediastinum compressing right brachiocephalic vein and superior vena cava. We successfully performed awake fiberoptic intubation with local/topical anaesthesia of airway. We have discussed the significance of careful approach, planning and preparation in the management of such a case

Awake insertion of a Laryngeal Mask Airway-Proseal™ as alternative to awake fiberoptic intubation in management of anticipated difficult airway in ambulatory surgery / Inserção de máscara laríngea ProSeal™ em paciente acordado como opção para intubação por meio de fibra óptica para o manejo de via aérea difícil prevista em cirurgia ambulatorial

Abstract Background and objectives The decision whether to manage an ambulatory patient with a previously documented difficult airway with a supraglottic device remain controversial. We report an awake insertion of a Laryngeal Mask Airway Proseal™ in a patient with known difficult airway scheduled for ambulatory surgery. Case report A 46-yr-old woman was programmed as a day case surgery for breast nodule resection. Her anesthetic record included an impossible intubation with cancelation of surgery and subsequent awake fibroscopic intubation. She reported emotional distress with the previous experience and declined this approach. In view of the previous experience, an awake airway control with a Laryngeal Mask Airway Proseal™ was planned after explaining and reassuring the patient. After adequate topicalisation, a size 4 Laryngeal Mask Airway Proseal™ was successfully inserted after two attempts, and their patency was confirmed by capnography. Anesthesia was induced intravenously and the surgery was uneventful. Conclusion We describe a feasible alternative strategy to awake intubation in a patient with known difficult airway undergoing ambulatory surgery. In this specific clinical situation, if tracheal intubation is deemed unnecessary, awake supraglottic airway might allow adequate ventilation and their use should be considered.

Resumo Justificativa e objetivo A decisão quanto ao manejo de paciente ambulatorial com via aérea difícil previamente diagnosticada com o uso de dispositivo supraglótico permanece controversa. Relatamos o caso de inserção de máscara laríngea ProSeal™ em paciente acordado, com via aérea difícil prevista, agendado para cirurgia ambulatorial. Relato de caso Paciente do sexo feminino, 46 anos, programada para cirurgia de ressecção de nódulo de mama com alta hospitalar no mesmo dia. A história anestésica incluía uma intubação impossível, com o cancelamento da cirurgia e posterior intubação com o uso de fibroscópio, com a paciente acordada. A paciente relatou que ficou emocionalmente abalada com a experiência anterior e recusou essa abordagem. Considerando essa experiência anterior, uma abordagem das vias aéreas com a paciente acordada e o uso de uma máscara laríngea ProSeal™ foi planejada, após se explicar o procedimento para a paciente e tranquilizá-la. Após topicalização adequada, uma máscara laríngea (LMA ProSeal™) de tamanho 4 foi inserida com sucesso depois de duas tentativas e a permeabilidade foi confirmada por capnografia. A anestesia foi induzida por via intravenosa e a cirurgia foi feita sem intercorrências. Conclusão Descrevemos uma estratégia opcional viável para a intubação em uma paciente acordada com via aérea difícil previamente diagnosticada submetida a cirurgia ambulatorial. Nessa situação clínica específica, quando a intubação traqueal é considerada desnecessária, a via aérea supraglótica em paciente acordado pode permitir uma ventilação adequada e seu uso deve ser considerado.

Comparison of the Ambu Aura-i with the Air-Q Intubating Laryngeal Airway as A Conduit for Fiberoptic-guided Tracheal Intubation in Children with Ear Deformity / 中国医学科学院学报

