Search Results (13)

Introduction: Airway management remains a high-risk intervention in a subset of patients, with traditional predictors like the Mallampati score demonstrating poor sensitivity and specificity. Point-of-care ultrasound (POCUS) has emerged as a transformative tool, offering real-time, objective assessment of airway anatomy to improve safety and outcomes. Methods: A narrative approach was conducted to evaluate the literature on airway ultrasound, incorporating clinical metrics and procedural applications. Results: Ultrasound has demonstrated utility in pre-intubation risk stratification using quantitative measures such as skin-to-epiglottis distance (>2.75 cm) and hyomental distance ratio (<1.2), which outperform traditional exams, especially in obese patients. Procedural uses include endotracheal tube confirmation with 98.9% sensitivity and enhanced success rates in emergent cricothyroidotomy—from 50% to nearly 100%—in patients with difficult anatomy. Dynamic applications like assessing laryngeal edema via parapharyngeal thickness offer advantages over traditional cuff leak tests. Technical considerations such as optimal probe selection, patient positioning, and interpretation of key anatomical landmarks are also discussed. Conclusions: Airway ultrasound is poised to become a standard tool in perioperative and critical care settings. The review concludes by emphasizing POCUS as an indispensable adjunct for modern airway management. Full article

Background: To compare tracheal temperature (T_ET) with nasopharyngeal temperature (T_NP) in patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Methods: T_ET was measured using a thermistor in the cuff of an endotracheal tube and T_NP was monitored using an esophageal stethoscope. Depending on the management of the CPB strategy, the operation was divided into four periods (pre-CPB, cooling, rewarming, and post-CPB). A Bland–Altman analysis was carried out to compare T_ET with T_NP in each period. The concordance correlation coefficient for repeated measures analysis and various time lags was used to validate the time lag maximizing the concordance correlation coefficient between the two methods. Results: A total of 7191 pairs of temperature recordings acquired from 24 patients were included in the analysis. During steady normothermia, 81.7% (95% confidence interval [CI], 79.8–83.5%) of the pairs had a difference within ±0.5 °C, with a mean bias of −0.28 °C and limits of agreement (LOA) of −0.74 °C to 0.18 °C. The LOA during the cooling and rewarming phase of CPB were −1.13 °C to 0.51 °C and −0.91 °C to 1.29 °C, respectively. The mean bias and LOA throughout the entire operation were −0.10 °C and −0.98 °C to 0.77 °C, respectively. Throughout the entire operation, −2 min of time lag on T_ET maximized the concordance correlation coefficient (0.94 [95% CI, 0.92–0.96] to 0.95 [95% CI, 0.93–0.96]), indicating an earlier response of T_ET than T_NP. Conclusions: T_ET could be an alternative to T_NP during cardiac surgery using CPB. Full article

This study aimed to assess the performance, accuracy, precision and repeatability of two single-use airway pressure manometers as a cost-effective alternative for inflation of endotracheal tubes with high-volume, low-pressure cuffs. The manometers were tested in a bench top model against a U-tube manometer. Eighteen units of each device were tested. Three consecutive measurements were performed at pressures of 20, 25 and 30 cmH₂O each. The mean ± SD of the recorded pressures and maximum deviation from the target pressures were calculated for each device and each target pressure. For device A, the mean ± SD pressures were 19.6 ± 0.7, 23.6 ± 0.8 and 28.3 ± 0.8 cmH₂O; for device B, the mean ± SD pressures were 19.3 ± 0.6, 24.3 ± 0.9 and 29.2 ± 0.67 cmH₂O for target pressures of 20, 25 and 30 cmH₂O, respectively. The bias for device A was −0.4, −1.4, and −1.7 cmH₂O and for device B, −0.7, −0.7, and −0.8 cmH₂O for target pressures of 20, 25, and 30 cmH₂O, respectively. Both devices showed results comparable to those reported for commercial cuff manometers. They represent inexpensive tools that provide clinically sufficient accuracy, precision and repeatability for ETT cuff inflation between pressures of 20 and 30 cmH₂O. Full article

Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of “Institute for Healthcare Improvement Ventilator Bundle”, i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the “IHI Ventilator Bundle” combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle’s compliance should be the gold standard combination. Full article

Endotracheal intubation is a routine procedure in veterinary anaesthesia, yet no consensus guidelines exist for endotracheal tube (ETT) cuff inflation and pressure measurement. The aim of this study was to assess current practice of ETT cuff inflation and seal verification in veterinary medicine. An online questionnaire was distributed among veterinary professionals who administer anaesthesia, comprising six demographic and twelve ETT cuff-related questions per species. N = 348 questionnaires were completed. Cuff pressure was measured by 30% of respondents in cats, 32% in dogs and 9% in both farm animals and horses. Anaesthesia diplomates were not more likely to measure cuff pressure than others, except in cats (OR: 1.8; 95% CI: 1.1–2.9). The most frequently selected recommended range of cuff pressure was 20–30 cm H₂O, regardless of species, although >30 cm H₂O was selected significantly more often in horses compared to dogs, cats and farm animals. The preferred technique to verify cuff seal was minimal occlusive volume in dogs, cats and farm animals, whereas in horses, the preferred method was verification of normal capnogram waveform. ETT cuff pressure measurement remains uncommon in veterinary anaesthesia. The development of consensus recommendations for cuff inflation, including evidence-based target cuff pressure ranges for various species and different ETT models or materials, can help to improve practice. Full article

Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP. Full article

The COVID-19 outbreak has increased the incidence of tracheal lesions in patients who underwent invasive mechanical ventilation. We measured the pressure exerted by the cuff on the walls of a test bench mimicking the laryngotracheal tract. The test bench was designed to acquire the pressure exerted by endotracheal tube cuffs inflated inside an artificial model of a human trachea. The experimental protocol consisted of measuring pressure values before and after applying a maneuver on two types of endotracheal tubes placed in two mock-ups resembling two different sized tracheal tracts. Increasing pressure values were used to inflate the cuff and the pressures were recorded in two different body positions. The recorded pressure increased proportionally to the input pressure. Moreover, the pressure values measured when using the non-armored (NA) tube were usually higher than those recorded when using the armored (A) tube. A periodic check of the cuff pressure upon changing the body position and/or when performing maneuvers on the tube appears to be necessary to prevent a pressure increase on the tracheal wall. In addition, in our model, the cuff of the A tube gave a more stable output pressure on the tracheal wall than that of the NA tube. Full article

Accumulated secretion above the endotracheal tube cuff can be aspirated during extubation after deflation. The possible techniques for minimizing pulmonary aspiration from subglottic secretion during extubation have not been well explored. This study aimed to determine the effect of different extubation techniques on secretion leakage. An endotracheal tube was placed in a tube mimicking an airway. We measured the leak volume of water or artificial sputum of different viscosities with three extubation techniques—negative pressure with suctioning; positive pressure with a resuscitator; and continuous positive airway pressure set at 5, 10, and 20 cm H₂O. Extubation with continuous positive airway pressure resulted in lower secretion leakage than that with negative pressure with suctioning and positive pressure with a resuscitator. Increasing the continuous positive airway pressure level decreased secretion leakage volume during extubation. We further determined a correlation of leak volume with sputum viscosity. Continuous positive airway pressure at 5 cm H₂O produced lower volume secretion leakage than the other two techniques, even with higher secretion viscosity. Based on these results, using continuous positive airway pressure with a previous ventilator continuous positive airway pressure/positive end-expiratory pressure setting for extubation is recommended. Full article

The ventilator bundle consists of multiple methods to reduce ventilator-associated pneumonia (VAP) rates in Intensive Care Units (ICU). The aim of the study was to evaluate how the continuous automatic pressure control in tapered cuffs of endotracheal/tracheostomy tubes applied along with continuous automatic subglottic secretion suction affect the incidence of VAP. In the prospective cohort (n = 198), the standard VAP bundle was modified by continuous automatic pressure control in taper-shaped cuff of endotracheal/tracheostomy tubes and subglottic secretion suction. VAP incidence, time to VAP onset, invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality, and multidrug-resistant bacteria were assessed and compared to the retrospective cohort (n = 173) with the standard bundle (intermittent cuff pressure of standard cuff, lack of subglottic secretion suction). A smaller incidence of VAP (9.6% vs. 19.1%) and early onset VAP (1.5% vs. 8.1%) was found in the prospective compared to the retrospective cohort (p < 0.01). Patients in the prospective cohort were less likely to develop VAP (RR = 0.50; 95% CI: 0.29 to 0.85) and early-onset VAP (RR = 0.19; 95% CI: 0.05 to 0.64) and had longer time to onset VAP (median 9 vs. 5 days; p = 0.03). There was no significant difference (p > 0.05) between both cohorts in terms of invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality and multidrug-resistant bacteria. Modification of the bundle for prevention of VAP can reduce early-onset VAP and total incidence of VAP and delay the time of VAP occurrence. Full article

Proper bronchial cuff pressure (BCP) is important when using a double-lumen endotracheal tube (DLT), especially in thoracic surgery. As positional change during endotracheal tube placement could alter cuff pressure, we aim to evaluate the change in BCP of DLT from the supine to the lateral decubitus position during thoracic surgery. A total of 69 patients aged 18–70 years who underwent elective lung surgery were recruited. BCP was measured at a series of time points in the supine and lateral decubitus positions after confirming the DLT placement. The primary outcome was change in the initial established BCP (BCPi), which is the maximum pressure at which the BCP did not exceed 40 cmH₂O without air leak in the supine position, after lateral decubitus positioning. As the primary outcome, the BCPi increased from 25.4 ± 9.0 cmH₂O in the supine position to 29.1 ± 12.2 cmH₂O in the lateral decubitus position (p < 0.001). Out of the 69 participants, 43 and 26 patients underwent surgery in the left-lateral decubitus position (LLD group) and the right-lateral decubitus position (RLD group) respectively. In the LLD group, the BCPi increased significantly (p < 0.001) after lateral positioning and the beginning of surgery and the difference value, ∆BCPi, from supine to lateral position was significantly higher in the LLD group than in the RLD group (p = 0.034). Positional change from supine to lateral decubitus could increase the BCPi of DLT and the increase was significantly greater in LLD that in RLD. Full article

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination. Full article

Scarless remote access endoscopic and robotic thyroidectomy has been recently performed as a safe and feasible method. However, little is known about the laryngo-pharyngeal complications after surgery and the effect of adjusting the endotracheal tube cuff pressure during surgery on laryngo-pharyngeal complications. Patients were randomized into two groups: the control group (n = 52) and adjusted group (n = 52). The initial cuff pressure was set to 25 mmHg and then monitored without adjustment (control group) or with adjustment at approximately 25 mmHg (adjusted group) throughout surgery. The incidences and severity of postoperative sore throat (POST), hoarseness, dysphagia, and cough were recorded at 1, 6, 24, and 48 h after surgery. Cuff pressures of the control group changed significantly over time and were higher than those of the adjusted group. The incidence of POST was lower in the adjusted group at 24 h postoperatively (p = 0.035), and there was a significant difference in the severity of POST at 6 and 24 h postoperatively between the two groups. There were no differences in the incidence of hoarseness, dysphagia, and cough between the two groups, except dysphagia and cough at 6 h postoperatively. Therefore, intraoperative monitoring and adjustment of the cuff pressure can reduce the incidence of laryngo-pharyngeal complications. Full article