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   Table of Contents - Current issue
May-August 2021
Volume 4 | Issue 2
Page Nos. 0-143

Online since Tuesday, August 10, 2021

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Airway Fellowship p. 0
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Tracheal tube introducers: The way ahead Highly accessed article p. 69
Pankaj Kundra
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A magical journey into knowledge creation in emergency difficult airway access - Sample size calculation and choosing statistical tests with the ‘Research Genie’ p. 71
Arumugam Ramesh
This article is the third of a four-article series intended to ignite the minds of readers and empower them to create new knowledge in the context of 'emergency difficult airway access'. This article describes sample size calculation, descriptive statistics and inferential statistics in simple and lucid language without using any formulae. The reader should have followed the steps of knowledge creation as described in the first two articles and framed objectives for a given challenging healthcare situation. The study design and variables to operationalise the objective should have been defined. With this information in the background, the article empowers the reader to calculate sample size for a given objective. The pathway to access this information on the 'Research Genie (RG)' app is described for every objective in all the nine relevant domains of healthcare, i.e. description, laboratory range estimation, incidence/prevalence estimation, evaluating therapies, measuring costs in healthcare, critically evaluating new tests, measuring risk, correlating variables and describing experiences, perceptions and beliefs. Mathematical and statistical jargon are deliberately kept at bay. This is followed by describing summary measures and tests of significance for each objective. The pathway to access this on RG is described. On reading and assimilating this article, healthcare personnel can communicate meaningfully with the biostatistician while explaining the data required to calculate the sample size for a given objective. The researcher learns to list the possible summary measures and tests of significance for a particular objective. With an intention to demystify all these complicated concepts, I may have erred on the side of oversimplification. I pray for forgiveness from the biostatisticians and sincerely recommend all these are discussed with the biostatistician and approval sought before putting them in print.
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Awake tracheal intubation during COVID-19 pandemic: An audit of 23 cases in a tertiary cancer centre p. 79
Rudranil Nandi, Kruti Bhajikhav, Nandita Gupta, Angshuman Rudra Pal, Neha Desai, Jyotsna Goswami
Background: Coronavirus disease 2019 (COVID-19) pandemic has significantly affected routine healthcare including cancer care across the world. Head and neck cancer (HNC) is the most common cancer in India and has a good prognosis if treated surgically in early stages. HNC patients often present with difficult airway with reduced mouth opening requiring awake tracheal intubation (ATI). Health professionals are at a risk of getting infected with COVID-19 during ATI, a potential aerosol-generating procedure. We aimed to evaluate the modifications of ATI techniques used during the COVID-19 pandemic in our institution. Methodology: This retrospective observational study was conducted in a tertiary cancer care centre. All patients who had ATI performed between 25th March 2020 and 31st May 2020 were included in the study. The type of barrier methods used to prevent aerosol spread and the methods used to provide topical anaesthesia of the airway were documented and analysed. Results: Twenty-three patients underwent ATI during that period. Barrier methods such as aerosol box or transparent plastic drapes to prevent aerosol spread were used in 48% of patients. Lignocaine nebulisation and transtracheal lignocaine injection were administered in 70% and 87% of patients, respectively, during the study period. Spray-as-you-go lignocaine topicalisation and oral lignocaine spray for airway topicalisation were used in 22% and 39% of patients, respectively, during this period. Five techniques were used for ATI – conventional, under aerosol box (single anaesthesiologist and two anaesthesiologists) and under transparent plastic drape (in one technique, both airway topicalisation and intubation were done under the drape; in another, only intubation was performed under the drape). Conclusions: With modifications of the routine technique, ATI can be performed safely during the COVID-19 pandemic.