Objective To compare the Ambu Aura-i with the Air-Q intubating laryngeal airway for fiberoptic-guided tracheal intubation in ear deformity children.Methods Totally 120 children who were scheduled for elective auricular reconstruction surgery requiring general anaesthesia with tracheal intubation were enrolled in this prospective study. They were randomized to receive either the Ambu Aura-i (Aura-i group) or Air-Q (Air-Q group). The time for successful tracheal intubation was assessed. The attempts for successful device insertion, leak pressures, cuff pressures, fiberoptic grade of laryngeal view, time for removal of the device after endotracheal intubation, and complications were recorded. Results Device placement, endotracheal intubation, and removal after endotracheal intubation were successful in all patients. The Air-Q group required longer time than the Aura-i group in device placement[(14.1±7.2) s vs. (10.8±5.2) s, P<0.05], successful endotracheal intubation [(39.8±9.5) s vs. (24.1±8.2) s, P<0.05], and device removal [(18.2±5.1) s vs. (14.7±3.7) s, P<0.05]. There were no differences in fiberoptic grade of view between these devices, and the percentage of glottis seen was 80.0% (Air-Q group) vs. 86.7% (Aura-i group). The leak pressure was (20.5±4.8) cmHO in the Air-Q group and (22.2±5.0) cmHO in the Aura-i group (P<0.05), and the cuff pressure was (22.9±11.5)cmHO in the Air-Q group and (33.9±15.9) cmHO in the Aura-i group (P<0.05). Hemodynamic changes were not significantly different between two group. The incidence rate of sore throat two hours after operation was 6.5% (n=4) in the Air-Q group and 5% (n=3) in the Aura-i group. Conclusion Both Ambu Aura-i and Air-Q intubating laryngeal airway are effective conduits for beroptic-guided tracheal intubation, with advantages including simple operation, high success rate, and fewer complications, especially the Ambu Aura-i.

Evaluation of Endotracheal Intubation with a Flexible Fiberoptic Bronchoscope in Lateral Patient Positioning: A Prospective Randomized Controlled Trial / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>There is an unmet need for a reliable method of airway management for patients in the lateral position. This prospective randomized controlled two-center study was designed to evaluate the feasibility of intubation using a flexible fiberoptic bronchoscope in the lateral position during surgery.</p><p><b>METHODS</b>Seventy-two patients scheduled for elective nonobstetric surgery in the lateral decubitus position requiring tracheal intubation under general anesthesia at Lishui Central Hospital of Zhejiang Province and Jiaxing First Hospital of Zhejiang Province from April 1, 2015, to September 30, 2015, were enrolled in this study. Patients were randomly assigned to the supine position group (Group S, n = 38) and the lateral position group (Group L, n = 34). Experienced anesthetists performed tracheal intubation with a fiberoptic bronchoscope after general anesthesia. The time required for intubation, intubation success rates, and hemodynamic changes was recorded. Between-group differences were assessed using the Student's t-test, Mann-Whitney U-test, or Chi-square test.</p><p><b>RESULTS</b>The median total time to tracheal intubation was significantly longer in Group S (140.0 [135.8, 150.0] s) compared to Group L (33.0 [24.0, 38.8] s) (P < 0.01). The first-attempt intubation success rate was significantly higher in Group L (97%) compared to Group S (16%). Hemodynamic changes immediately after intubation were more exaggerated in Group S compared to Group L (P = 0.02).</p><p><b>CONCLUSION</b>Endotracheal intubation with a flexible fiberoptic bronchoscope may be an effective and timesaving technique for patients in the lateral position.</p><p><b>TRIAL REGISTRATION</b>Chinese Clinical Trial Register, ChiCTR-IIR-16007814; http://www.chictr.org.cn/showproj.aspx?proj=13183.</p>

Comparison of the i-gelTM and the Laryngeal Mask Airway ClassicTM in terms of clinical performance / Comparação da máscara laríngea i-gel (i-gelTM) com a máscara laríngea clássica (LMA-ClassicTM) em relação ao desempenho clínico

ABSTRACTPURPOSE: The i-gelTM is one of the second generation supraglottic airway devices. Our study was designed to compare the i-gel and the Laryngeal Mask Airway ClassicTM with respect to the clinical performance.METHODS: We compared the performance of the i-gel with that of the Laryngeal Mask Airway Classic in 120 patients undergoing urologic surgery during general anesthesia without muscle relaxant with respect to the number of attempts for successful insertion, insertion time, peak airway pressure, incidence of regurgitation, fiberoptic glottic view and postoperative complications. Second generation supraglottic airway devices were inserted by the same anesthesiologist, experienced in use of both devices (>200 uses and first time failure rate <5%). Methylene blue method was used to detect gastric regurgitation.RESULTS: There was no statistical difference between the two groups regarding the success of insertion of second generation supraglottic airway device (p = 0.951). The laryngeal mask insertion time for the i-gel group was significantly shorter than that for the Laryngeal Mask Airway Classic group (11.6 ± 2.4 s versus 13.1 ± 1.8 s [p = 0.001]). The fiberoptic glottic view scores for the i-gel group was significantly better than that for the ones for the Laryngeal Mask Airway Classic group (p = 0.001). On fiberoptic view, there was no sign of methylene blue dye at any time point in either group. In addition, there was no difference between the groups in patient response regarding the presence of a sore throat when questioned 24 h after the procedure (p = 0.752).CONCLUSION: Both devices had good performance with low postoperative complications and without occurrence of regurgitation. The i-gel provided a shorter insertion time and a better fiberoptic view than the Laryngeal Mask Airway Classic.

