[Recommendations of the new S1 guidelines on airway management]. / Empfehlungen zur neuen S1-Leitlinie Atemwegsmanagement.

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

Curious Case of Pediatric One-Lung Ventilation with Two Endotracheal Tubes: A Case Report.

ABSTRACT: One-lung ventilation is indicated during thoracic surgery for visualization and exposure of surgical site. It is achieved with bronchial blockers, double-lumen endobronchial tube, single-lumen endotracheal tubes and Univent tube for infants and children. Fibreoptic bronchoscope is required for placing and confirming the correct position of these tubes. We report a perioperative management of safe conduct of one lung ventilation for a 6-year child undergoing left lower lobe lobectomy through C-MAC video laryngoscope guided two single lumen tubes in limited resource settings where paediatric-sized fibreoptic bronchoscope is unavailable.

Efficacy of bougie first approach for endotracheal intubation with video laryngoscopy during continuous chest compression: a randomized crossover manikin trial.

BACKGROUND: Endotracheal intubation is challenging during cardiopulmonary resuscitation, and video laryngoscopy has showed benefits for this procedure. The aim of this study was to compare the effectiveness of various intubation approaches, including the bougie first, preloaded bougie, endotracheal tube (ETT) with stylet, and ETT without stylet, on first-attempt success using video laryngoscopy during chest compression. METHODS: This was a randomized crossover trial conducted in a general tertiary teaching hospital. We included anesthesia residents in postgraduate year one to three who passed the screening test. Each resident performed intubation with video laryngoscopy using the four approaches in a randomized sequence on an adult manikin during continuous chest compression. The primary outcome was the first-attempt success defined as starting ventilation within a one minute. RESULTS: A total of 260 endotracheal intubations conducted by 65 residents were randomized and analyzed with 65 procedures in each group. First-attempt success occurred in 64 (98.5%), 57 (87.7%), 56 (86.2%), and 46 (70.8%) intubations in the bougie-first, preloaded bougie, ETT with stylet, and ETT without stylet approaches, respectively. The bougie-first approach had a significantly higher possibility of first-attempt success than the preloaded bougie approach [risk ratio (RR) 8.00, 95% confidence interval (CI) 1.03 to 62.16, P = 0.047], the ETT with stylet approach (RR 9.00, 95% CI 1.17 to 69.02, P = 0.035), and the ETT without stylet approach (RR 19.00, 95% CI 2.62 to 137.79, P = 0.004) in the generalized estimating equation logistic model accounting for clustering of intubations operated by the same resident. In addition, the bougie first approach did not result in prolonged intubation or increased self-reported difficulty among the study participants. CONCLUSIONS: The bougie first approach with video laryngoscopy had the highest possibility of first-attempt success during chest compression. These results helped inform the intubation approach during CPR. However, further studies in an actual clinical environment are warranted to validate these findings. TRIAL REGISTRATION: Clinicaltrials.gov; identifier: NCT05689125; date: January 18, 2023.

Multi-instance learning based artificial intelligence model to assist vocal fold leukoplakia diagnosis: A multicentre diagnostic study.

OBJECTIVE: To develop a multi-instance learning (MIL) based artificial intelligence (AI)-assisted diagnosis models by using laryngoscopic images to differentiate benign and malignant vocal fold leukoplakia (VFL). METHODS: The AI system was developed, trained and validated on 5362 images of 551 patients from three hospitals. Automated regions of interest (ROI) segmentation algorithm was utilized to construct image-level features. MIL was used to fusion image level results to patient level features, then the extracted features were modeled by seven machine learning algorithms. Finally, we evaluated the image level and patient level results. Additionally, 50 videos of VFL were prospectively gathered to assess the system's real-time diagnostic capabilities. A human-machine comparison database was also constructed to compare the diagnostic performance of otolaryngologists with and without AI assistance. RESULTS: In internal and external validation sets, the maximum area under the curve (AUC) for image level segmentation models was 0.775 (95 % CI 0.740-0.811) and 0.720 (95 % CI 0.684-0.756), respectively. Utilizing a MIL-based fusion strategy, the AUC at the patient level increased to 0.869 (95 % CI 0.798-0.940) and 0.851 (95 % CI 0.756-0.945). For real-time video diagnosis, the maximum AUC at the patient level reached 0.850 (95 % CI, 0.743-0.957). With AI assistance, the AUC improved from 0.720 (95 % CI 0.682-0.755) to 0.808 (95 % CI 0.775-0.839) for senior otolaryngologists and from 0.647 (95 % CI 0.608-0.686) to 0.807 (95 % CI 0.773-0.837) for junior otolaryngologists. CONCLUSIONS: The MIL based AI-assisted diagnosis system can significantly improve the diagnostic performance of otolaryngologists for VFL and help to make proper clinical decisions.

Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants.

BACKGROUND: Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain. METHODS: In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection. RESULTS: Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively. CONCLUSIONS: Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).

[A clinical case of successful treatment of an air cyst of the larynx]. / Klinicheskii sluchai uspeshnogo lecheniya vozdushnoi kisty gortani.

Laryngeal air cyst (laryngocele) is a rare disease that is an abnormal cystic expansion of the deep structures of the laryngeal ventricle. They can be accompanied by serious complaints, such as shortness of breath, difficulty breathing during exercise, as well as at rest with large cysts. Computed tomography is the most effective method for determining the type, localization and degree of laryngocele. Although surgical treatment is considered the method of choice in cases of laryngeal air cyst, the approach significantly depends on the size of the lesion.

[Laryngeal carcinosarcoma]. / Kartsinosarkoma gortani.

A clinical case of a rare malignant tumor of the larynx, carcinosarcoma, is described. The features of the clinical picture, diagnostic methods: instrumental and morphological are presented.

Left head rotation (LeHeR), an innovative approach for intubation in patients with missing and loose teeth.

Missing and loose central incisors pose a great difficulty to anaesthesiologists during laryngoscopy and intubation. Left head rotation is a novel technique which facilitates intubation by improving the laryngoscopic view. We report the use of this technique in two patients with missing or loose central incisors to prevent dental trauma.

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage. This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required. The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

Prediction of a Difficult Airway Using the ARNE Score and Flexible Laryngoscopy in Patients with Laryngeal Pathology.

Background and Objectives: The ARNE score was developed for the prediction of a difficult airway for both general and ear, nose and throat (ENT) surgery with a universal cut-off value. We tested the accuracy of this score in the case of laryngeal surgery and provided an insight into its effects in combination with flexible laryngoscopy. Materials and Methods: This prospective pilot clinical study included 100 patients who were being scheduled for microscopic laryngeal surgery. We calculated the ARNE score for every patient, and flexible laryngoscopy was provided preoperative. Difficult intubation was assessed according to the intubation difficulty score (IDS). Results: A total of 33% patients had difficult intubation according to the IDS. The ARNE score showed limited accuracy for the prediction of difficult intubation in laryngology with p < 0.0001 and an AUC of 0.784. Flexible laryngoscopy also showed limitations when used as an independent parameter with p < 0.0001 and an AUC of 0.766. We defined a new cut-off value of 15.50 for laryngology, according to the AUC. After the patients were divided into two groups, according to the new cut-off value and provided cut-off value, the AUC improved to 0.707 from 0.619, respectively. Flexible laryngoscopy improved the prediction model of the ARNE score to an AUC of 0.882 and of the new cut-off value to an AUC of 0.833. Conclusions: It is recommended to use flexible laryngoscopy together with the ARNE score in difficult airway prediction in patients with laryngeal pathology. Also, the universally recommended cut-off value of 11 cannot be effectively used in laryngology, and a new cut-off value of 15.50 is recommended.

Evaluation of a novel, low-cost, 3D printed video laryngoscope with borescope in anesthetized Beagle dogs.

