PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (623930)

Clipboard (0)
None

Related Articles

1.  Preparation of the patient and the airway for awake intubation 
Indian Journal of Anaesthesia  2011;55(5):442-447.
Awake intubation is usually performed electively in the presence of a difficult airway. A detailed airway examination is time-consuming and often not feasible in an emergency. A simple 1-2-3 rule for airway examination allows one to identify potential airway difficulty within a minute. A more detailed airway examination can give a better idea about the exact nature of difficulty and the course of action to be taken to overcome it. When faced with an anticipated difficult airway, the anaesthesiologist needs to consider securing the airway in an awake state without the use of anaesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacologically for awake intubation. Psychological preparation is best initiated by an anaesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anaesthetising the airway through topical application of local anaesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anaesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anaesthesiologist can go a long way in making awake intubation acceptable for all concerned.
doi:10.4103/0019-5049.89863
PMCID: PMC3237141  PMID: 22174458
Awake intubation; monitoring; pharmacological preparation; psychological preparation; topical anaesthesia
2.  Airway management in patients with maxillofacial trauma – A retrospective study of 177 cases 
Background:
Airway management in maxillofacial injuries presents with a unique set of problems. Compromised airway is still a challenge to the anesthesiologist in spite of all modalities available. Maxillofacial injuries are the result of high-velocity trauma arising from road traffic accidents, sport injuries, falls and gunshot wounds. Any flaw in airway management may lead to grave morbidity and mortality in prehospital or hospital settings and as well as for reconstruction of fractures subsequently.
Methods:
One hundred and seventy-seven patients of maxillofacial injuries, operated over a period of one and half years during July 2008 to December 2009 in Al-Nahdha hospital were reviewed. All patients were reviewed in depth with age related type of injury, etiology and techniques of difficult airway management.
Results:
The major etiology of injuries were road traffic accidents (67%) followed by sport (15%) and fall (15%). Majority of patients were young in the age group of 11-30 years (71 %). Fracture mandible (53%) was the most common injury, followed by fracture maxilla (21%), fracture zygoma (19%) and pan-facial fractures (6%). Maxillofacial injuries compromise mask ventilation and difficult airway due to facial fractures, tissue edema and deranged anatomy. Shared airway with the surgeon needs special attention due to restrictions imposed during surgery. Several methods available for securing the airway, both decision-making and performance, are important in such circumstances. Airway secured by nasal intubation with direct visualization of vocal cords was the most common (57%), followed by oral intubation (17%). Other methods like tracheostomy and blind nasal intubation was avoided by fiberoptic bronchoscopic nasal intubation in 26% of patients.
Conclusion:
The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient without wiring an open mouth and alternative techniques like fiberoptic bronchoscopic intubation, it is unnecessary to carry out tracheostomy for securing the airway as frequently as in the past.
doi:10.4103/1658-354X.76476
PMCID: PMC3101764  PMID: 21655009
Difficult airway; fiberoptic bronchoscopic intubation; maxillofacial injuries; tracheostomy
3.  Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy 
Canadian Journal of Surgery  2008;51(1):57-69.
Traumatic injury remains the leading cause of potentially preventable death in Canadians under age 40 years. Although only a minority of patients present with hemodynamic instability, these patients have a significant chance of dying. The causes of instability must be recognized and corrected quickly by using a systematic approach. To allow key supportive interventions to be undertaken swiftly, it is more important to identify and prioritize systemic compromise than to confirm specific diagnoses. Most potentially preventable trauma death relates to airway obstruction, hemopneumothorax, intracranial hemorrhage and intracavitary bleeding. Definitive airway control should be assured as a first priority. Hemopneumothoraces are typically addressed by chest tube insertion, although thoracic exploration will occasionally be urgently required. Hemorrhage control is much more important than fluid resuscitation and mandates the earliest possible definitive management. Unstable patients nearing physiological exhaustion require abbreviated or “damage-control” surgical tactics. This should be recognized early in the resuscitation rather than late in an operative procedure. The management of expanding intracranial hemorrhage requires optimization of oxygenation, ventilation and circulatory support while urgent CT and expert neurosurgical care are provided. Polytrauma presenting with head injury challenges the most developed of trauma systems, necessitating thoughtful prioritization of care and taking into consideration local capabilities. Bedside trauma sonography is an evolving tool that complements the physical examination during an initial survey. Future breakthroughs in trauma resuscitation may involve procoagulant medications, imaging technology, circulatory assist techniques and the use of inflammatory modulators. The greatest future challenge in trauma care, though, will be the provision of basic organized resuscitative care to the global community.