RESUMOJUSTIFICATIVA E OBJETIVO: A i-gel é um dos dispositivos supraglóticos de segunda geração para o manejo das vias aéreas. Nosso estudo foi projetado para comparar a i-gelTM e a máscara laríngea clássica (Laryngeal Mask Airway ClassicTM, LMA-C) em relação ao desempenho clínico.MÉTODOS: Avaliamos os desempenhos de i-gel e LMA-C em 120 pacientes submetidos à cirurgia urológica sob anestesia geral sem relaxante muscular. Comparamos o número de tentativas de inserção bem-sucedidas, o tempo de inserção, a pressão de pico das vias aéreas, a incidência de regurgitação, a visibilidade da glote com o uso de fibra óptica e as complicações no pós-operatório. Os dispositivos supraglóticos de segunda geração foram inseridos pelo mesmo anestesiologista com experiência na aplicação de ambos os dispositivos (> 200 aplicações e taxa de falha na primeira tentativa < 5%). O corante azul de metileno foi usado para detectar regurgitação gástrica.RESULTADOS: Não houve diferença estatística entre os dois grupos em relação ao sucesso da inserção do dispositivo supraglótico de segunda geração (p = 0,951). O tempo de inserção da máscara laríngea no grupo i-gel foi significativamente menor do que no grupo LMA-C (11,6 ± 2,4 segundos vs. 13,1 ± 1,8 segundos, p = 0,001). O escore de visibilidade da glote via fibra óptica do grupo i-gel foi significativamente melhor do que o do grupo LMA-C (p = 0,001). Na visão via fibra ótica, sinais do corante azul de metileno não foram observados em qualquer momento em ambos os grupos. Além disso, não houve diferença entre as respostas dos grupos quando perguntados sobre a presença de dor de garganta 24 horas após o procedimento (p = 0,752).CONCLUSÃO: Ambos os dispositivos apresentaram bom desempenho, com poucas complicações no pós-operatório e sem ocorrência de regurgitação. A máscara laríngea i-gel proporcionou um tempo de inserção mais curto e uma visão via fibra óptica melhor do que a LMA-C.

The influence of airway supporting maneuvers on glottis view in pediatric fiberoptic bronchoscopy / A influência das manobras de suporte das vias aéreas sobre a visibilidade da glote em fibrobroncoscopia pediátrica

ABSTRACTINTRODUCTION:Flexible fiber optic bronchoscopy is a valuable intervention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. The aim of this study is to investigate the influence of the airway supporting maneuvers on glottis view during pediatric flexible fiberoptic bronchoscopy.MATERIALS AND METHODS:In this randomized, controlled, crossover study; patients aged between 0 and 15 years who underwent flexible fiberoptic bronchoscopy procedure having American Society of Anesthesiologists I---II risk score were included. Patients having risk of difficult intubation, intubated or patients with tracheostomy, and patients with reduced neck mobility or having cautions for neck mobility were excluded from this study. After obtaining best glottic view at the neutral position, patients were positioned jaw trust with open mouth, jaw trust with teeth prottution, head tilt chin lift and triple airway maneuvers and best glottis scores were recorded.RESULTS:Total of 121 pediatric patients, 57 girls and 64 boys, were included in this study. Both jaw trust with open mouth and jaw trust with teeth prottution maneuvers improved the glottis view compared with neutral position (p < 0.05), but we did not observe any difference between jaw trust with open mouth and jaw trust with teeth prottution maneuvers (p > 0.05). Head tilt chin lift and triple airway maneuvers improved glottis view when compared with both jaw trust with open mouth and jaw trust with teeth prottution maneuvers and neutral position (p < 0.05); however we found no differences between head tilt chin lift and triple airway maneuvers (p > 0.05).