OBJECTIVE: To develop and evaluate a low-cost three-dimensional (3D)-printed video laryngoscope (VLVET) for use with a commercial borescope. STUDY DESIGN: Instrument development and pilot study. ANIMALS: A total of six adult male Beagle dogs. METHODS: The VLVET consisted of a laryngoscope handle and a Miller-type blade, and a detachable camera holder that attached to various locations along the blade. The laryngoscope and camera holder were 3D-printed using black polylactic acid filament. Dogs were premedicated with intravenous (IV) medetomidine (15 µg kg-1) and anesthesia induced with IV alfaxalone (1.5 mg kg-1). The VLVET, combined with a borescope, was used for laryngeal visualization and intubation. Performance was evaluated by comparing direct and video-assisted views in sternal recumbency. The borescope camera was sequentially positioned at 2, 4, 6, 8 and 10 cm from the blade tip (distanceLARYNX-CAM), which was placed on the epiglottis during intubation or laryngoscopy. At the 10 cm distanceLARYNX-CAM, laryngeal visualization was sequentially scored at inter-incisor gaps of 10, 8, 6, 4 and 2 cm. Laryngeal visualization scores (0-3 range, with 0 = obstructed and 3 = unobstructed views) were statistically analyzed using the Friedman's test. RESULTS: Under direct visualization, the 2 cm distanceLARYNX-CAM had a significantly lower score compared with all other distanceLARYNX-CAM (all p = 0.014) because the view was obstructed by the camera holder and borescope camera. With both direct and camera-assisted views, visualization scores were higher at inter-incisor gaps ≥ 4 cm compared with 2 cm (all p < 0.05). CONCLUSIONS AND CLINICAL RELEVANCE: During laryngoscopy and intubation, the VLVET and borescope facilitated both direct and video laryngoscopy at distanceLARYNX-CAM in Beagle dogs when inter-incisor gaps were ≥ 4 cm.

Determinants of difficult laryngoscopy based on upper airway indicators: a prospective observational study.

BACKGROUND: The main cause of anesthesia-related deaths is the failure to manage difficult airways. Difficult laryngoscopic exposure is a major cause of unsuccessful management of difficult airways. Inadequate preoperative airway assessment hinders the clinical management of difficult airways cases, emphasizing the critical need for accurate identification of difficult airways. Currently, no definitive and reliable indicators are available to predict a difficult airway. Our study aims to predict laryngoscope exposure risk factors by combining ultrasonically measured upper airway anatomic parameters with physical examination indicators. METHODS: Patients aged 18 to 75 years, classified as American Standards Association (ASA) I-III, and scheduled for elective general anesthesia with endotracheal intubation were included. All patients received the upper airway and ultrasonographic measurements. After anesthesia induction, laryngoscope exposure was analyzed using the Cormack-Lehane grading system, with Grades III and IV as indicative of difficult laryngoscopy. Univariate and multivariate logistic regression analyses were performed to identify reliable indicators for predicting difficult laryngoscopy. Receiver Operating Characteristic (ROC) curve analysis was utilized to assess the predictive performance of each indicator. RESULTS: A total of 1120 patients finished the study, with 710 cases found in Grade I laryngoscopic exposure group, 360 cases in Grade II group, and 50 cases in Grade III group. There was no case observed in Grade IV group, thereby resulting in an incidence of difficult laryngoscopy of 4.46%. Univariate logistic regression analysis revealed that several parameters including age, Body Mass Index (BMI), neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance were identified as significant risk factors for difficult laryngoscopy (P < 0.05). Among these, BMI, and neck circumference exhibited notable predictive value, with Area Under The Curve (AUC) values of 0.746 (95%CI 0.649-0.842) and 0.732 (95%CI 0.638-0.827), respectively. Neck mobility was also identified as an independent risk factor for predicting difficult laryngoscopy (P = 0.009) in multivariate logistic regression analysis, with an AUC of 0.672 (0.562-0.782) in the ROC curve. CONCLUSIONS: Our findings revealed a direct correlation between difficult laryngoscopy and age, BMI, neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance. Furthermore, neck mobility was identified as an independent predictive factor. TRIAL REGISTRATION: The trial was registered prior to patient enrollment at clinicaltrials.gov (register no. ChiCTR2100053826, Date of registration: November 30, 2021).

Low cost smart phone based laryngoscopy for the assessment of vocal cords in patients undergoing thyroid surgery: A pilot study.

Can a smart phone application be reliably used for laryngoscopy? This thesis was tested for peri-operative evaluation of vocal cords in patients undergoing thyroid and parathyroid surgery.