Medical intensivist directed VV ECMO cannulation for the facilitation of tracheostomy in a patient with severe tracheal stenosis: A case report

Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.

COVID-19 and The Surgical Neonate

COVID-19 pandemic in 2020-2021 affected millions of people including children. Though uncommon, there are few reports of COVID in neonates also. COVID is primarily managed by pediatricians;however, they are involved when providing anesthesia to these neonates for surgery. The role of anesthetists, besides during surgery, has proven to be vital in COVID pandemic for their expertise in airway and ventilatory management, also putting them to the highest risk of exposure. Various testing methods are available, and TrueNAT and RTPCR have emerged as most reliable. Most neonates remain asymptomatic or have mild symptoms;however, RTPCR testing should be done in all at least 72 h of preoperative. Utmost care should be taken during the preoperative evaluation, and in the perioperative period, goal is to prevent transmission of COVID to noninfected HCW involved in the perioperative period, to other newborns and neonates, and also to avoid increasing the severity of the diseases in the positive neonates, while keeping in mind the vulnerability of these babies in combination with their surgical disease and the changing neonatal physiology. COVID care protocols should be followed at all times. Anesthetic considerations remain the same as described in other chapters in the book, in newborns and neonates, both term and preterm. All OT personnel need to don the PPE, which can be problematic especially for the anesthetist, as it restricts the normal unhindered movements, use of stethoscope for chest auscultation for heart rate, respiration, and ETT positioning. Hence, one needs to be very meticulous in IV line and ET placement and their securing to prevent accidental dislodging during positioning and under the drapes. All disposable and non-disposable equipment used for the covid positive baby, should be adequately treated or discarded, as the case may be, after each surgery. Only emergency surgery should be undertaken in COVID-positive neonates to prevent high postoperative morbidity and mortality. There is not much data available in neonates, and most guidelines have been introduced for children and adolescents. Neonatal care has emerged from the experience of the anesthesiologist and from extrapolation of the available pediatric guidelines. Here, we will be discussing COVID in neonates and anesthetic management in COVID-positive neonates undergoing surgery. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023.

Antenatal anaesthetic assessment of parturients with BMI > 40 kg/m2

Introduction: Frimley Park Hospital criteria for referral to High-Risk Obstetric Anaesthetic Clinic (HROAC) included all parturients with BMI > 40. The COVID-19 pandemic necessitated HROAC becoming virtual. It was still possible to discuss risk and assess patients' airways, but not to reliably assess the likely ease of neuraxial techniques or cannulation. Observationally, little useful clinical information was gained, and airway problems rarely noted. An audit was planned to assess how often clinically useful information about the women's airways was gained during appointments. Method(s): HROAC database search for women referred with BMI > 40 with estimated date of delivery 20/04/20-03/04/21 to see whether any airway difficulties were predicted (Mallampati 3 or 4;limited neck movement;jaw slide B or C;limited mouth opening). Result(s): 82 women had BMI > 40, of which 3 were assessed as having a potentially difficult airway: two had BMI > 50 and one had retrognathism causing difficult airway prediction unrelated to her BMI of 41.7. One woman, BMI 58.7, was assessed as having a straightforward airway but her notes revealed her airway had been challenging to intubate in the past. One was assessed in video consultation as straightforward but an airway assessment during admission at the end of her previous pregnancy was Mallampti 3. Five women declined a video consultation. Discussion(s): In view of the minimal gain of clinically useful information and the routine presence of difficult airway kit for the obstetric emergency theatre, it was deemed safe and more relevant to make airway and neuraxial assessments on admission to labour ward rather than in the antenatal clinic for women with BMI<50. The assessment would therefore be made by the duty trainee anaesthetist who would be responsible for managing the patient, thus facilitating appropriate planning and communication if a woman with a challenging airway was identified. It is therefore also made at the very end of pregnancy when weight gain and its impact on airway is likely to be at its maximum. This approach, in conjunction with an antenatal information leaflet, and the ability of any obstetrician to refer to the HROAC, complies with the need for timely assessment of women as required by GPAS [1]. By formalising the assessment of women with high BMI on the labour ward it is hoped that patient safety and planning can be maximised.Copyright © 2023 Elsevier Ltd