RESUMOINTRODUÇÃO: A broncofibroscopia flexível (BF) é uma valiosa intervenção para o manejo eavaliação de doenças respiratórias em pacientes tanto pediátricos quanto adultos. O obje-tivo deste estudo foi investigar a influência das manobras de apoio das vias aéreas sobre avisibilidade da glote durante a BF pediátrica.MATERIAL E MÉTODO: Estudo cruzado, randômico e controlado, incluindo pacientes com idadesentre 0-15 anos, ASA I-II, que foram submetidos à BF. Pacientes com risco de intubação difí-cil, entubados ou com traqueostomia e aqueles com mobilidade reduzida do pescoço ou queexigissem cuidados para a mobilidade do pescoço foram excluídos do estudo. Depois de obter amelhor visibilidade da glote na posição neutra, os pacientes foram posicionados com elevaçãoda mandíbula e abertura da aberta (EMBA), com elevação da mandíbula e protrusão dos dentes(EMPD), com inclinação da cabeça elevação do queixo (ICEQ) e com a tripla manobra das viasaéreas (TMVA). Os melhores escores da glote foram registrados.RESULTADOS: No total, 121 pacientes pediátricos foram incluídos no estudo: 57 pacientes do sexofeminino e 64 do sexo masculino. Ambos as manobras EMBA e EMPD melhoraram a visibilidadeda glote em comparação com a posição neutra (p < 0,05), mas não observamos diferença entreas manobras EMBA e EMPD (p > 0,05). As manobras ICEQ e TMVA melhoraram a visibilidade daglote em comparação com as manobras EMBA e EMPD e a posição neutra (p < 0,05); porém, nãoencontramos diferenças entre a ICEQ e a TMVA (p > 0,05).CONCLUSÃO: Todas as manobras de acesso às vias aéreas melhoraram a visibilidade da glotedurante a BF pediátrica; porém, a inclinação da cabeça e elevação do queixo e a tripla manobradas vias aéreas foram consideradas as manobras mais eficazes.

Traqueostomía percutánea con asistencia fibrobroncoscópica: una década de experiencia en un hospital universitario / Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

RESUMEN Objetivo: Evaluar eficacia y seguridad de la traqueostomía percutánea, mediante dilatación única con asistencia fibrobroncoscópica, en pacientes críticos sometidos a ventilación mecánica. Métodos: Entre los años 2004 y 2014, se incluyeron prospectivamente 512 enfermos consecutivos con indicación de traqueostomía según los criterios clínicos de nuestro centro. Un tercio de los pacientes fueron de alto riesgo. Se registraron variables demográficas, puntaje APACHE II, y días de ventilación mecánica previo a traqueostomía percutánea. La eficacia del procedimiento fue evaluada mediante tasa de éxito en su ejecución y necesidad de conversión a técnica abierta. La seguridad fue evaluada por tasa de complicaciones operatorias y postoperatorias. Resultados: La edad media del grupo fue 64 ± 18 años (203 mujeres y 309 varones). El puntaje APACHE II fue 21 ± 3. Los pacientes permanecieron en promedio 11 ± 3 días en ventilación mecánica antes de la realización de la traqueostomía percutánea. Todos los procedimientos se completaron exitosamente, sin necesidad de convertir a técnica abierta. Dieciocho pacientes (3,5%) presentaron complicaciones operatorias. Cinco pacientes experimentaron desaturación transitoria, cuatro presentaron hipotensión relacionada a la sedación, y nueve presentaron sangrado menor, pero ninguno requirió transfusión. No se registraron complicaciones graves, ni muertes asociadas al procedimiento. Once pacientes (2,1%) presentaron complicaciones postoperatorias. Siete presentaron sangrado menor y transitorio del estoma de la traqueostomía percutánea, 2 sufrieron desplazamiento de la cánula de traqueostomía y 2 desarrollaron infección superficial del estoma. Conclusión: La traqueostomía percutánea mediante la técnica de dilatación única con asistencia fibrobroncoscópica, parece ser efectiva y segura en enfermos críticos sometidos a ventilación mecánica, cuando es realizada por intensivistas experimentados mediante un abordaje ...

