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Seminars in Fetal & Neonatal Medicine Oct 2023Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in... (Review)
Review
Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.
Topics: Infant; Infant, Newborn; Humans; Intubation, Intratracheal; Infant, Premature; Resuscitation; Masks; Respiration
PubMed: 38000926
DOI: 10.1016/j.siny.2023.101488 -
Anaesthesia Aug 2023The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing... (Randomized Controlled Trial)
Randomized Controlled Trial
The two most commonly used airway management techniques during general anaesthesia are supraglottic airway devices and tracheal tubes. In older patients undergoing elective non-cardiothoracic surgery under general anaesthesia with positive pressure ventilation, we hypothesised that a composite measure of in-hospital postoperative pulmonary complications would be less frequent when a supraglottic airway device was used compared with a tracheal tube. We studied patients aged ≥ 70 years in 17 clinical centres. Patients were allocated randomly to airway management with a supraglottic airway device or a tracheal tube. Between August 2016 and April 2020, 2900 patients were studied, of whom 2751 were included in the primary analysis (1387 with supraglottic airway device and 1364 with a tracheal tube). Pre-operatively, 2431 (88.4%) patients were estimated to have a postoperative pulmonary complication risk index of 1-2. Postoperative pulmonary complications, mostly coughing, occurred in 270 of 1387 patients (19.5%) allocated to a supraglottic airway device and 342 of 1364 patients (25.1%) assigned to a tracheal tube (absolute difference -5.6% (95%CI -8.7 to -2.5), risk ratio 0.78 (95%CI 0.67-0.89); p < 0.001). Among otherwise healthy older patients undergoing elective surgery under general anaesthesia with intra-operative positive pressure ventilation of their lungs, there were fewer postoperative pulmonary complications when the airway was managed with a supraglottic airway device compared with a tracheal tube.
Topics: Humans; Aged; Laryngeal Masks; Intubation, Intratracheal; Airway Management; Anesthesia, General; Postoperative Complications; Lung
PubMed: 37270923
DOI: 10.1111/anae.16030 -
Critical Care Nursing Clinics of North... Mar 2024Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk... (Review)
Review
Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.
Topics: Infant, Newborn; Humans; Noninvasive Ventilation; Respiration, Artificial; Continuous Positive Airway Pressure; Intermittent Positive-Pressure Ventilation; Interactive Ventilatory Support
PubMed: 38296376
DOI: 10.1016/j.cnc.2023.11.001 -
British Journal of Anaesthesia Nov 2023Airway-related articles have featured heavily in the British Journal of Anaesthesia since it was founded in 1923. In the 100 years thereafter, 1102 airway-related...
Airway-related articles have featured heavily in the British Journal of Anaesthesia since it was founded in 1923. In the 100 years thereafter, 1102 airway-related articles have been published in the journal, written by 2955 unique authors from 55 different countries. In this editorial, we highlight some of the major publications in airway management and their impact on the specialty. Summaries of the most cited articles are contained within online supplementary material as well as links to all airway-related articles for readers who wish to delve deeper into this body of work.
Topics: Humans; Intubation, Intratracheal; Laryngeal Masks; Laryngoscopy; Airway Management; Anesthesia
PubMed: 37775452
DOI: 10.1016/j.bja.2023.08.027 -
Seminars in Fetal & Neonatal Medicine Oct 2023This chapter focuses on the pharmacological management of newborn infants in the peri-extubation period to reduce the risk of re-intubation and prolonged mechanical... (Review)
Review
This chapter focuses on the pharmacological management of newborn infants in the peri-extubation period to reduce the risk of re-intubation and prolonged mechanical ventilation. Drugs used to promote respiratory drive, reduce the risk of apnoea, reduce lung inflammation and avoid bronchospasm are critically assessed. When available, Cochrane reviews and randomised trials are used as the primary sources of evidence. Methylxanthines, particularly caffeine, are well studied and there is accumulating evidence to guide clinicians on the timing and dosage that may be used. Efficacy and safety for doxapram, steroids, adrenaline and salbutamol are summarised. Management of term infants, extubation following surgery, accidental and complicated extubation and the use of cuffed endotracheal tubes are presented. Overall, caffeine is the only drug with a substantial evidence base, proven to increase the likelihood of successful extubation in preterm infants; no drugs are needed to facilitate extubation in most term infants. Future studies might further define the role of caffeine in late preterm infants and evaluate medications for post-extubation stridor, bronchospasm or apnoea not responsive to methylxanthines.
Topics: Infant, Newborn; Humans; Infant, Premature; Caffeine; Apnea; Ventilator Weaning; Bronchial Spasm; Intermittent Positive-Pressure Ventilation; Airway Extubation
PubMed: 38030435
DOI: 10.1016/j.siny.2023.101490 -
Sleep Medicine Clinics Sep 2023Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA... (Review)
Review
Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index.
Topics: Humans; Continuous Positive Airway Pressure; Sleep Apnea, Obstructive; Mandibular Advancement
PubMed: 37532368
DOI: 10.1016/j.jsmc.2023.05.011 -
JAMA Network Open Jul 2023The NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive... (Randomized Controlled Trial)
Randomized Controlled Trial
Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure: A Secondary Analysis of a...