Anesthesia for penetrating injury of the oropharynx in a child: a case report

BackgroundPenetrating injury of the oropharynx occurs frequently in children, however, anesthetic management is seldom described in such cases.Case presentationA 2-year old child came to the emergency room with a toothbrush impacted in the gingivobuccal sulcus making airway management difficult. We used a simple yet unique approach to secure the airway safely given the lack of pediatric size fibreoptic and videolaryngoscopes in our emergency operation theatre. The patient was kept in Pediatric ICU and watched for any complications and discharged on the 4th postoperative day.ConclusionsThus, ingenious non-invasive techniques to secure the airway can prevent the patient from undergoing surgical tracheostomy.

Comparing nasopharyngeal apnoeic oxygenation at 18 l/min to preoxygenation alone in obese patients - A randomised controlled study.

STUDY OBJECTIVE: Investigate a low-cost, nasopharyngeal apnoeic oxygenation technique, establish its efficacy, and compare it to preoxygenation only in an obese population. The study's hypothesis was that nasopharyngeal apnoeic oxygenation at 18 l.min-1 would significantly prolong safe apnoea time compared to preoxygenation alone. DESIGN: Randomised controlled study. SETTING: Theatre complex of a resource constrained hospital. PATIENTS: 30 adult, obese (BMI ≥ 35 kg.m-2) patients presenting for elective surgery. Patients with limiting cardio-respiratory disease, suspected difficult airway, risk of aspiration, and that were pregnant, were excluded. Patients were allocated by block randomisation in a 1:2 ratio to a preoxygenation-only (No-AO) and an intervention group (NPA-O2). INTERVENTIONS: All patients were preoxygenated to an Et-O2 > 80%, followed by a standardised induction. The intervention group received oxygen at 18 l.min-1 via the nasopharyngeal catheter intervention. The desaturation process was documented until an SpO2 of 92% or 600 s was reached. MEASUREMENTS: Baseline demographic and clinical characteristics were collected. The primary outcome was safe apnoea time, defined as the time taken to desaturate to an SpO2 of 92%. Secondary outcomes were rate of carbon dioxide accumulation and factors affecting the risk of desaturation. MAIN RESULTS: The study was conducted in a morbidly obese population (NoAO = 41,1 kg.m-2; NPA-O2 = 42,5 kg.m-2). The risk of desaturation was signifantly lower in the intervention group (Hazzard Ratio = 0,072, 95% CI[0,019-0,283]) (Log-Rank test, p < 0.001). The median safe apnoea time was significantly longer in the intervention group (NoAO = 262 s [IQR 190-316]; NPA-O2 = 600 s [IQR 600-600]) (Mann-Whitney-U test, p < 0.001). The mean rate of CO2 accumalation was significantly slower in the intervention group (NoAO = 0,47 ± 0,14 kPa.min-1; NPA-O2 = 0,3 ± 0,09 kPa.min-1) (t-test, p = 0.003). There were no statistically significant risk factors associated with an increased risk of desaturation found. CONCLUSIONS: Nasopharyngeal apnoeic oxygenation at 18 l/min prolongs safe apnoea time, compared to preoxygenation alone, and reduces the risk of desaturation in morbidly obese patients. CLINICAL TRIAL REGISTRATION: PACTR202202665252087; WC/202004/007.

Anaesthetic concerns in post-COVID mucormycosis at a tertiary care hospital in India: An observational study.

Administration of anaesthesia in post-COVID mucormycosis patients is a real challenge due to complications such as dyselectrolytemia, renal failure, multi-organ failure, and sepsis. The aim of this study was to evaluate the challenges and perioperative complications of administration of anaesthesia in terms of morbidity and mortality in patients undergoing surgical resection of post-COVID rhino-orbito-cerebral mucormycosis (ROCM). The present study was a case series, which was carried out on 30 post-COVID, biopsy-proven mucormycosis patients enrolled for ROCM resection under general anaesthesia, and all data were collected retrospectively for this series. The post-COVID mucormycosis patients had diabetes mellitus as the most common comorbidity (96.6%), and difficult airway was a common feature (60%) among them. Anaesthetic management of post-COVID mucormycosis patients is a real challenge due to associated comorbidities.