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Evaluation of difficult airway in trauma patients from lateral cervical radiographs p. 85
Aysenur Gultekin, Mustafa Korkut, Secgin Soyuncu, Cihan Bedel
Background: Many tests have been developed that are used either singly or in combination to identify a difficult airway. However, airway patency may not be adequately evaluated in some patients despite these tests. Lateral cervical radiography can be an auxiliary technique to evaluate difficult airway in patients of trauma due to its bedside applicability, cost-efficiency and rapidity. The aim of this study was to investigate the usefulness of lateral cervical radiographic measurements in predicting difficult laryngoscopy in trauma patients. Patients and Methods: The study consisted of patients of trauma who were admitted to the emergency department between July 2017 and March 2018. All patients underwent bedside cervical radiography and seven measurements were obtained. The anterior and posterior mandibular depths, effective mandibular length, atlanto-occipital distance, mandibulohyoid distance, thyromental distance and distance between the superior temporomandibular joint and the inferior edge of the fourth cervical vertebra (C4) were measured on the radiographs. Patients were divided into two groups as difficult and easy laryngoscopy groups, and the parameters were compared between the groups. Results: A total of 97 patients were included in our study. Of these patients, 54 (55.6%) were in the difficult laryngoscopy group, while 43 (44.4%) were in the easy laryngoscopy group. The interincisor, hyomental and thyrohyoid distances were significantly lower in the difficult laryngoscopy group compared to the easy laryngoscopy group. Conclusion: Bedside lateral cervical radiography is not a useful imaging method to demonstrate difficulty in laryngoscopy in patients of trauma.
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Simulator-based videolaryngoscopy training for capacity building in intubation during COVID-19 pandemic: An institutional experience from North India p. 90
Sanjay Agrawal, Sharmistha Pathak, Bharat Bhushan Bhardwaj, Poonam Arora, Ankita Kabi, Rajesh Kathrotia, Shalinee Rao
Background: Coronavirus disease 2019 (COVID-19) pandemic has presented the healthcare sector with unique challenges. The use of a videolaryngoscope (VL) for intubation is one of the recommendations. The paucity of availability of VL outside the operation room results in lack of intubation skills with VL among clinicians. This study was undertaken to analyse the effectiveness of fast-tracked simulation-based training in enabling frontline resident doctors with skills of videolaryngoscopy. Material and Methods: Residents already trained in the skills of direct laryngoscopy underwent training on VL using the King Vision™ VL (channeled blade) through structured simulation-based training in batches of <20. Sessions included interactive lecture, demonstration by the instructor and supervised hands-on practice by residents on an airway manikin. Knowledge gained was assessed with multiple-choice questions through a pre-test and post-test. Skills gained were assessed through Objective Structured Clinical Examination (OSCE) and Direct Observation of Procedural Skills (DOPS). Feedback was taken from participants on a 3-point Likert scale. Results: 190 residents were enabled with skills of videolaryngoscopy within 3 months. Overall mean pre-test scores of 6.16 ± 1.79 improved to 7.21 ± 2.02 in post-test scores and improvement in knowledge was found to be statistically significant (P < 0.0001). Skill assessment through DOPS revealed excellent performance by 72% of participants while 3% scored borderline. OSCE results showed overall good performance by residents across various clinical disciplines. 90.4% of participants responded that training gave them the confidence to perform videolaryngoscopy. Conclusion: A well-structured simulation-based training on videolaryngoscopy is effective in imparting indirect airway management skills to residents of various clinical specialties. Simulation-based fast-tracked training is an effective method to train a large number of clinicians within a limited period.
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Tracheal intubation using a videolaryngoscope assisted by transtracheal illumination with an LED vein finder p. 98
Kinna G Shah, Jayshree Thakkar
Introduction: Retrograde illumination of the glottis using an LED vein finder placed over the cricothyroid membrane produces a red-orange glow of light inside the airway that can be used to assist the intubator during videolaryngoscopy. The endotracheal tube can be guided through this red-orange glow illuminating the glottis and trachea. Patients and Methods: In this prospective, randomised, single-blinded study, a total of 200 patients posted for elective head and neck cancer surgeries were included. Patients were placed supine with their heads in a neutral position without a pillow. Intubation was done with The Anesthetist Scope videolaryngoscope in Group TI (transillumination) with an assistant holding the LED vein finder over the cricothyroid membrane. The glottic opening was identified by a red-orange glow within the airway and the intubation was performed. In Group C (conventional direct laryngoscopy), transillumination was not done during intubation. Exposure time was taken from the time when the patient's mouth was opened to the time when the best glottic view was obtained. Intubation time was noted from the introduction of the videolaryngoscope or conventional laryngoscope into the mouth, through successful intubation and identification of 3 complete capnographic waveforms. A total of three attempts were allowed for each patient. Results: The success rate was better in Group TI. Exposure time and intubation time were shorter in Group TI as compared to Group C. In three patients with carcinoma of the vocal cords, the glottic opening was identified only by retrograde light transmission from the vein finder. Conclusion: A combination of videolaryngoscopy and LED vein finder is an effective method to achieve a better success rate of tracheal intubation.
