Articles: intubation.
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Review
Nasogastric tube insertion length measurement and tip verification in adults: a narrative review.
Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. ⋯ Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.
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Recently, a non-commercial oxygenation laryngoscope was able to maintain apneic oxygenation during simulated intubation efforts. Since that prototype was 3 mm wider than a standard Macintosh laryngoscope blade, the intubation performance of this device may differ from standard blades. A new prototype of an oxygenation laryngoscope was developed, consisting of a standard-size Macintosh blade and a fixed oxygen supply line to the side. Actually, it is unclear at which point of this blade the oxygen supply line should end to facilitate the best possible oxygen supply for apneic oxygenation. ⋯ In this simulation study with a preoxygenated airway manikin, the use of a modified Macintosh laryngoscope blade with oxygen line attached at the tip or at the middle were able to maintain apneic oxygenation without measurable drop of oxygen content over 20 min. Proximal placement of the oxygen supply line still showed an advantage against room air, however it did not completely prevent room air from entering the airway.
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Observational Study
The difference in rotation angle of the distal endotracheal tube through nasal approach.
Nasal intubation using a fiberoptic scope is a useful technique. In clinical practice, we have experienced difficulty in advancing the endotracheal tube (ETT) over the fiberoptic scope because of resistance to the passage of the ETT against rotation in the nasal cavity, when it gets hung up on structures of the laryngeal inlet. Several maneuvers have been proposed to overcome this difficulty. The gap between the tip of the ETT and the fiberoptic scope can be reduced using a thicker fiberoptic scope and a thinner ETT. Moreover, simultaneous rotation of the fiberoptic scope and ETT could lead to successful intubation by reducing impingement on the ETT. However, the discrepancy between these rotation angles is unclear. This observational prospective study aimed to investigate the discrepancy in the rotation angle between the ETT and fiberoptic scope during nasal intubation. ⋯ Simultaneous rotation by the proximal end of the ETT and fiberscope above the glottis for the nasal approach induced significant differences in the distal end of the ETT. The larger tube lagged by the resistance of the nasal passages during rotation. Therefore, the ETT does not rotate as much as the rotation angle.
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Review Meta Analysis
Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis.
Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of unrecognised oesophageal intubation. We conducted a systematic review and meta-analysis of the diagnostic accuracy of five clinical examination tests and the oesophageal detector device when used to confirm tracheal intubation. ⋯ Tests to exclude events that invariably lead to severe damage or death must have a negligible false positive rate. Misting or auscultation have too high a false positive rate to reliably exclude oesophageal intubation and there is insufficient evidence to support the use of 'hang-up' or chest rise. The oesophageal detector device may be considered where other more reliable means are not available, though waveform capnography remains the reference standard for confirmation of tracheal intubation.
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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.