Personalized Mechanical Ventilation: Improving Quality of Care

In dealing with the unprecedented COVID-19 pandemic, there are an increased number of patients requiring personalized management as the disease pathology varies. With variable lung compliance and airway resistance as well as the severity of the disease, one size will not fit all patients. This book is problem-oriented with evidence-based discussions of the daily encountered scenarios in the ICU for mechanically ventilated patients, dealing with the pathology, monitoring and troubleshooting facing intensivists daily. These scenarios are managed utilizing a goal-directed approach and algorithms to achieve these goals. All chapters contain an explanation of a different solution illustrating the respiratory mechanics, physiology and pathology involved in such a scenario. Each chapter also closes with a take-home message to summarize the content. In addition to describing the ventilation of different patient categories, this text also features ventilation cases specific to COVID-19 including airway management in the enhanced air born isolated patient, pulmonary embolism, different states of shock and differential lung ventilation. There is also a specific chapter on monitoring mechanical ventilation with point of care ultrasound, which is an available modality in most ICUs. Another unique chapter describes how to connect more than one patient to one ventilator in case of a shortage of machines. Written by experts in the field, Personalized Mechanical Ventilation is a timely and valuable resource for critical care physicians, nurses and respiratory therapists on the front lines of both COVID-19 and day-to-day care of mechanically ventilated patients in the ICU. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Selected Bibliography of Recent Research in Sleep (2020–2021)

The American Journal of Respiratory and Critical Care Medicine· AmakATS and the American Journal of Respiratory Cell and Molecular Biology· as well as non-American Thoracic Society journals JAMA, lite Lancet Respiratory tledicine, and Cltest are reviewed in this article as outstanding studies in the field of sleep medicine that were published in 2020 and 2021. We notably highlight the influence of the coronavirus disease (COVID-19) pandemic on the provision of sleep care, significant advancements in machine learning, and the phenotyping of obstructive sleep apnea (OSA). precision health, new epidemiologic insights on the causes, effects, and treatment response of OSA, as well as improvements in our knowledge of obesity and respiratory pathophysiology in sleep.

New Paradigm in Robotic Prostatectomy: Planned Same Day Discharge in All Patients

INTRODUCTION AND OBJECTIVE: In 2016 we began offering optional same-day discharge (SDD) to all robotic prostatectomy (RP) patients with increasing acceptance that accelerated during the COVID pandemic. Our resulting 98% SDD rate for RP after COVID facilitated initiation of an ambulatory surgery center (ASC) robotic urology program without overnight capability and planned SDD in all patients. We assessed our outcomes with planned outpatient RP in all patients in both the hospital and ASC settings. METHOD(S): We reviewed one year of consecutive RPs performed by a single surgeon at either a free-standing ASC or one of three hospitals between October 2021-October 2022. Pelvic lymphadenectomy was performed in all patients. Assignment to ASC versus hospital RP was based primarily on insurance eligibility. ASC policy for robotic or non-robotic procedures alike excluded history of severe cardiac disease, difficult airway, malignant hyperthermia, or BMI >45kg/m2 with no additional limitations applied to robotic surgery. All patients were instructed to expect same-day discharge (SDD) directly from the recovery room regardless of ASC or hospital location with overnight stay only for unexpected complications or side effects of anesthesia. RESULT(S): Among 359 RP cases (162 ASC and 197 hospital), 356 (99%) were successfully discharged the same day as surgery with 3 overnight stays in the hospital group and none in the ASC group. Patients in the ASC group were younger (61.4yrs vs 67.1yrs, p<001) with no statistically-significant difference in BMI (29.2 kg/m2 vs 29.3 kg/ m2, p=0.3), preoperative Gleason Score (p=0.1), operative time (131min vs 134min, p=0.2) or blood loss (87.5cc vs 84.8cc, p=0.71). Excluding the three overnight patients in the hospital group, the mean postoperative recovery room stay among SDD patients was shorter in the ASC group (1.7hrs vs 2.3hrs, p<0.0001). The 90-day readmission rate was 2.5% in both groups (4/162 and 5/197, p=0.93). No readmissions occurred within 24 hours of surgery and only one within the first week. CONCLUSION(S): Same day discharge as a routine following robotic prostatectomy is feasible and safe with readmission rates no higher than series with overnight stays. SDD may enable ASC RP when overnight stay capabilities are not available at an ASC with minimal risk of need for hospital transfer.