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Misleading endoscopic airway images – Who does the examination matters!!! p. 104
Gautham Ganesan, Ramkumar Dhanasekaran
We report a 38-year-old female, post-oesophagectomy with transposed colon, presenting with dysphagia for oesophageal dilatation. General anaesthesia was requested for as the patient did not tolerate previous dilatation attempts under local anaesthesia. Endoscopic images provided by the otorhinolaryngologists and gastroenterologists showed a good view of the glottis, suggesting a possible easy intubation. But direct laryngoscopy after sedation and airway topicalisation revealed an airway with extensive adhesions that would have been impossible to intubate. The patient was awakened and planned for the procedure after tracheostomy. Endoscopic images done by non-anaesthesiologists should be interpreted with caution.
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Airway and ventilation management for excision of recurrent bronchogenic cyst followed by removal of metallic bronchial stent in a child p. 108
Jacob Chandy, Ekta Rai
Conventional lung isolation is at times not possible as was the case with our child who had a migrated bronchial stent. The Cook® airway exchange catheter was used as a backup for oxygenation/ventilation in case of the stent getting stuck during its removal. A specially designed device for facilitating egress of air during jet ventilation was indigenously created and held as a backup plan.
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Difficult retrieval of a bronchial foreign body in a patient with maxillofacial trauma p. 111
Thirumurugan Arikrishnan, Deepak Chakravarthy, Stalin Vinayagam
Maxillofacial trauma is often associated with avulsion of the tooth and an attendant risk of aspiration of the tooth. Delay in diagnosis and intervention can pose a serious threat to life if the central airway is obstructed. Bronchoscopy-guided retrieval of the aspirated tooth in patients with maxillofacial trauma poses a significant challenge to anaesthesiologists in maintaining the airway without compromising oxygenation and ventilation. We report a case of delayed yet difficult bronchoscopic retrieval of a tooth in the right bronchus in a patient with maxillofacial trauma.
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Well-planned successful tracheostomy tube change in a child p. 114
Unnathi Purushotham Manampadi, Sumitra G Bakshi, Bindiya Salunke, Shivakumar Thiagarajan
Paediatric tracheostomy and tracheostomy tube change are associated with a higher incidence of adverse events that need to be recognised, mandating thorough evaluation and meticulous planning to avert such events. In addition, implementation of standard guidelines in every institute is necessary to maintain optimum safety. We report the successful management of a difficult paediatric tracheostomy tube change in a 3-year-old boy who had a history of failure of tracheostomy tube change in the ward 1 month following the initial tracheostomy. The initial attempt of changing the tube to secure the airway was unsuccessful. As difficulty in tube exchange was anticipated, we were able to secure the airway with endotracheal tube loaded on to a paediatric fibreoptic bronchoscope which was already positioned in the trachea. We believe that a well-planned management strategy executed in a monitored and well-equipped surrounding helped in avoiding grave consequences.
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Management of anticipated difficult airway in a case of neurofibromatosis during the COVID-19 pandemic p. 117
Jhanvi S Bajaj, Anita N Shetty, Priti Devalkar
Neurofibromata with a potential to affect the airway occur mostly in the head, neck, face and larynx, posing a risk to the airway and making intubation difficult. Management of an anticipated difficult airway needs special precautions and airway protection strategies during the COVID-19 pandemic. A 50-year-old woman was scheduled for excision of cervical neurofibroma measuring 6.6 cm × 7.2 cm on the right side of nape of neck, resulting in limited neck extension. We decided to intubate this patient under anaesthesia as against an awake fibreoptic intubation for three reasons. Our patient was not willing for awake intubation,we wanted to prevent aerosolisation during intubation and computerised tomography of the chest showed signs of postinfective sequelae probably suggestive of a lower respiratory tract infection. All precautions to protect the airway operator from aerosol exposure were followed such as using an aerosol box and a videolaryngoscope. Our case highlights the importance of collaborative decision-making, careful preparation and thorough management of anticipated difficult airway in neurosurgery patients during the COVID pandemic.