PMCID: PMC2386316  PMID: 18248707
4.  ProSeal laryngeal mask airway improves oxygenation when used as a conduit prior to laryngoscope guided intubation in bariatric patients 
Indian Journal of Anaesthesia  2013;57(1):25-30.
Background:
The primary objective of this study was to compare the effect of ventilation using the ProSeal™ laryngeal mask airway (PLMA) with facemask and oropharyngeal airway (FM), prior to laryngoscopy, on arterial oxygenation in morbidly obese patients undergoing bariatric surgery.
Methods:
Forty morbidly obese patients were randomly recruited to either PLMA or FM. After pre-oxygenation (FiO2 1.0) in the ramp position with continuous positive airway pressure of 10 cm H2O for 5 min, anaesthesia was induced. Following loss of jaw thrust oropharyngeal airway, the FM and PLMA were inserted. On achieving paralysis, volume control ventilation with PEEP (5 cm H2O) was initiated. The difficulty in mask ventilation (DMV) in FM, number of attempts at PLMA and laryngoscopy were graded (Cormack and Lehane) in all patients. Time from onset of laryngoscopy to endotracheal tube confirmation was recorded. Hypoxia was defined as mild (SpO2 ≤95%), moderate (SpO2 ≤90%) and severe (SpO2 ≤85%).
Results:
Significant rise in pO2 was observed within both groups (P=0.001), and this was significantly higher in the PLMA (P=0.0001) when compared between the groups. SpO2 ≥ 90% (P=0.018) was seen in 19/20 (95%) patients in PLMA and 13/20 (65%) in FM at confirmation of tracheal tube. A strong association was found between DMV and Cormack Lehane in the FM group and with number of attempts in the PLMA group. No adverse events were observed.
Conclusion:
ProSeal™ laryngeal mask airway as conduit prior to laryngoscopy in morbidly obese patients seems effective in increasing oxygen reserves, and can be suggested as a routine airway management technique when managing the airway in the morbidly obese.
doi:10.4103/0019-5049.108557
PMCID: PMC3658330  PMID: 23716762
Bariatric; morbidly obese; oxygenation; ProSeal™
5.  Oxygenation, Ventilation, and Airway Management in Out-of-Hospital Cardiac Arrest: A Review 
BioMed Research International  2014;2014:376871.
Recently published evidence has challenged some protocols related to oxygenation, ventilation, and airway management for out-of-hospital cardiac arrest. Interrupting chest compressions to attempt airway intervention in the early stages of OHCA in adults may worsen patient outcomes. The change of BLS algorithms from ABC to CAB was recommended by the AHA in 2010. Passive insufflation of oxygen into a patent airway may provide oxygenation in the early stages of cardiac arrest. Various alternatives to tracheal intubation or bag-mask ventilation have been trialled for prehospital airway management. Simple methods of airway management are associated with similar outcomes as tracheal intubation in patients with OHCA. The insertion of a laryngeal mask airway is probably associated with worse neurologically intact survival rates in comparison with other methods of airway management. Hyperoxemia following OHCA may have a deleterious effect on the neurological recovery of patients. Extracorporeal oxygenation techniques have been utilized by specialized centers, though their use in OHCA remains controversial. Chest hyperinflation and positive airway pressure may have a negative impact on hemodynamics during resuscitation and should be avoided. Dyscarbia in the postresuscitation period is relatively common, mainly in association with therapeutic hypothermia, and may worsen neurological outcome.
doi:10.1155/2014/376871
PMCID: PMC3958787  PMID: 24724081
6.  The difficult airway in the emergency department 
Background
The patient with difficult airways is a common challenge for emergency physicians.
Aims
Our goal was to study the reasons for difficult airways in the emergency department.
Methods
We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.
Results
There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.
