Search Results (44)

Background: The management of difficult airways is one of the most critical and challenging aspects of emergency and ICU care. Despite technological advances, unanticipated airway difficulty can result in serious complications, including hypoxia, brain injury, and death. This comprehensive narrative review aims to consolidate current algorithms and evidence-based strategies to guide clinicians in the assessment and management of difficult airways. Methods: A comprehensive literature review was conducted using PubMed, Embase, and Google Scholar to identify relevant studies, clinical guidelines, and expert consensus documents related to difficult airway management. The focus was placed on both pre-intubation assessment tools and intervention strategies used in various clinical contexts. Results: Airway difficulty is best anticipated through a combination of history, physical examination, and validated tools such as the Mallampati score. Several algorithms, including those from the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS), provide structured approaches that emphasize preoxygenation, preparedness for failed intubation, and the use of adjuncts such as video laryngoscopy, supraglottic airway devices, and awake intubation techniques. Crisis algorithms such as the Vortex approach help simplify decision-making during emergencies. It is important to have adjuncts available in cases of anticipated difficult airways, such as fiberoptic intubation, while surgical airway access is an important component of a stepwise airway management algorithm when critical scenarios are encountered. Conclusions: Effective difficult airway management requires anticipation, a structured plan, familiarity with advanced airway tools, and adherence to validated algorithms. Training in crisis resource management and multidisciplinary rehearsal of airway scenarios are essential to improving outcomes. Full article

Background: Airway management in otolaryngology presents unique challenges due to shared airway access, altered anatomy, and specific procedural requirements. This article examines current techniques and oxygenation strategies across various ENT procedures to provide a guide for otolaryngologists. Methods: A narrative review was performed of the contemporary literature, focusing on airway techniques in ENT surgery, including laryngeal surgery, pediatric bronchoscopy, transoral surgery, and trauma and emergency scenarios. A systematic search for difficult airway guidelines was performed using the EMBASE, Pubmed, and Cochrane databases to examine where guidelines are published. Results: The key areas for specialist airway management included laryngeal surgery in the tubeless field and adjuncts for emergency situations. High-flow nasal oxygen (HFNO), jet ventilation, video laryngoscopy, and specialized tubes emerged as key technological advances, improving safety and outcomes. A systematic search identified 947 difficult airway articles across 82 publishers. These were predominantly in anesthetic journals (n = 301), with limited representation in the otolaryngology literature (n = 8) and limited guidance concerning awake surgical tracheostomies under local anesthetic. Awake tracheal intubation and emergency front-of-neck access were identified as key techniques across multiple publications. Conclusions: Modern ENT airway management requires multidisciplinary planning, advanced equipment familiarity, and procedure-specific techniques. Despite having the expertise to perform the gold standard, the limited otolaryngology literature on difficult airways suggests that guidelines are primarily developed by the anesthetic community. Full article

Voice disorders occur frequently in schoolteachers. The aim of the present cross-sectional study involving 124 German teachers was to investigate whether singing, voice training, and high self-efficacy are protective factors for vocal health. Furthermore, vocal self-concept was examined as a potential mediator explaining this relationship. Participants were assigned to the cases group if they had a clinically significant finding in voice examinations consisting of video laryngoscopy (VLS), auditory assessment (RBH), and the Voice Handicap Index (VHI) were assigned to the cases group. Psychosocial assessments comprised questions about singing activities and participation in voice training as well as validated questionnaires regarding self-efficacy (LSWS) and vocal self-concept (FESS). Group comparisons and mediation analyses were conducted. Analyses revealed a decreased risk of voice problems for teachers who sing regularly (OR: 0.442, p = 0.038). Furthermore, the absence of voice problems was associated significantly with higher self-efficacy ratings (t(113) = 1.71, p = 0.045). Both associations were mediated by vocal self-concept ratings (singing: ab = −0.422, 95%-CI [−1.102, −0.037]; self-efficacy: ab = −0.075, 95%-CI [−0.155, −0.022]). Participation in voice training in the past did not reduce the risk of voice problems significantly. The presented data suggest that regular singing and self-efficacy should be promoted in health care and prevention programs. Since no impact of sporadic participation in voice training activities on the occurrence of voice problems was found, efforts regarding the transfer of regular vocal exercises into daily life need to be intensified. Full article