Airway management in patients with COVID-19: an updated guide for clinicians in the emergency department

The coronavirus disease, also known as Coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 virus has changed the characteristics of many methods used by healthcare providers. These modifications aimed to provide safety and reduce the risk of virus transmission. Some of the recommendations to reduce the risk of aerosol transmission during the intubation are usage of personal protective equipment (PPE) and video laryngoscopy (VL). After satisfactory preoxygenation, along with sedation and paralysis of the patient, modified rapid sequence induction is the recommended technique. Intubation timing and period should be arranged well in order to minimize aerosol spread. During intubation, barrier devices, such as screens and intubation boxes should be considered. Patient coughing during intubation can generate aerosols and should be avoided. Gentle airway manipulation is assured. It is prudent to use VL rather than direct laryngoscopy for intubation because VL increases the distance between the healthcare worker's face and the patient's face, which may minimize the risk of contamination. In this narrative review, we aimed to focus on protective measures and modifications occurred during COVID-19 pandemic. Copyright (C) 2022 Wolters Kluwer Health, Inc. All rights reserved.

Oral lesions in patients with severe COVID-19 in the National Institute of Respiratory Diseases in Mexico: Case series

Introduction SARS-CoV-2 is a neurotropic, mucotropic, and sialotropic virus that can affect the salivary glands' function, taste sensations, smell, and oral mucosa integrity.1 The oral cavity is a perfect habitat for SARS-CoV-2 invasion due to the special affinity the virus has for cells with angiotensinconverting enzyme (ACE2) receptors, such as those from the respiratory tract, oral mucosa, tongue, and salivary glands. Aphthous lesions with necrosis and hemorrhagic crusts have been described to manifest more regularly in older adults with immunosuppression and severe COVID-19 infection;one hypothesis for the development of aphthous lesions and/or ulcers is given due to the ACE2 receptor and the SARS-CoV-2 interaction, which could alter the epithelial lining of salivary glands and keratinocytes, causing lesions in the oral cavity.4 At the same time, different etiological factors such as infections, immune system alterations, and direct trauma to the oral mucosa or epithelium,5 may be related to the stress of a prolonged hospital stay.6 Including pressure in the oral cavity conditioned by the prone position, malposition of the endotracheal tube (mainly in the corners of the lips),7 medication-related nutritional deficiencies8 such as lopinavir, and ritonavir, oseltamivir, hydroxychloroquine, among others.9-12 Thrombotic vasculopathy secondary to COVID-19 has also been described, induced by system mediators in the microvascular walls, which impairs endothelial cells, and activates coagulation factors13 and a possible hypersensitivity reaction of the mucosa to the presence of SARS-CoV-2 in the epithelium14,15;there is also the hypothesis that it could be associated with an exanthem pattern induced by the inflammatory action of the SARSCoV-2 virus,16 presented as increased levels of cytokines (including interleukin-1, tumor necrosis facto-a), and arachidonic acid metabolites (prostaglandins) secondary to the stem cell factor production and the basic fibroblast growth factor of keratinocytes from the basal layer, in relation to post-inflammatory pigmentations that could appear in areas previously affected by trauma or chronic inflammation.17 Oral manifestations in COVID-19 patients appear, on many occasions, even before respiratory symptoms, although exanthematic lesions observed in COVID-19 patients can also be observed in other viral processes. Physical examination revealed a patient in a supine position with orotracheal intubation and orogastric tube, with aphthous-type ulcers, some of them had blood crusts of different sizes on the lower lip (both skin and mucosa), dorsum, and lateral edge of the tongue, gum, and vestibular fornix (Figure 3). Initial physical examination shows the patient in a supine position supported by high-flow nasal prongs, upper and lower lips edema and ulcer-like lesions with hematic crusts on both lips (Figure 4), topical management with steroids and GELCLAIRE® Oral Gel (glycyrrhetinic acid and polyvinylpyrrolidone) is observed.

