A surgical mask worn by the patient in addition to the barrier box reduces the droplet spray during endoscopy

Recent guidelines for the prevention of COVID-19 advocate that all the elective procedures should be postponed as these produce aerosols that may affect the staff engaged. Sagami R et al and Neven L et al published the use of a barrier box to prevent the spread of droplets.1, 2 We have done some modifications to this technique. Our endoscopic shield is made of three plastic square walls with a height and width of 50 cm and a length of 40 cm. The wall facing the patient has a hole of 10cm for insertion of the scope. The foot and head sides of the cube are left open. The opening in the head side helps the assistant to keep the patient in proper position, along with the mouth-piece and nasal prong. One may argue that it would lead to the spread of droplets but the previous study has shown that the droplets fall more on the wall facing the patient’s mouth, hence placing the surgical mask over the patient’s face further reduces the head-ward spread of droplets.3 This also helps to facilitate the to and fro movement of the box so that the intubation hole moves away and the intact part of the front wall faces the mouth. A surgical mask with a small hole is placed in a way that the hole is aligned with the mouthpiece hole. The shield is placed over the patient’s head. The scope is passed through the endoscopic port made in the wall of the shield facing the patient and endoscopy is performed. This technique has a few advantages. First, it gives free access to the assistant during the procedure. Second, putting the face mask further reduces the risk of the spread of droplets. Third, an appropriate window for endoscope insertion allows the operator to work at ease, especially during challenging procedures. Continuous....

Face mask versus nasal prong or nasopharyngeal tube for neonatal resuscitation in the delivery room: a systematic review and meta-analysis

ImportanceThe current neonatal resuscitation guidelines recommend positive pressure ventilation via face mask or nasal prongs at birth. Using a nasal interface may have the potential to improve outcomes for newborn infants.ObjectiveTo determine whether nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks’ gestation in the delivery room reduces in-hospital mortality and morbidity.Data sourcesMEDLINE (through PubMed), Google Scholar and EMBASE, Clinical Trials.gov and the Cochrane Central Register of Controlled Trials through August 2019.Study selectionRandomised controlled trials comparing nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks’ gestation in the delivery room.Data analysisRisk of bias was assessed using the Covidence Collaboration Tool, results were pooled into a meta-analysis using a random effects model.Main outcomeIn-hospital mortality.ResultsFive RCTs enrolling 873 infants were combined into a meta-analysis. There was no statistical difference in in-hospital mortality (risk ratio (RR 0.98, 95% CI 0.63 to 1.52, p=0.92, I2=11%), rate of chest compressions in the delivery room (RR 0.37, 95% CI 0.10 to 1.33, p=0.13, I2=28%), rate of intraventricular haemorrhage (RR 1.54, 95% CI 0.88 to 2.70, p=0.13, I2=0%) or delivery room intubations in infants ventilated with a nasal prong/tube (RR 0.63, 95% CI 0.39,1.02, p=0.06, I2=52%).ConclusionIn infants born <37 weeks’ gestation, in-hospital mortality and morbidity were similar following positive pressure ventilation during initial stabilisation with a nasal prong/tube or a face mask.

Apneic laryngeal oxygenation during elective fiberoptic intubation – a technical simulation

Background Sedation during elective fiberoptic intubation for difficult airway can cause respiratory depression, apnea and periods of desaturation. During apneic episodes, hypoxemia can be prevented by insufflation of oxygen in the deep laryngeal space. The aim of this study was to evaluate an oropharyngeal oxygenation device (OOD) designed for deep laryngeal insufflation during fiberoptic intubation. Methods The OOD is split in the front to form a path for the bronchoscope. An external lumen delivers oxygen in the deep laryngeal space. In this experimental study, air application (as control group), oxygen application via nasal prongs, oxygen application via the OOD, and oxygen application via the working channel of a bronchoscope were compared in a technical simulation. In a preoxygenated test lung of a manikin, decrease of the oxygen saturation was measured over 20 min for each method. Results Oxygen saturation in the test lung dropped from 97 ± 1% (baseline in all groups) to 58 ± 3% in the control-group (p < 0.001 compared to all other groups) and to 78 ± 1% in the nasal prong group (p < 0.001 compared to all other groups). Oxygen saturation remained at 95 ± 2% in both the OOD group and the bronchoscopy group (p = 0.451 between those two groups). Conclusion Simulating apneic laryngeal oxygenation in a preoxygenated manikin, both oxygen insufflation via the OOD and the bronchoscope kept oxygen saturation in the test lung at 95% over 20 min. Both methods significantly were more effective than oxygen insufflation via nasal prongs.