ABSTRACT Objective: To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation. Methods: Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates. Results: The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma. Conclusion: Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using ...

Experimental infection with the Toxoplasma gondii ME-49 strain in the Brazilian BR-1 mini pig is a suitable animal model for human toxoplasmosis

Toxoplasma gondii causes toxoplasmosis, a worldwide disease. Experimentation with pigs is necessary for the development of new therapeutic approaches to human diseases. BR-1 mini pigs were intramuscularly infected with T. gondii with tachyzoites (RH strain) or orally infected with cysts (ME-49 strain). Haematology and serum biochemistry were analysed and buffy coat cells were inoculated in mice to determine tachyzoite circulation. No alterations were observed in erythrocyte and platelet values; however, band neutrophils increased seven days after infection with ME-49. Serology of the mice inoculated with pig blood leucocytes revealed circulating ME-49 or RH strain tachyzoites in the pigs' peripheral blood at two and seven or nine days post-infection. The tachyzoites were also directly observed in blood smears from the infected pigs outside and inside leucocytes for longer periods. Alanine-aminotransferase was high at days 21 and 32 in the RH infected pigs. After 90 days, the pigs were euthanised and their tissue samples were processed and inoculated into mice. The mice serology revealed the presence of parasites in the hearts, ileums and mesenteric lymph nodes of the pigs. Additionally, cysts in the mice were only observed after pig heart tissue inoculation. The infected pigs presented similar human outcomes with relatively low pathogenicity and the BR-1 mini pig model infected with ME-49 is suitable to monitor experimental toxoplasmosis.

Awake tracheal intubation in a patient with a supraglottic mass with the Bonfils fibrescope after failed attempts with a flexible fibrescope

Awake intubation with a flexible fibrescope is usually done electively in patients with a known difficult airway. Herein, we describe the case of an elective awake tracheal intubation that was performed on a patient with a large, obstructive supraglottic mass. The intubation was successfully performed using the Bonfils fibrescope after several failed attempts with a flexible fibrescope. This case highlights the usefulness of the Bonfils fibrescope and the limitations of the flexible fibrescope in certain clinical situations.

Dexmedetomidine-midazolam versus Sufentanil-midazolam for Awake Fiberoptic Nasotracheal Intubation: A Randomized Double-blind Study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Awake fiberoptic intubation (AFOI) is usually performed in the management of the predicted difficult airway. The aim of this study was to evaluate the feasibility of dexmedetomidine with midazolam (DM) and sufentanil with midazolam (SM) for sedation for awake fiberoptic nasotracheal intubation.</p><p><b>METHODS</b>Fifty patients with limited mouth opening scheduled for AFOI were randomly assigned to two groups (n = 25 per group) by a computer-generated randomization schedule. All subjects received midazolam 0.02 mg/kg as premedication and airway topical anesthesia with a modified "spray-as-you-go" technique. Group DM received dexmedetomidine at a loading dose of 0.5 μg/kg over 10 min followed by a continuous infusion of 0.25 μg·kg-1·h-1, whereas Group SM received sufentanil at a loading dose of 0.2 μg/kg over 10 min followed by a continuous infusion of 0.1 μg·kg-1·h-1. As necessary, since the end of the administration of the loading dose of the study drug, an additional dose of midazolam 0.5 mg at 2-min intervals was given to achieve a modified Observers' Assessment of Alertness/Sedation of 2-3. The quality of intubation conditions and adverse events were observed.</p><p><b>RESULTS</b>The scores of ease of the AFOI procedure, patient's reaction during AFOI, coughing severity, tolerance after intubation, recall of the procedure and discomfort during the procedure were comparable in both groups (z = 0.572, 0.664, 1.297, 0.467, 0.895, and 0.188, respectively, P > 0.05). Hypoxic episodes similarly occurred in the two groups, but the first partial pressure of end-tidal CO2after intubation was higher in Group SM than that in Group DM (45.2 ± 4.2 mmHg vs. 42.2 ± 4.3 mmHg, t = 2.495, P < 0.05).</p><p><b>CONCLUSIONS</b>Both dexmedetomidine and sufentanil are effective as an adjuvant for AFOI under airway topical anesthesia combined with midazolam sedation, but respiratory depression is still a potential risk in the sufentanil regimen.</p>