An unbroken ring of the chain of survival.

This is a commentary on the study conducted by Kennedy et al. from Victoria, Australia, that analyzed the cohort of all adult EMS-witnessed out-of-hospital cardiac arrest (OHCA) patients in the region and compared patients treated during the COVID-19 period to a historical comparator period. The commentary summarizes the study findings and discusses the importance of the study in the context of the chain of survival and changes in airway management for OHCA patients during the COVID-19 pandemic.

Cricothyroidotomy Simulator: A Makerspace and Augmented Reality Approach

A cricothyroidotomy is an incision made on the cricothyroid membrane at its midline to create an airway for oxygenation and ventilation. Cricothyroidotomy is a complex procedure involving motor, psychological, and decision-making skills, amply used during the COVID-19 pandemic. This procedure requires extensive training, and simulators facilitate teaching advanced airway management techniques to health care professionals. However, upper airway simulators are expensive and limited to specialized facilities inaccessible during the COVID-19 pandemic when in-laboratory practices shifted to online synchronous and asynchronous teaching. Such a scenario sparked interest in makerspace technologies for creating cost-effective simulators. This paper presents the prototyping of a cricothyroidotomy simulator through a Design Thinking approach to ideate a cost-effective solution that contains all 3D printed structures properly representing the real anatomical parts needed for the procedure. Additionally, we propose an augmentation of the 3D printed model employing Augmented Reality (AR) to enhance how information about the procedure can be accessed without relying on traditional instruction materials. Our preliminary results have led to a makerspace cricothyrotomy simulator used in training sessions in conferences and workshops and the prototyping of an AR complementary tool. © 2022 IEEE.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS: We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS: Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS: During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

RéSUMé: OBJECTIF: Les pratiques d'intubation ont changé au cours de la pandémie de COVID-19 afin de protéger le personnel de santé contre la transmission de la maladie. Nos objectifs étaient de décrire les caractéristiques de l'intubation et les résultats pour les patients testés pour l'infection par le CoV-2 du SRAS. Nous avons comparé les résultats entre les patients testés positifs au SARS COV-2 et ceux testés négatifs. MéTHODES: Nous avons effectué un examen des dossiers de santé à l'aide du registre du Réseau canadien d'intervention rapide dans les services d'urgence pour la COVID-19 (RCIRSUC). Nous avons inclus les patients éligibles consécutifs qui se sont présentés à l'un des 47 services d'urgence du Canada entre le 1er mars 2020 et le 20 juin 2021, qui ont été testés pour le SRAS-CoV-2 et qui ont été intubés dans le service d'urgence. Le résultat principal était la proportion de patients ayant subi un événement indésirable après l'intubation pendant leur séjour aux urgences. Les critères de jugement secondaires comprenaient le succès du premier passage, les pratiques d'intubation et la mortalité hospitalière. Nous avons utilisé des statistiques descriptives pour résumer les variables avec des différences de sous-groupes examinées à l'aide de tests t, de tests z ou de tests du chi carré, le cas échéant, avec des IC à 95%. RéSULTATS: Sur les 1720 patients suspects de COVID-19 qui ont été intubés aux urgences pendant la période de l'étude, 337 (19,6%) ont été testés positifs au SARS-CoV-2 et 1383 (80,4%) négatifs au SARS-CoV-2. Les patients positifs au SRAS-CoV-2 se sont présentés à l'hôpital avec des niveaux d'oxygène inférieurs à ceux des patients négatifs pour le SRAS-CoV-2 (oxymètre de pouls moyen SaO2 86% contre 94%, p < 0,001). Au total, 8,5% des patients ont présenté un événement indésirable après l'intubation. Un plus grand nombre de patients du sous-groupe positif au SRAS-CoV-2 ont présenté une hypoxémie post-intubation (4,5% vs 2,2%, p = 0,019). La mortalité hospitalière était plus élevée chez les patients ayant subi des événements indésirables liés à l'intubation (43,2% vs 33,2%, p = 0,018). Il n'y avait pas de différence significative dans la mortalité associée aux événements indésirables selon le statut du SRAS-CoV-2. Le succès du premier passage a été obtenu dans 92,4% de toutes les intubations, sans différence selon le statut SARS-CoV-2 CONCLUSIONS: Pendant la pandémie de COVID-19, nous avons observé un faible risque d'événements indésirables associés à l'intubation, même si l'hypoxémie était fréquente chez les patients atteints de SRAS-CoV-2 confirmé. Nous avons observé des taux élevés de réussite du premier passage et des taux faibles d'incapacité à intuber. Le nombre limité d'événements indésirables a empêché les ajustements multivariés. Les résultats de l'étude devraient rassurer les praticiens de la médecine d'urgence que les modifications apportées aux processus d'intubation en réponse à la pandémie de COVID-19 ne semblent pas être associées à des résultats plus défavorables que les pratiques antérieures à la pandémie de COVID-19.

