Digital tracheal intubation and finger palpation to confirm endotracheal tube tip position in neonates: A systematic review and meta-analysis.
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ABSTRACT: Background
To evaluate digital tracheal intubation (DTI) when compared to laryngoscope-assisted TI; finger palpation of endotracheal tube (ETT) tip position when compared to any standard method.Design
A systematic review of Medline, Embase, CENTRAL, and CINAHL with synthesis of data using meta-analysis was performed.Main outcome measure
The proportion of successful TI and correct ETT tip positioning were the main outcome measures.Results
Five studies (one observational study and four RCTs) enrolling 310 neonates were included. 94% (81%-98%) of the DTI were successful on the first attempt (certainty of evidence [CoE]: low). The proportion of successful intubation on the first attempt was higher with DTI when compared to laryngoscope-assisted TI (RR 95% CI: 1.81 [1.18; 2.76]) (CoE: very low). Time to successful TI with DTI was 7.4 (95% CI: 6.3, 8.5) s (CoE: low). Time to successful TI was significantly shorter with DTI when compared to laryngoscope assisted TI (MD [95% CI]: -4.9 [-7.3, -2.4] s) (CoE: very low). There was a trend towards a higher proportion of correct ETT tip positions with finger palpation when compared to weight-based formulae alone (RR 95% CI: 1.12 [0.96; 1.31]) (CoE: very low).Conclusions
DTI and finger palpation to ascertain ETT tip position in neonates are promising strategies. Future studies with emphasis on their learning trajectory and generalizability are needed.
SUBMITTER: Ramaswamy VV
PROVIDER: S-EPMC8457083 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectiveAdvancement of the endotracheal tube through a fibreoptic scope can sometimes prove to be challenging in obese patients. The Parker Flex-Tip endotracheal tube was developed with a curved and tapered distal tip to facilitate easier placement in the trachea. This study examined the use of the Parker Flex-Tip tube as compared to standard endotracheal tubes in patients with a body mass index of 30 or greater.MethodsSixty patients undergoing surgery requiring general anaesthesia were randomised into two groups. Using the fibreoptic scope, one group was intubated with the Parker Flex-Tip tube and the other group with a standard polyvinyl Portex tube. The time for intubation and the number of attempts required to place the endotracheal tube were measured and recorded.ResultsUsing the Mann-Whitney U rank sum test, the median time needed for intubation with the two types of endotracheal tubes did not show a significant difference. The chi-square analyses were conducted for the number of attempts needed to place the endotracheal tubes, which also did not demonstrate any significant difference.ConclusionsParker Flex-Tip endotracheal tube was not superior to the standard endotracheal tubes for fibreoptic intubation in obese patients.
| S-EPMC6756311 | biostudies-literature
Project description:IntroductionTracheal intubation is one of the most daily practiced procedures performed in intensive care unit (ICU). It is associated with severe life-threatening complications, which can lead to intubation-related cardiac arrest. Using a preshaped endotracheal tube plus stylet may have potential advantages over endotracheal tube without stylet. The stylet is a rigid but malleable introducer which fits inside the endotracheal tube and allows for manipulation of the tube shape; to facilitate passage of the tube through the laryngeal inlet. However, some complications from stylets have been reported including mucosal bleeding, perforation of the trachea or oesophagus and sore throat. The use of a stylet for first-attempt intubation has never been assessed in ICU and benefit remains to be established.Methods and analysisThe endotracheal tube plus stylet to increase first-attempt success during orotracheal intubation compared with endotracheal tube alone in ICU patients (STYLETO) trial is an investigator-initiated, multicentre, stratified, parallel-group unblinded trial with an electronic system-based randomisation. Patients will be randomly assigned to undergo the initial intubation attempt with endotracheal tube alone (ie,without stylet, control group) or endotracheal tube + stylet (experimental group). The primary outcome is the proportion of patients with successful first-attempt orotracheal intubation. The single, prespecified, secondary outcome is the incidence of complications related to intubation, in the hour following intubation. Other outcomes analysed will include safety, exploratory procedural and clinical outcomes.Ethics and disseminationThe study project has been approved by the appropriate ethics committee 'Comité-de-Protection-des-Personnes Nord-Ouest3-19.04.26.65808 Cat2 RECHMPL19_0216/STYLETO2019-A01180-57'". Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If combined use of endotracheal tube plus stylet facilitates tracheal intubation of ICU patients compared with endotracheal tube alone, its use will become standard practice, thereby decreasing first-attempt intubation failure rates and, potentially, the frequency of intubation-related complications.Trial registration detailsClinicalTrials.gov Identifier: NCT04079387; Pre-results.