IMPORTANCE
The NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive mechanical ventilation (IMV) in preterm infants, whereas NHFOV and noninvasive intermittent positive pressure ventilation (NIPPV) result in fewer reintubations than nasal continuous positive airway pressure (NCPAP). It is unknown whether NHFOV is similarly effective in extremely preterm neonates or in those with more severe respiratory failure (based on the duration of previous ventilation and CO2 levels).
OBJECTIVE
To clarify whether NHFOV is better than NIPPV and NCPAP in reducing the duration of IMV in extremely preterm neonates or those with severe respiratory failure.
DESIGN, SETTING, AND PARTICIPANTS
This study is a predefined secondary analyses of a multicenter randomized clinical trial that was performed at tertiary academic neonatal intensive care units (NICUs) in China. Participants included neonates enrolled in the NASONE trial between December 2017 and May 2021 and belonging to 3 predefined subgroups: (1) born at less than or equal to 28 weeks' (plus 6 days) gestation, (2) invasively ventilated for more than 1 week from birth, and (3) with CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Data analysis was performed in August 2022.
INTERVENTION
NCPAP, NIPPV, or NHFOV since the first extubation and until NICU discharge, with airway pressure higher in NHFOV than in NIPPV and than in NCPAP.
MAIN OUTCOMES AND MEASURES
The co-primary outcomes were total duration of IMV during the NICU stay, need for reintubation, and ventilator-free days calculated as per the original trial protocol. Outcomes were analyzed on an intention-to-treat basis as for the whole trial, and subgroup analyses followed the original statistical plan.
RESULTS
Among 1137 preterm infants, 455 (279 boys [61.3%]) were born at 28 weeks' gestation or less, 375 (218 boys [58.1%]) underwent IMV for more than 1 week from birth, and 307 (183 boys [59.6%]) had CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Both NIPPV and NHFOV were associated with significantly fewer reintubations (risk difference range, -28% [95% CI, -39% to -17%] to -15% [95% CI, -25% to -4%]; number needed to treat, 3-7 infants) and early reintubations (risk difference range, -24% [95% CI, -35% to -14%] to -20% [95% CI, -30% to -10%]) than NCPAP, and these reintubations were less frequently due to refractory hypoxemia. IMV was shorter in the NIPPV and NHFOV groups (mean difference range, -5.0 days [95% CI, -6.8 to -3.1 days] to -2.3 days [95% CI, -4.1 to -0.4 days]) than in the NCPAP group. Co-primary outcomes were not different between NIPPV and NHFOV; there was no significant interaction effect. Infants in the NHFOV group showed significantly less moderate-to-severe bronchopulmonary dysplasia than infants in the NCPAP group (range, -12% to -10%; number needed to treat, 8-9 infants) and better postextubation gas exchange in all subgroups. The 3 interventions were provided at different mean airway pressure and were equally safe.
CONCLUSIONS AND RELEVANCE
The subgroup analyses of extremely preterm or more ill infants confirm the results obtained in the whole population: NIPPV and NHFOV appeared equally effective in reducing duration of IMV compared with NCPAP.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03181958.
Topics: Male; Infant; Infant, Newborn; Humans; Intermittent Positive-Pressure Ventilation; Continuous Positive Airway Pressure; Airway Extubation; Carbon Dioxide; Infant, Extremely Premature; Respiratory Insufficiency
PubMed: 37399009
DOI: 10.1001/jamanetworkopen.2023.21644 -
Oral and Maxillofacial Surgery Clinics... Feb 2024Vascular anomalies of the head and neck frequently involve the upper aerodigestive tract and can cause some level of airway obstruction. It is important to fully... (Review)
Review
Vascular anomalies of the head and neck frequently involve the upper aerodigestive tract and can cause some level of airway obstruction. It is important to fully evaluate the extent of a lesion and resultant functional impairment with a flexible fiberoptic laryngoscopy. Treating these lesions is difficult and considering how to manage the airway during a procedure is critical. A multidisciplinary approach should be used for airway management with alternative intubation plans established prior to induction of anesthesia. Edema and hemorrhage are expected complications from the treatment of vascular anomalies and should be considered when planning for extubation at the end of a procedure.
Topics: Humans; Airway Management; Anesthesia, Dental; Anesthesiology; Neck
PubMed: 37981345
DOI: 10.1016/j.coms.2023.09.002 -
Critical Care Clinics Apr 2024Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during... (Review)
Review
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
Topics: Humans; Ventilator Weaning; Airway Extubation; Noninvasive Ventilation; Pulmonary Disease, Chronic Obstructive
PubMed: 38432702
DOI: 10.1016/j.ccc.2024.01.007 -
Emergency Medicine Clinics of North... Aug 2023Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have... (Review)
Review
Appropriate airway management is critical to successful cardiac arrest resuscitation. However, the timing and method of airway management during cardiac arrest have traditionally been guided by expert and consensus opinion informed by observational data. In the last 5 years, recent studies, including several randomized controlled trials (RCTs), have provided additional clarity to help guide airway management. This article will review both current data and guidelines for airway management in cardiac arrest, a stepwise approach to airway management, the utility of various airway adjuncts, and best practices for oxygenation and ventilation in the peri-arrest period.
Topics: Humans; Airway Management; Heart Arrest; Resuscitation
PubMed: 37391249
DOI: 10.1016/j.emc.2023.03.007