This literature review explores factors influencing neonatal ICU intubation success, compares outcomes across settings, and identifies strategies to improve outcomes in this vulnerable population. A PubMed search was conducted using relevant keywords related to neonatal tracheal intubation. Studies published in English from 2000 to 2024 were included, with additional sources identified through manual bibliography reviews. Extracted findings were qualitatively synthesized by themes such as procedural outcomes, intubation setting, and provider training level. Nearly half of all neonatal tracheal intubations (TIs) are unsuccessful, with the rate of tracheal intubation adverse events (TIAEs) increasing with each additional attempt. First-pass success rates (FPSRs) correlate with provider experience, with attending physicians achieving the highest rates across all settings. Video laryngoscopy is associated with improved outcomes, particularly in neonates with difficult airways; however, direct laryngoscopy (DL) remains more commonly used. Premedication has been shown to reduce TIAEs and enhance FPSR, yet it remains underutilized in clinical practice. Standardized protocols, improved simulation-based training, and multidisciplinary strategies are essential to reduce complications. Future research should prioritize optimizing airway management and evaluating the impact of otorhinolaryngologist involvement, especially in difficult airway cases. Full article

Background/Objectives: Endotracheal intubation in critically ill patients presents significant challenges due to anatomical and physiological complexities, making airway management crucial. Video laryngoscopy (VL) has emerged as a promising alternative to direct laryngoscopy (DL), offering improved and higher success rates. This systematic review and meta-analysis evaluated the comparative efficacy and safety of VL versus DL in critically ill adults. Methods: A systematic search was conducted in PubMed, Embase, and Cochrane Library through August 2024 following PRISMA-2020 guidelines. Randomized controlled trials comparing VL and DL in critically ill adult patients were included. The RoB 2.0 tool assessed bias, and GRADE evaluated the certainty of evidence. The primary outcome was first-attempt success; secondary outcomes included intubation time, glottic visualization, and complications. Random effects models were used for data synthesis. Results: Fifteen studies (4582 intubations) were included. VL improved first-attempt success rates (RR 1.12; 95% CI: 1.04–1.21; I² = 87%). It also reduced esophageal intubation (RR 0.44; 95% CI: 0.26–0.75), dental injuries (RR 0.32; 95% CI: 0.16–0.67), and poor glottic visualization. No significant differences were found in hypoxemia, hypotension, or mortality. Conclusions: VL enhances intubation success and reduces specific complications, particularly in difficult airways. However, high heterogeneity and low certainty of evidence warrant further studies to clarify its impact on critical patient outcomes. Full article

Background/Objectives: This report details a rare instance of an infant with achondroplasia developing acute tetraparesis after a cervical whiplash injury, highlighting key multidisciplinary management considerations and specific anesthetic strategies to mitigate potential risks. Case presentation: A 1-year-old boy with achondroplasia presented with acute tetraparesis after a whiplash injury. Initial craniocervical computed tomography demonstrated a reduced volume of the posterior fossa, foramen magnum stenosis, and ventriculomegaly, without any fractures or dislocations. Moreover, magnetic resonance imaging (MRI) revealed pathological signal changes in the medulla oblongata, cervical spinal cord in segments C1 and C2, and the posterior atlantoaxial ligament. After initial conservative therapy and head immobilization using a soft cervical collar, partial remission of the tetraparesis was achieved. Two weeks post-injury, microsurgical posterior fossa decompression extending to the foramen magnum and C1 laminectomy was performed under general anesthesia with intraoperative neuromonitoring. Following an unsuccessful intubation attempt using a fiberoptic bronchoscope, successful airway management was achieved using a combined technique incorporating video laryngoscopy. Venous access was secured under ultrasound guidance. The patient exhibited complete remission of neurological symptoms by the third postoperative month during follow-up. Conclusions: This case report underscores the crucial need for a multidisciplinary approach in managing children with achondroplasia, especially with foramen magnum stenosis and complex cervical spine injuries. Anesthetic management required meticulously planned airway strategies using advanced techniques like video laryngoscopy and fiberoptic bronchoscopy to reduce airway risks. It also highlights the importance of conservative therapy paired with timely neurosurgical intervention, resulting in the patient’s full recovery. Full article

