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The New England Journal of Medicine Aug 2023Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.
METHODS
In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.
RESULTS
The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.
CONCLUSIONS
Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).
Topics: Humans; Adult; Laryngoscopy; Critical Illness; Intubation, Intratracheal; Laryngoscopes; Emergency Service, Hospital; Video Recording
PubMed: 37326325
DOI: 10.1056/NEJMoa2301601 -
Laryngoscope Investigative... Aug 2023To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine. (Review)
Review
OBJECTIVE
To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.
METHODS
Narrative review of available literature.
RESULTS
Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.
CONCLUSION
Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.
PubMed: 37621262
DOI: 10.1002/lio2.1109 -
Frontiers in Pharmacology 2023Postoperative sore throat (POST) is one of the most reported complications after general anesthesia with an incidence of as high as 60% which may impact patient... (Review)
Review
Postoperative sore throat (POST) is one of the most reported complications after general anesthesia with an incidence of as high as 60% which may impact patient satisfaction and increase the cost of treatment. The aim of this review is to summarize the currently accepted approaches and new trends intended to reduce the risk and increase the treatment efficacy of POST. Difficult intubation, traumatic intubation, and several other factors contribute to the development of POST. Endotracheal intubation using a stylet-loaded tube exerts excessive pressure on the anterior tracheal wall predisposing to mucosal trauma and contributing to development of POST. Pharmacological interventions are aimed at prevention, amelioration of symptoms, and treatment of POST. Medications suggested for this purpose include corticosteroids, topical sprays and creams, non-steroidal anti-inflammatory drugs (NSAID), and N-methyl-D-aspartate (NMDA) receptor antagonists. The use of video-laryngoscopes (VL) for endotracheal intubation improves the glottic view and increases the success rates with less force required to ensure adequate laryngoscopic view. Nevertheless, despite advances in laryngoscopic devices, the incidence of POST remains high. A novel intubation technique with endotracheal tube (ETT) rotation 180 degrees (ETT 180°) has been suggested to overcome stylet related injury and, possibly, decrease the POST. To date, no clinical trials have been conducted to test the efficacy of ETT 180° in reducing the incidence of POST. Undoubtedly, the suggested method deserves further investigation to determine its role in patient care.
PubMed: 38074131
DOI: 10.3389/fphar.2023.1284071 -
European Journal of Pediatrics Apr 2024How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized...
How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope. Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.
Topics: Infant, Newborn; Humans; Intubation, Intratracheal; Laryngoscopes; Laryngoscopy; Manikins
PubMed: 38260994
DOI: 10.1007/s00431-023-05418-x -
Laryngoscope Investigative... Oct 2023Data from the National Health and Nutrition Examination Survey (NHANES) has not been previously utilized to study the prevalence of tinnitus and depression among adults...
BACKGROUND
Data from the National Health and Nutrition Examination Survey (NHANES) has not been previously utilized to study the prevalence of tinnitus and depression among adults over 20 years old, nor the impact of tinnitus on depression.
OBJECTIVE
The aim of this study was to evaluate the relationship between tinnitus and depression among adults in the United States.
MATERIALS AND METHODS
This cross-sectional study drew upon data from the 2005-2018 NHANES, incorporating adults aged 20 and older who had completed the tinnitus and depression questionnaire. Depression was assessed using the PHQ-9 questionnaire. Multivariate logistic regression models, subgroup analyses, and sensitivity analyses were performed to examine the association between tinnitus and depression.
RESULTS
This nationally representative study included 10,409 participants, of whom 17.69% reported experiencing tinnitus. The prevalence of depression was 6.2% among those without tinnitus and 15.1% among those with tinnitus ( < .0001). Accounting for potential confounders such as demographic and socioeconomic variables, participants who experienced tinnitus were more likely to exhibit depression symptoms (adjusted odds ratio = 2.0, 95% confidence interval = 1.61-2.48). Subgroup analyses further suggested that tinnitus was associated with an increased prevalence of depression across all subgroups. Sensitivity analysis affirmed these findings.
CONCLUSIONS
This study suggests that there is a significant association between tinnitus and the risk of depression in the adult population of the United States, emphasizing the importance of psychological factors in the clinical management of tinnitus.
LEVEL OF EVIDENCE
2b.
PubMed: 37899867
DOI: 10.1002/lio2.1134 -
Journal of Dental Anesthesia and Pain... Apr 2024Nasotracheal intubation (NTI) plays an important role in pediatric airway management, offering advantages in specific situations, such as oral and maxillofacial surgery... (Review)
Review
Nasotracheal intubation (NTI) plays an important role in pediatric airway management, offering advantages in specific situations, such as oral and maxillofacial surgery and situations requiring stable tube positioning. However, compared to adults, NTI in children presents unique challenges owing to anatomical differences and limited space. This limited space, in combination with a large tongue and short mandible, along with large tonsils and adenoids, can complicate intubation. Owing to the short tracheal length in pediatric patients, it is crucial to place the tube at the correct depth to prevent it from being displaced due to neck movements, and causing injury to the glottis. The equipment used for NTI includes different tube types, direct laryngoscopy vs. video laryngoscopy, and fiberoptic bronchoscopy. Considering pediatric anatomy, the advantages of video laryngoscopy have been questioned. Studies comparing different techniques have provided insights into their efficacy. Determining the appropriate size and depth of nasotracheal tubes for pediatric patients remains a challenge. Various formulas based on age, weight, and height have been explored, including the recommendation of depth-mark-based NTI. This review provides a comprehensive overview of NTI in pediatric patients, including the relevant anatomy, equipment, clinical judgment, and possible complications.
PubMed: 38584754
DOI: 10.17245/jdapm.2024.24.2.81 -
Laryngoscope Investigative... Oct 2023
PubMed: 37899880
DOI: 10.1002/lio2.1142