Browsing by Subject "Intubation, Intratracheal"
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Item Choice of Anesthetic Induction Drugs for Tracheal Intubation in Critically Ill Patients and Impact on Outcomes: A Systematic Review(2024-01-30) Khawaja, Asad; Karamchandani, Kunal; Tyagi, Abhay; Singh, Preet MohinderBACKGROUND: Airway management in critically ill patients can significantly impact patient outcomes, and the choice of induction drugs used for endotracheal intubation (TI) is key for a successful and safe airway management. However, critically ill patients often have physiologic derangements leading to complications such as hypoxemia, hypotension, arrythmias, and cardiac arrest. HYPOTHESIS: This review aims to analyze the usage and outcomes of induction drugs used for airway management in critically ill adult patients to determine if there are select induction drugs that have better success rates and patient outcomes. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials published since January 1, 2003, on critically ill adult patients who underwent TI in an emergency, ICU, or trauma setting. Our search yielded 1526 results, of which 18 were chosen. FINDINGS: These 18 studies include 15 randomized control trials, 2 ongoing phase 4 clinical trials, and 1 single blinded randomized study, for a total of 3142 patients. Etomidate and ketamine were the two most common drugs used, with 13 studies involving the use of etomidate, for a total of 1470 patients, and 7 studies involving the use of ketamine, for a total of 1082 patients. Etomidate and ketamine were compared the most frequently (n = 7), followed by etomidate and midazolam (n = 4). Most studies were performed in either the ICU (n = 6) or the ED/ER (n = 5). Hospital mortality (n = 10) and peri-intubation hypotension (n = 11) were also the most common outcomes studied. CONCLUSIONS: In general, there was no major trend that could be identified regarding patient outcomes when two induction drugs were compared with each other. This was due to the variability in the use of induction drugs for TI in critically ill patients and their patient outcomes. Comparing findings of different studies was limited by the heterogeneity of the studies. Further research is needed to identify the impact of the choice of induction drugs for TI in critically ill patients.Item The Difficult Airway: Incidence and Predictors in Lean vs. Obese Patients(2017-01-17) Volnov, Yuri; Gonzales, Michael; Sun, Josh; Kim, Agnes; Sung, John; Moon, TiffanyBACKGROUND: As the incidence of morbid obesity continues to rise, anesthesiologists are increasingly concerned with the possible association between morbid obesity and difficult intubation. Current literature exploring the association between the morbidly obese and difficult intubation is contradictory1-6. Moreover, "difficult intubation" lacks standardization with studies variably utilizing the Intubation Difficulty Scale2,3,5,7, the Cormack-Lehane grade8,9, or institutional or investigator preference1,4,6. Overall, results remain uncertain despite best attempts to aggregate past data10. METHODS: A cohort of 127 morbidly obese individuals (BMI≥40) and 739 non-morbidly obese individuals (BMI<40) consented to participate in the study. Individuals were preoperatively assessed for obstructive sleep apnea (OSA), neck range of motion (ROM), neck circumference (NC), thyromental distance (TM), sternomental distance (SM), interincisor distance (IID), upper lip bite test (ULBT), and Mallampati score. Following intubation, the laryngoscopist was asked to assess difficulty using the validated Intubation Difficulty Scale (IDS) (Adnet 1997). Difficult endotracheal intubation, difficult laryngoscopy, and difficult mask ventilation were defined as an IDS score ≥6, a Cormack-Lehane grade of 3 or 4, and by designation of the provider, respectively. RESULTS: The incidence of difficult endotracheal intubation, difficult laryngoscopy and difficult mask ventilation was determined to be 4.7%, 9.5% and 6.3% in the morbidly obese cohort as compared to 4.7%, 6.8% and, 2.4% in the non-morbidly obese cohort. BMI is not associated with difficult intubation (p-value=0.995); however, gender (p-value=0.037), OSA (p-value=0.006), NC (p-value=0.012), IID (p-value=0.034), ULBT (p-value=0.020), and Mallampati (p-value=0.006) are. BMI is also not associated with difficult laryngoscopy (p-value=0.279); however, gender (p-value=0.048), OSA (p-value=0.011), neck ROM (p-value=0.028), NC (p-value=0.002), TM (p-value=0.017), SM (p-value=0.001), ULBT (p-value=0.036) and Mallampati (p-value=0.014) are. BMI is associated with difficult mask ventilation (p-value=<0.001). CONCLUSIONS: BMI is not associated with difficult intubation or laryngoscopy, only difficult mask ventilation. Thus, a high BMI by itself does not predict difficult intubation. Other factors such as gender, Mallampati classification, and presence of OSA may