Management of the Normal and Difficult Pediatric Airway: Unique Challenges in the Time of COVID-19.

Purpose of Review: This review focuses on the challenges faced by acute care healthcare workers in the management of the normal and difficult pediatric airway during the COVID-19 pandemic and how these protocols and practices evolved during the pandemic. The current state of knowledge on timing of surgery and anesthesia is also discussed. Recent Findings: In the early days of the pandemic, information about the SARS-CoV-2 virus and disease process was scarce. Governmental, healthcare, and professional organizations created several guidelines to protect invaluable healthcare workers from the contagious virus while also delivering appropriate care to children with COVID-19. With the emergence of new studies and the deployment of new life-saving COVID-19 vaccines and other therapies, these guidelines evolved. The use of aerosol containment devices such as aerosol boxes and flexible barrier techniques was found to be ineffective in reliably containing virus particles while posing potential harm to both healthcare workers and patients. Also, the definition of aerosol-generating and dispersing medical procedures was vastly broadened. To date, use of appropriate personal protection equipment and COVID-19 vaccination are the most effective ways to protect healthcare workers and safely manage children infected with SARS-CoV-2 who require airway intervention. Summary: Evidence-based public health measures and appropriate personal protective equipment remain the best way to protect both healthcare workers and patients. As the virus and population evolve and COVID-19 vaccines become more widely available, clinicians must be willing to adapt to the emerging evidence of their impact on how safe pediatric perioperative care is delivered.

Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly 3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate the practices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the team and a senior resident (37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscope for intubation (62.8%), whereas video laryngoscope was used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

Performance of Aerosol Boxes for Endotracheal Intubation during the COVID-19 Pandemic with Systematic Review.

Introduction: In the backdrop of the COVID-19 pandemic, endotracheal intubation using an aerosol box (AB) became the norm in the emergency department (ED) and the intensive care unit. We compared two models of AB with different dimensions to compare and identify a device that helps in reducing viral exposure without compromising successful airway management. Methods: We conducted this prospective observational study for 7 months (October 20-April 21) on 143 patients presenting with an acute airway compromise to the ED. All intubations were performed using one of the two models available. The primary outcome was time taken for intubation (TTI). Results: The overall median time taken to intubate using any AB was 63 (interquartile range [IQR]: 46.2-87.7) s with an 81.9% first-pass success (FPS) rate. TTI for AB I was 67 (IQR: 53-106) s with a 76.3% FPS rate, while TTI for AB II was 57 (IQR: 44-75) s with an 85.9% FPS rate. TTI was much shorter without the use of an AB (34: IQR: 24-53 s) with a 92% FPS rate. Intubations done by emergency physicians with more than 2 years of experience were faster in both with or without AB when compared to intubations done by physicians with <2 years of experience. Conclusion: The use of an AB is associated with a longer TTI when compared to intubations done without an AB. TTI was relatively shorter when more experienced emergency physicians performed intubation. FPS rates were low with intubations done using AB.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects.

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020. With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly. We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU). We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020 and June 2020 to determine if they met the inclusion criteria. These subjects were required to be spontaneously ventilating upon admission and eventually required intubation. Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospective ICU admission analysis. We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects. Our primary outcome of interest was intubation-related mortality. We defined intubation mortality as unexpected death (within 48 hours of intubation). Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress. COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects. COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed the rates of intubation survival were no different between the COVID and non-COVID groups. We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.