| S-EPMC7542923 | biostudies-literature
Project description:Data on neonatal tracheal length are needed to inform the standardization of safety features for endotracheal tubes (ETTs) such as glottic depth markings. Laryngotracheal airway measurements are available from digital imaging in infants and children but not in neonates. We aimed to determine the tracheal length (TL) of intubated preterm and term neonates. An observational study was performed on 57 neonates of 22-42 weeks' gestation and <1 week of age. Two clinicians independently reviewed 153 digital chest radiographs to determine the carina position and TL. TL was measured from carina to mid-C4 (cricoid level). We analyzed interrater agreement (within 0.5 vertebral levels) on the position of the carina and TL. TL was plotted as a function of gestational age and weight, using graphical and regression analyses. Carina position ranged from T3 to T5.5, with an interrater agreement of 95%. On image pairs concordant for carina position, TL determinations were virtually identical between readers (mean difference 0.1 mm, 95% CI -0.5-0.6 mm). Average mid-tracheal length overlies the body of T1. In infants aged less than 32 weeks' gestation, the mid-trachea lies <20 mm from the carina or the larynx. TL linearly correlates with gestational age, but correlation with birthweight best fits a segmented regression with a node at 1 kg. The functional length of the laryngotracheal airway can be reliably measured in sick neonates. It correlates well with gestational age and birthweight, and this information can inform the redesign of ETT markings to promote the safer use of these devices.
| S-EPMC8870647 | biostudies-literature
Project description:BackgroundEstablishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.ObjectivesTo determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.Search methodsWe used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.Selection criteriaRCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.Data collection and analysisReview authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.Main resultsThe search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.Authors' conclusionsModerate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.
| S-EPMC6513507 | biostudies-literature
Project description:BackgroundLidocaine (LDC) is a local anesthetic widely used to relieve intubation-related airway responses. However, low drug concentration and short effective duration of LDC is inadequate to provide a satisfactory anesthetic effect on the surface of the airway. The present study sought to develop a LDC-delivery endotracheal tube (ETT) to achieve high local drug concentration and sustained drug release with the aim of attenuating an intubation-related airway response.MethodsETTs and polyvinyl chloride (PVC) discs were coated with different molecular weight (MW) poly lactic-co-glycolic acid (PLGA: 50/50; MW: 3,000, 6,000, and 10,000) loaded with LDC by airbrush spray. The morphology of LDC-eluting coatings was analyzed using scanning electron microscopy. In vitro drug release was determined by ultraviolet spectrophotometer. An in vivo study was performed to investigate the differences in plasma LDC concentration, intubation tolerance, and tracheal tissue injury in rabbits undergoing intubation of blank, LDC-spray, or LDC-coated ETTs.ResultsApproximate 5 mg/cm2 coatings (containing 2.5 mg/cm2 LDC) were deposited onto the PVC discs and ETTs. While even distribution and smooth surfaces were generated in PLGA3000 + LDC and PLGA6000 + LDC coatings, PLGA10000 + LDC formed uneven and gullied coatings. Burst release within the first 4 h and sustained release for at least 5 days was achieved in vitro in PLGA + LDC coatings and the in vivo study demonstrated higher plasma LDC concentration and longer drug release duration in LDC-coated ETTs compared with LDC-spray. LDC-coated ETTs significantly improved intubation tolerance in rabbits, as measured by less general anesthetic consumption and longer tube tolerance duration in contrast to blank ETTs with or without LDC spray. Histology assessment showed less mucosal edema area in the PLGA3000 + LDC and PLGA6000 + LDC groups compared to the control, LDC-spray, and PLGA10000 + LDC groups. Among the different MW PLGAs, PLGA6000 presented optimal morphological characteristics, drug release, and anesthetic effect.ConclusionsETTs coated with PLGA + LDC effectively attenuate an intubation-related airway response via increasing local drug concentration and extending drug action duration, which demonstrates a potential therapeutic benefit for patients undergoing intubation.