Background: Simulation offers the opportunity to train healthcare professionals in complex scenarios, such as those with as traumatized patients. Methods: We conducted an observational cross-sectional research simulating trauma with cervical immobilization. We compared five techniques/devices: direct laryngoscopy (DL), videolaryngoscopy (VLS, Glidescope or McGrath), combined laryngo-bronchoscopy intubation (CLBI) and articulating video stylet (ProVu). The primary outcomes were as follows: (1) success rate (SR) by third attempt (each lasting up to 60 s), and (2) corrected time-to-intubation (cTTI, accounting for failed attempts). Results: In a single center, we enrolled 42 consultants experienced in DL/VLS, but reporting no experience with ProVu, and hypothesized that ProVu would have offered encouraging performances. By the third attempt, ProVu had a SR of 73.8%, identical to Glidescope (p = 1.00) and inferior only to McGrath (97.6%; p = 0.003). The cTTI (seconds) of ProVu (57.5 [45–174]) was similar to Glidescope (51.2 [29–159]; p = 0.391), inferior to DL and McGrath (31.0 [22–46]; p = 0.001; and 49.6 [27–88]; p = 0.014, respectively), and superior to CLBI (157.5 [41–180]; p = 0.023). Conclusions: In consultants with no experience, as compared to DL and VLS, the video stylet ProVu showed encouraging results under simulated circumstances of cervical immobilization. The results should be interpreted in light of the participants being novices to ProVu and skilled in DL/VLS. Adequate training is required before the clinical introduction of any airway device. Full article

Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table’s height was adjusted at four points: the operator’s umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table’s height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures. Full article

The topic of phonation onset gestures is of great interest to singers, acousticians, and voice physiologists alike. The vocal pedagogue and voice researcher Manuel Garcia, in the mid-19th century, first coined the term “coup de la glotte”. Given that Garcia defined the process as “a precise articulation of the glottis that leads to a precise and clean tone attack”, the term can certainly be linked to the concept of “vocal onset” as we understand it today. However, Garcia did not, by any means, have the technical measures at his disposal to investigate this phenomenon. In order to better understand modern ways of investigating vocal onset—and the limitations that still exist—it seems worthwhile to approach the subject from a historical perspective. High-speed video laryngoscopy (HSV) can be regarded as the gold standard among today’s examination methods. Nonetheless, it still does not allow the three-dimensionality of vocal fold vibrations to be examined as it relates to vocal onset. Clearly, measuring methods in voice physiology have developed fundamentally since Garcia’s time. This offers grounds for hope that the still unanswered questions around the phenomenon of vocal onset will be resolved in the near future. One promising approach could be to develop ultra-fast three-dimensional MRI further. Full article

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o’clock direction) while maintaining the bronchial lumen towards the left (9 o’clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3–11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique. Full article

The C-MAC video stylet (Karl Storz KG, Tuttlingen, Germany) is proposed as a successor to the familiar retromolar intubation endoscope. With its flexible tip, it may be especially useful for patients with a limited mouth opening. An awake or sedated airway management technique is often preferred when a difficult airway is anticipated. Due to the challenges in preparation, sedation, topical airway anesthesia and the execution of such an airway management technique itself, these techniques are often clinically underused. The C-MAC video stylet seems to be well suited for an awake or sedated airway approach, as its handling is easier and faster than a flexible fiberscope. It does not exert pressure on the tongue as direct laryngoscopy or video laryngoscopy do. We report two cases of a difficult airway in which intubation was performed by using the C-MAC video stylet in sedated, spontaneously breathing patients. After a low dose of 3 mg midazolam IV, remimazolam was administered continuously (0.46–0.92 mg/kg/h). This was supplemented with a low dose of remifentanil (0.04–0.05 µg/kg/min). The Trachospray device (MedSpray Anesthesia BV, Enschede, The Netherlands) was used for topicalization of the upper airway by means of 4 mL of lidocaine 5%. In addition, a further 5 mL of lidocaine 5% was sprayed via an epidural catheter advanced through the oxygenation port of the C-MAC video stylet for further topicalization of the vocal cords and proximal part of the trachea. The well-coordinated steps described in these two cases may represent a blueprint and a good starting point for future studies with a larger number of patients. Full article