Efficacy of high-flow nasal prong therapy in trauma patients with rib fractures and high-risk features for respiratory deterioration: a randomized controlled trial

BackgroundPatients with rib fractures require analgesia, oxygen supplementation and physiotherapy. This combination has been shown to reduce morbidity and mortality due to rib fractures. There has been movement towards the use of high-flow nasal prong (HFNP) oxygen. However there are no studies demonstrating the effectiveness of HFNP in this population. The aim of this study was to compare HFNP to venturi mask (VM) in rib fracture patients.MethodsRandomized controlled trial. Patient population included patients with rib fractures and high-risk features (three or more rib fractures, flail segment, bilateral rib fractures, smoker or chronic obstructive pulmonary disease). Exclusion criteria included initial mechanical ventilation and contraindications to HFNP. Patients were randomized to HFNP or VM. Primary outcome was deterioration requiring mechanical invasive/non‐invasive ventilation, or unplanned admission to intensive care unit. Secondary outcomes included mortality, length of stay, high dependency length of stay, comfort levels, breathing exertion levels (as measured by Borg Scale), oxygen saturation, respiratory rate, heart rate, chest X-ray and arterial blood gas parameters.Results220 patients (average age 60 years and average of four rib fractures each) were randomized to HFNP (n=113) and VM (n=107). There was no statistically significant difference in the primary outcome comparing HFNP and VM (6.2% vs. 6.5%, p=1.0). There were also no statistically significant differences in the secondary outcomes except for PaCO2 (43.6 vs. 45.5, p=0.039)ConclusionHFNP oxygen supplementation does not appear to be more effective than VM oxygen supplementation in patients with rib fractures.

Extended Pharmacopeial Characterization of Surfactant Aerosols Generated by a Customized eFlow Neos Nebulizer Delivered through Neonatal Nasal Prongs

The delivery of nebulized medications to preterm infants during Non-Invasive Ventilation (NIV) remains an unmet clinical need. In this regard, the effective delivery of nebulized surfactant has been particularly investigated in preclinical and clinical studies. In this work, we investigated the feasibility of delivering nebulized surfactant through various commercially available nasal prong types. We first performed a compendial characterization of surfactant aerosols generated by the eFlow Neos nebulizer, customized to be used in neonates, determining the amount of surfactant delivered by the device as well as the aerodynamic characteristics of surfactant aerosols. Additionally, we extended the compendial characterization by testing the effect of different nasal prong types on the estimated lung dose using a realistic Continuous Positive Airway Pressure (CPAP) circuit that included a cast of the upper airways of a preterm neonate. The compendial characterization of surfactant aerosols delivered through different nasal prongs achieved relatively high delivered surfactant doses (in the range 63–74% of the nominal dose), with aerodynamic characteristics displaying mass median aerodynamic diameters ranging between 2.52 and 2.81 µm. Nevertheless, when using a representative in vitro setup mimicking NIV in a clinical setting, significant differences were observed in terms of the estimated lung dose accounting for up to two-fold differences (from 10% to 20% estimated lung deposition of the nominal dose) depending on the chosen nasal prong type. Considering that surfactant lung deposition rates are correlated with therapeutic efficacy, this study points out the relevance of choosing the appropriate NIV interface to maximize the lung dose of nebulized medications.

Analysis of intensive care admissions among paediatric obstructive sleep apnoea referrals

Introduction The aim of this study was to identify the proportion of children referred to a paediatric tertiary referral centre who required admission to the paediatric intensive care unit (PICU) following surgery for obstructive sleep apnoea (OSA) and to establish risk factors for these admissions. Methods Retrospective review of case notes and the operative database was performed for all children undergoing adenotonsillectomy for sleep disordered breathing and OSA symptoms in Great Ormond Street Hospital over a 10-year period. Results Overall, 1,328 children underwent adenotonsillectomy for sleep disordered breathing and OSA. The mean age was 3.1 years (standard deviation [SD]: 1.7 years). A total of 37 (2.8%) were admitted to the PICU postoperatively (mean length of PICU stay: 1.2 days, standard deviation [SD]: 0.6 days) and 282 (21.2%) required nasopharyngeal airway (nasal prong) insertion intraoperatively. The mean length of stay on the ward following surgery was 1.4 days (SD: 0.8 days). Patients with severe OSA (apnoea–hypopnoea index [AHI] >10) and ASA (American Society of Anesthesiologists) grade ≥3 were more likely to require postoperative PICU admission (22/37 vs 381/1,291 [p<0.001] and 29/37 vs 660/1,291 [p=0.001] respectively). Severe OSA was also more common in children who required nasal prong insertion intraoperatively (186/282 vs 217/1,046, p<0.001). Conclusions Very few children referred to a paediatric tertiary referral centre actually require PICU admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe OSA (AHI >10) and an ASA grade of ≥3, nasopharyngeal airway insertion and potential admission to the PICU should be considered.