| S-EPMC8184491 | biostudies-literature
Project description:This study compares the performance of pediatricians and anesthetists in neonatal and pediatric endotracheal intubations (ETI) during simulated settings. Participants completed a questionnaire and performed an ETI scenario on a neonatal and a child manikin. The procedures were recorded with head cameras and cameras attached to standard laryngoscope blades. The outcomes were successful intubation, time to successful intubation, number of attempts, complications, total performance score, end-assessment rating, and an assessment whether the participant was sufficiently able to perform an ETI. Fifty-two pediatricians and 52 anesthetists were included. For the neonatal ETI, the rate of successful intubation was in favor of anesthetists although not significant. Anesthetists performed significantly better in all other outcomes. Of the pediatricians, 65% was rated sufficiently adept to perform a neonatal ETI vs 100% of the anesthetists. Pediatricians (29%) overestimated while anesthetists (33%) underestimated their performance in neonatal ETI. For the pediatric ETI, all outcomes were significantly better for anesthetists. Only 15% of all pediatricians were considered sufficiently able to perform pediatric ETI vs 94% of the anesthetists.Conclusion: Anesthetists are far more adept in performing ETI in neonates and children compared with pediatricians in a simulated setting. Complications are expected to occur less frequently and less seriously when anesthetists perform ETI. What is Known: • Endotracheal intubation (ETI) performed by inexperienced care providers can lead to unsuccessful and/or prolonged intubation attempts. This can cause complications such as hypoxemia, trauma to the oropharynx and larynx, and prolonged interruption of resuscitation, which results in a high morbidity/mortality. • Fifty to 60 real-life ETI procedures are needed before ETI can be performed with a 90% success rate. Despite this, 18% of providers still require some assistance even after performing 80 intubations. Skill fade will occur if there is too little exposure. What is New: • This study shows that, on both neonatal and child manikins, anesthetists perform better in ETI compared with pediatricians. Besides this, complications are expected to occur less frequently and less seriously when anesthetists are performing the ETIs on neonates and children. • In those countries where there are no clear interprofessional agreements made in general hospitals on who will perform ETI on neonates and children in acute care settings, these agreements are urgently necessary.
| S-EPMC6647518 | biostudies-literature
Project description:Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. We assessed whether the LTP could also prevent pulmonary colonization and infections caused by an endotracheal tube (ETT) biofilm.Eighteen pigs were intubated with ETTs colonized by Pseudomonas aeruginosa biofilm. Pigs were positioned in LTP and randomized to be on mechanical ventilatin (MV) up to 24 hour, 48 hour, 48 hour with acute lung injury (ALI) by oleic acid and 72 hour. Bacteriologic and microscopy studies confirmed presence of biofilm within the ETT. Upon autopsy, samples from the proximal and distal airways were excised for P.aeruginosa quantification. Ventilator-associated tracheobronchitis (VAT) was confirmed by bronchial tissue culture ?3 log colony forming units per gram (cfu/g). In pulmonary lobes with gross findings of pneumonia, ventilator-associated pneumonia (VAP) was confirmed by lung tissue culture ?3 log cfu/g.P.aeruginosa colonized the internal lumen of 16 out of 18 ETTs (88.89%), and a mature biofilm was consistently present. P.aeruginosa colonization did not differ among groups, and was found in 23.6% of samples from the proximal airways, and in 7.1% from the distal bronchi (P?=?0.001). Animals of the 24 hour group never developed respiratory infections, whereas 20%, 60% and 25% of the animals in group 48 hour, 48 hour-ALI and 72 hour developed P.aeruginosa VAT, respectively (P?=?0.327). Nevertheless, VAP never developed.Our findings imply that during the course of invasive MV up to 72 hour, an ETT P.aeruginosa biofilm hastily colonizes the respiratory tract. Yet, the LTP compartmentalizes colonization and infection within the proximal airways and VAP never develops.
| S-EPMC4355496 | biostudies-literature
Project description:BackgroundThe success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement.ObjectivesTo assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions.Selection criteriaWe planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit.Data collection and analysisTwo review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria.Main resultsWe did not identify any studies meeting the criteria for inclusion in this review.Authors' conclusionsThere is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
| S-EPMC6513417 | biostudies-literature
Project description:ImportanceFor critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.ObjectiveTo determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.Design, setting, and participantsThe Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.InterventionsPatients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).Main outcomes and measuresThe primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.ResultsAmong 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.Conclusions and relevanceAmong critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.Trial registrationClinicalTrials.gov Identifier: NCT03928925
| S-EPMC8655668 | biostudies-literature
Project description:IntroductionGrayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.MethodsA convenience sample of emergency and critical care physicians at various levels of training and experience participated in an online assessment. Participants viewed US video clips of patients, which included either tracheal or esophageal intubations captured in grayscale or with CDI; there were five videos of each for a total of 20 videos. Participants were asked to watch each clip and then assess the location of the ETT.ResultsThirty-eight subjects participated in the online assessment. Levels of training included medical students (13%), emergency medicine (EM) residents (50%), EM attendings (32%), and critical care attendings (5%). The odds ratio of properly assessing tracheal placement using color relative to a grayscale imaging technique was 1.5 (p = 0.21). Regarding the correct assessment of esophageal placement, CDI had 1.4 times the odds of being correctly assessed relative to grayscale (p = 0.26). The relationship between training level and correct assessments was not significant for either tracheal or esophageal placements.ConclusionIn this pilot study we found no significant improvement in correct identification of ETT placement using color Doppler compared to grayscale ultrasound; however, there was a trend toward improvement that might be better elucidated in a larger study.
| S-EPMC7390584 | biostudies-literature