This study develops a predictive model for video laryngoscopic views using advanced machine learning techniques, aiming to enhance airway management’s efficiency and safety. A total of 212 participants were involved, with 169 in the training set and 43 in the test set. We assessed outcomes using the percentage of glottic opening (POGO) score and considered factors like the modified Mallampati classification, thyromental height and distance, sternomental distance, mouth opening distance, and neck circumference. A range of machine learning algorithms was employed for data analysis, including Random Forest, Light Gradient Boosting Machine, K-Nearest Neighbors, Support Vector Regression, Ridge Regression, and Lasso Regression. The models’ performance was evaluated on the test set, with Root Mean Squared Error values ranging from 20.4 to 21.9. SHapley Additive exPlanations value analysis revealed that age is a consistent and significant predictor of POGO score across all models, highlighting its critical role in the predictive accuracy of these techniques. Full article

Background and Objective: Obesity is associated with difficult or failed intubation attempts, making general anesthesia challenging for anesthesiologists to perform. The purpose of this study was to evaluate and compare the efficacy of a McCoy laryngoscope and a C-MAC D-blade video laryngoscope for intubation in obese patients with a body mass index (BMI) ≥ 35 kg/m². Methods: In total, 104 patients were randomly assigned to be intubated with a McCoy (McCoy group) or C-MAC D-blade video laryngoscope (C-MAC group). The primary outcome was intubation time. The secondary outcomes were vocal cord exposure time, vocal cord passage time, proportion of successful intubation, mask ventilation scale, intubation difficulty scale (IDS), percentage of glottis opening (POGO) score, and hemodynamic variables. Results: Although the intubation time did not significantly differ, the C-MAC group showed shorter vocal cord exposure times and a higher rate of successful vocal cord exposure within 5 s. The IDS value was significantly lower in the C-MAC group than in the McCoy group. The proportion of patients who required an increase in lifting force during laryngoscopy was higher in the McCoy group than in the C-MAC group, which may explain the difference in MAP between the groups. Conclusions: Both the McCoy laryngoscope and the C-MAC D-blade video laryngoscope were useful during the intubation of obese patients. The C-MAC D-blade video laryngoscope might be more useful for obese patients in terms of hemodynamic stability. Full article

Background: Tracheal intubation in the Sellick and Trendelenburg position (ST position) can prevent pulmonary aspiration but increase the difficulty of tracheal intubation. We compared tracheal intubation using video and direct laryngoscopy in the ST position with direct laryngoscopy in the supine sniffing position to evaluate the overall intubation performance. Methods: One hundred and twenty patients were randomly assigned to three groups: direct laryngoscope in the supine sniffing position (control), direct laryngoscope in the ST position (ST direct), and video laryngoscope in the ST position (ST video). The primary outcome was the intubation time; secondary outcomes included the first attempt success rate of tracheal intubation, intubation difficulty scale score, operator’s subjective assessment of intubation difficulty, and modified Cormack–Lehane grades. Results: The median intubation times were greater in the ST direct (36.0 s) and video (34.5 s) than the control (28.0 s) groups. The first attempt success rate decreased in the ST direct (77.5%) but not the video (95.0%) group compared with the control group (100%). Conclusions: The challenges of tracheal intubation in the ST position, aimed at reducing the risk of pulmonary aspiration, can be mitigated by using a video laryngoscope, despite slightly longer intubation times. Full article

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery. Full article