Intubation Ergonomics and Effectiveness using Aerosol Box

The pandemic COVID-19 has caused a rupture and disturbance in many ecosystems, especially in healthcare. Although previously patients were treated and given first-hand treatment especially during life threatening event, currently, the safety of healthcare workers have also become the utmost priority. Due to the nature of COVID-19 virus that is able to spread easily via respiratory droplets and aerosols, using mouth and eyes as the route of entry, healthcare workers need to protect themselves while saving the patients at the same time. Therefore, the most common lifesaving procedure at accident and emergency department was chosen, i.e. the intubation procedure. The aerosol box is introduced and used widely during the intubation procedure, especially in accident and emergency department. The study has three objectives. First, to determine whether the aerosol box can provide protection to its users, secondly to suggest an improvement based on the current design of the aerosol box and thirdly to determine the risk of musculoskeletal injuries among healthcare workers using Rapid Entire Body Assessment (REBA). In this study, direct observation was made during the assessment before suggesting the required recommendation on how to improve the existing aerosol box. The first objective was achieved by conducting a direct observation when participants were conducting the intubation procedure. Any possibility of participants getting exposed to the risk of COVID-19 due to the failure of the box in guarding, was noted by the observer. Recommendation for improvement was made based on these findings, and served the second objective of the study. To achieve the third objective, ergonomics assessment using Rapid Entire Body Assessment (REBA) was conducted. REBA scores represent the severity of musculoskeletal risk imposed to healthcare workers during intubation procedure. Two participants took part in the study voluntarily. Results showed that the aerosol box used in this study does not protect healthcare workers from COVID-19. The current design of aerosol box used must be improvised in order to increase its effectiveness. As for body postures, REBA scores were between medium and high, thus it required immediate corrective actions. With modification, the aerosol box may better protect healthcare workers from being exposed to the COVID-19 virus.

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

Background Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity. Methods Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure. Results Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission. Conclusions Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen. Trial registration Clinical trial number: NCT02668458 (http://www.clinicaltrials.gov)

Correction to: Comparison of hypoxemia, intubation procedure, and complications for noninvasive ventilation against high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure: a nonrandomized retrospective analysis for effectiveness and safety (NIVaHIC-aHRF)

An amendment to this paper has been published and can be accessed via the original article.

Comparison of hypoxemia, intubation procedure, and complications for non-invasive ventilation against high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure: a non-randomized retrospective analysis for effectiveness and safety (NIVaHIC-aHRF)

Background Optimization of preoxygenation procedure can help to secure the method of intubation by reducing the risks of severe hypoxemia and other problems. There is confusion for efficacy of non-invasive ventilation compared to high-flow oxygen therapy regarding occurrence of severe hypoxemia during the intubation procedure. The purpose of the study was to compare the difference between noninvasive ventilation and high flow oxygen therapy to prevent desaturation during laryngoscopy. Methods Patients underwent high-flow nasal cannula oxygen therapy (HCO cohort, n = 161) or non-invasive ventilation procedure (NIV cohort, n = 154) for oxygenation and ventilation due to acute hypoxemic respiratory failure in the intensive care unit. Data before preoxygenation, preoxygenation, intubation, laryngoscopy, and complications of patients due to tracheal intubation were retrospectively collected and analyzed. Results There was no difference between both cohorts for the demographical and clinical conditions of the patients before preoxygenation (p > 0.05 for all parameters), numbers of patients with severe hypoxia during the intubation procedure (35 vs. 45, p = 0.303), the time duration of laryngoscopy (p = 0.847), number of laryngoscopies attempts (p = 0.804), and immediate and late complications during the intubation procedure. The values of pulse oximetry were reported higher for patients of NIV cohort than those of HCO cohort during preoxygenation. Fewer numbers of patients were reported with severe hypoxia among patients of the NIV cohort than those of the HCO cohort (24 vs., 40, p = 0.042) who have moderate-to-severe hypoxemia (partial pressure of arterial oxygen to fraction of inspired oxygen ratio ≤ 200 mmHg) before preoxygenation. The most common complications were hypertension, pulmonary aspiration, and increased 30-day mortality. Conclusions When compared, there was no difference between non-invasive ventilation technique and high-flow oxygen therapy to minimize severe hypoxia prior to laryngoscopy and endotracheal intubation in patients with acute respiratory failure.

Impact of aerosol enclosure barrier to videolaryngoscopic oro-tracheal intubation: A pilot manikin study

Background: Personal protective equipment used for protection of healthcare workers in the combat against Severe Acute Respiratory Syndrome Coronavirus 2 pandemic is in limited supply worldwide at present – 2020. Use of barrier enclosure during endotracheal intubation can potentially act as a cost-effective adjunct to minimize risks of transmitting the infection to healthcare workers. However, there is concern that the enclosure itself will act as a barrier to the intubation procedure in the emergency settings. Objective: To evaluate the negative effect of barrier enclosure (an aerosol box) on the performance of video-assisted intubation in a manikin Methods: A total of 41 Emergency Department doctors from a local hospital were recruited to perform intubation in a manikin simulating normal and more difficult airways (Cormack-Lehane grades I and IIb) with and without the box. The primary outcome was time of successful intubation. The secondary outcomes were first-attempt success rate, number of successful attempts, need of adjuncts, dental injury and ease of intubation as perceived by the participants. Results: The aerosol box had no significant negative effect on the time of successful intubation (p = 0.630 (Grade I airway) and p = 0.436 (Grade IIb airway)), first-attempt success rate, number of successful attempts, need of adjuncts or dental injury. Participants subjectively reported extra yet minor challenges during intubation in the presence of the box. Conclusion: Within limits of the pilot study, the aerosol box had no statistical significant difference but an increasing trend of prolonged endotracheal intubation interval in the Grade IIb airway and negative impact on first-pass success, and could potentially be used to protect healthcare workers during the aerosol-generating intubation procedure.

Chirurgie de l’endocardite infectieuse : à propos de 203 cas

Introduction: infectious endocarditis is a serious disease with a high morbimortality. Diagnosis relies on modified criteria of Dukes. The main surgical indication in emergency are hemodynamic, infectious and embolic complications. The aim of this work is to present epidemiological, clinical and ultrasonographic characteristics, and report our experience in order to assess the results of surgical treatment of the disease and to improve the management. Methods: This is a monocenter retrospective study of 203 patients operated for infective endocarditis, collected between January 2001and June 2015. This study interested only the operative period. Results: The mean age is 42 years with male predominance (62, 12%). The causal heart disease was predominantly rheumatic in 40 % of cases. 7. %88 had endocarditis on cardiac prosthesis. The causative germ in isolated in only 47% of cases; Staphylococcus and Streptococcus were the most frequent germs. The left ventricular function was altered in 24 % of cases. The patients were operated in emergency in 59 cases and delayed surgery in 144 cases. Valve replacement was done in 84,8 % of cases and valve repair in 15.2 % of cases. Stay in intensive care unit was more than 72 hours in 28 % of cases, intubation procedure < 24 hours in 69%, post-operative stay ≥ 7 days in 70 % and simple post-operative history in 60 % of cases. Conclusion: endocardial infection is a serious disease. Regular studies detailing epidemiology of these infections. The actual trend is in favor of earlier surgery, privileging valve repair.