be more suitable in predicting intubation difficulty.Item Incidence and Predictors of a Difficult Airway in Lean vs. Obese Surgical Patients: A Large Prospective Cohort Study(2021-05-01T05:00:00.000Z) Smith, Katelynn Marie; Moon, Tiffany; Fox, Pamela; Ogunnaike, BabatundeBACKGROUND: With the high incidence of obesity rates, the determination of whether obese individuals are more difficult to intubate is of the utmost importance. This study aimed to determine the incidence of difficult intubation in obese vs lean patients in the general surgery population at a large tertiary, teaching hospital and assess obesity as a risk factor for difficult intubation. In addition, this study examined additional patient characteristics and anthropometric factors as independent predictors of difficult intubation. I hypothesize that obesity will not be a significant risk factor for difficult intubation. Instead factors such as age, higher Mallampati score, and male sex will be better predictors of difficult intubation. METHODS: This prospective cohort observational study enrolled 4,003 patients undergoing general endotracheal anesthesia. Emergent cases, patients with a known or suspected difficult airway, and patients not expected to initially undergo direct laryngoscopy were excluded. Patients were stratified into two cohorts based on body mass index (BMI): a non-obese group (BMI <30 kg m-2) and an obese group (BMI ≥30 kg m-2). Intubation difficulty was determined using the Intubation Difficulty Scale (IDS). RESULTS: The incidence of severely difficult intubation (IDS ≥ 5) was 5.9% in the obese cohort compared to 4.6% in the non-obese cohort which was not significant (p= 0.061). Controlling for other factors, obese patients were more likely to be difficult to intubate (odds ratio (OR), 1.438; 95% confidence interval (95% CI), [1.064, 1.943], p=0.001). In the analysis of additional patient characteristics and anthropometric values, age > 45 years (OR, 1.586; 95% CI, [1.064, 1.943], p<0.001), male sex (OR, 2.034; 95% CI, [1.532, 2.702], p<0.001), Mallampati score of 3-4 (OR, 2.441; 95% CI, [1.820, 3.273], p<0.001), neck circumference (OR, 1.096 per cm increase; 95% CI, [1.066, 1.128], p<0.001), thyromental distance (OR, 0.757 per cm increase; 95% CI, [0.691,0.830], p<0.001) and sternomental distance (OR, 0.923 per cm increase; 95% CI, [0.770, 0.874], p<0.001) were also significant. However, inter-incisor distance and waist circumference were not. CONCLUSIONS: Obese patients are more likely to be difficult to intubate. However, male sex, age > 45 years, and a high Mallampati score are stronger predictors of difficult intubation compared to BMI. Therefore, while BMI still provides relevant information, BMI alone should not be used as a sole predictor of difficult intubation.Item Trends and Variations in Tracheal Intubation for Acute Respiratory Failure in the US(2024-01-30) Iancau, Alexander; Rosero, Eric B.; Karamchandani, KunalBACKGROUND: Acute respiratory failure (ARF) is a critical medical emergency with increasing mortality rates and hospitalizations in the United States (US). Tracheal intubation (TI) is often required to provide mechanical ventilation in these patients. However, recent evidence shows that TI in critically ill patients is associated with substantial morbidity and mortality, and hence, understanding trends and variations in the practice of TI in critically ill patients with ARF is crucial for improving patient outcomes and healthcare practices. HYPOTHESIS: The study aims to evaluate the frequency of TIs in ARF patients and to assess trends and variations in TI use across US hospitals. We hypothesize a declining trend in TIs among ARF patients and significant variability in TI utilization across US hospitals. METHODS: In our retrospective cohort study, we utilized the National Inpatient Sample (NIS) database from the HCUP. Patient selection relied on ICD 10th Revision codes to identify critically ill adults aged 18 and above who underwent TI and were diagnosed with ARF (2016-2020). We also extracted patient demographic and hospitalization details from the database. RESULTS: From 2016-2020, 2,531,420 patients were admitted to US hospitals with ARF, and of these, 522,746 underwent TI (26.02%). The mean age was 62 years, 44.4% were women, and the in-hospital mortality was 32.8% (95% CI, 32.6%-33.0%). The mortality among patients receiving TI increased significantly from 30.6% (95% CI, 30.1%-31.1%) in 2016 to 37.8% (95% CI, 37.3%-38.3%) in 2020 (p<.0001). However, the percentage of ARF-related hospitalizations receiving TI decreased from 23.9% (95% CI, 23.4% - 24.4%) in 2016 to 18.9% (95% CI, 18.5% - 19.3%) in 2020 (p<.0001). CONCLUSION: We found a decline in TI use for patients with ARF across hospitals in the United States. This could be due to the increased use of alternative techniques to manage ARF, such as non-invasive ventilation and high-flow nasal cannula.