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Role of preoperative multidetector computed tomography airway reconstruction in anaesthetic management of mucopolysaccharidosis type IV p. 121
Pradeep Tiwari, Nirav M Kotak, Anita N Shetty
Mucopolysaccharidoses (MPS) are a group of lysosomal storage disorders that often present with a difficult airway. The trachea is usually narrowed and flattened, making the choice of correct technique and endotracheal tube (ETT) size crucial. Multidetector computed tomography (MDCT) images have been used to assess the airway of children who are considered at risk for difficult intubation. However, it has not been standardised in preoperative assessment of MPS. We report a case in whom after failed fibreoptic intubation, titrated doses of injection propofol were given and direct laryngoscopy was performed. A 6.0 mm internal diameter (ID) and later a 5.0 mm ID ETT were tried but could not be negotiated. Subsequently, the airway was secured with a 4.5 mm ID ETT. Postoperatively, MDCT airway reconstruction demonstrated that the narrowest part of airway measured 4.3 mm. Anaesthesiologists often face a multitude of challenges in these patients. Our experience gained in retrospect suggests that a detailed preoperative evaluation including MDCT airway reconstruction, followed by meticulous planning, is essential for a safe outcome.
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Awake nasal intubation using a videolaryngoscope: A safe airway management strategy in the presence of restricted cervical spine mobility p. 125
Eleftheria Saoulidou, Orestis Argyriou, Amalia Douma, Antonia Dimakopoulou
We present a case of extremely difficult airway management in a 56-year-old patient presenting for an elective repair of a recurrent inguinal hernia. He was a diagnosed case of severe ankylosing spondylitis resulting in limited cervical spine mobility and restricted mouth opening. Airway management was achieved with awake nasal intubation and the procedure was completed uneventfully.
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Airway manoeuvres during anaesthetic management of adult acquired tracheo-oesophageal fistula p. 128
Kavita Udaykumar Adate, Jyoti Kale, Dhanashree Dongare, Kalyani Patil, Hrishikesh Yalgudkar
Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.
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Emergency airway management of a patient with Rosai-Dorfman disease p. 132
Chitta Ranjan Mohanty, Sangeeta Sahoo, Premangshu Ghoshal, Zaid Shaikh, Kishore Kumar Behera
Rosai-Dorfman disease is a rare histiocytic disorder that involves the over-production of non-Langerhans sinus histiocytes. It presents with cervical lymphadenopathy and huge neck swelling that could prove to be a challenging airway and a nightmare for anaesthesiologists. We discuss the airway management of a patient with Rosai-Dorfman disease requiring an emergency tracheostomy as a life-saving measure.
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Anaesthetic management for removal of intratracheal precarinal tumour: A unique challenge p. 135
Naresh R Kabra, Harshal D Wagh
We present successful management of a case of intratracheal tumour situated just above the carina in a 46-year-old male without any adverse outcome or the need for cardiopulmonary bypass. The tumour was originating from the right lateral wall of trachea just proximal to the carina and partially obstructing the right main bronchus. A reinforced endotracheal tube was guided over a fibreoptic bronchoscope into the left main bronchus and the patient provided one-lung ventilation till the trachea was opened. During tracheal resection and closure, the first reinforced tube was withdrawn till mid-trachea and a second reinforced tube was placed in the left main bronchus under direct vision by the surgeon and used for ventilation. Towards the end of procedure, the first reinforced tube (which had been withdrawn till mid-trachea before the surgeon passed the second tube) was advanced beyond the tracheal opening and used for ventilation. At the end of the procedure, the patient was extubated on table and was subsequently discharged without any complication. Our case illustrates the paramount importance of extensive planning, preparation of the operation theatre, good communication and coordination between all team members while dealing with these difficult cases.
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External reinforcement of cuffed endotracheal tube to prevent kinking during prolonged head-and-neck surgery p. 139
Divya V Gladston, Soumya CN, Rajasree Omanakutty Amma, Rachel Cherian Koshy
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A rare presentation of failed mask ventilation in a postmaxillectomy patient with orbito-oral communication p. 141
Aswini Kuberan, Meenakshi Sumadevi Pradeep, Sushmitha Dongari, Priya Rudingwa
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