Conclusions
Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.
doi:10.1007/s12245-008-0030-6
PMCID: PMC2657243  PMID: 19384660
Airway; Intubation; Laryngoscopy; Cricothyroidotomy; Tracheostomy
7.  Maxillofacial trauma patient: coping with the difficult airway 
Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.
doi:10.1186/1749-7922-4-21
PMCID: PMC2693512  PMID: 19473497
8.  Assessment of difficult laryngoscopy by electronically measured maxillo-pharyngeal angle on lateral cervical radiograph: A prospective study 
Saudi Journal of Anaesthesia  2010;4(3):158-162.
Background:
Difficult airway continued to be a major cause of anesthesia-related morbidity and mortality. Successful airway management depends on direct laryngoscopy and tracheal intubation. Difficult laryngoscopy is a resultant of incomplete structural arrangements during the process of head positioning. Through clinical history, examination of the patients along with craniofacial indices alerts the anesthetist for difficult laryngoscopy. But it does not predict all causes of difficult laryngoscopy during pre-anesthetic evaluation. The maxillo-pharyngeal angle, an upper airway anatomical balance, was proposed for better understanding the pathophysiology of difficult laryngoscopy. In our study we have assess difficult laryngoscopy by electronically measuring maxillo-pharyngeal angles on a lateral cervical radiograph. This angle is normally greater than 100°. Less than 90° angle suggests either impossible or difficult direct laryngoscopy when all known craniofacial indices were within the normal range. Cervical radiographic assessment is a simple, economical, and non-invasive predictive method for difficult laryngoscopy. It should be used routinely along with other indices as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy.
Context:
Difficulties with airway management continue to be a major cause of anesthesia-related morbidity, mortality, and litigation. Pre-operative assessment of difficult laryngoscopy by the simple and non-invasive radiological method can help to prevent them.
Aims:
To assess the difficult laryngoscopy pre operatively by a simple and non invasive radiological method by electronically measuring maxillo-pharyngeal angle on a lateral cervical radiograph and it’s correlation with Cormack and Lehane grading.
Settings and Design:
This is a controlled, nonrandomized, prospective, cohort observation study.
Patients and Methods:
The 157 adult consented patients of ASA grade I to III of either sex, scheduled for elective surgery under general anesthesia with endo-tracheal intubation, were studied. The patients with identified difficult airway indices were excluded from the study. The maxillo-pharyngeal angle was electronically measured on a lateral cervical radiograph and was correlated with ease or difficulty of laryngoscopy under general anesthesia. Their degree of laryngeal exposure according to Cormack and Lehane classification grade was also noted.
Statistical Analysis used:
We performed univariate analyses to evaluate the association between the covariates and direct laryngoscopy.
Results:
In 148 patients (94.28%), the maxillo-pharyngeal angle was more than 100°, in 7 patients (4.45%) it was less than 90°, and in 2 patients (1.27%) the M-P angle was less than 85° with normal craniofacial indices. When the MP angle was less than 90°, the direct laryngoscopy was difficult which could be compared with to Cormack and Lehane classification grade III and IV.
Conclusions:
Lateral cervical radiographic assessment should be used as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy as it is a simple, safe and non-invasive method.
doi:10.4103/1658-354X.71572
PMCID: PMC2980661  PMID: 21189852
Maxillo-pharyngeal angle; laryngoscopy; cervical radiograph; electronic measurement of angle; Cormack and Lehane grade
9.  Jaw-thrust induces sympathetic responses during induction of general anesthesia 
Korean Journal of Anesthesiology  2013;65(2):127-131.
Background
Jaw-thrust is a noxious stimulus that might induce sympathetic responses. The purpose of this study, was to evaluate the effects of jaw-thrust on sympathetic responses.
Methods
We investigated seventy three patients. Patients who received general anesthesia were randomly divided into a control group (maintenance of combined airway maneuver with head tilt, open mouth by mouthpiece, and chin-lift, n = 30) and jaw-thrust group (maintenance of head tilt, open mouth and jaw-thrust, n = 30). In the jaw-thrust group, four minutes of endoscopy-guided force to the mandible to get the best laryngeal view were applied. For the control group, the combined airway maneuver was maintained during the same period. Arterial blood pressure (AP) and heart rate (HR) were recorded at predetermined time points (1 min before anesthesia induction, 2 min after fiberoptic bronchoscopy placement, and thereafter 1 min-interval during each airway maneuver) during jaw-thrust and chin-lift maneuver. The force amplitude applied for best laryngeal view during jaw-thrust was also measured.
Results
Peak systolic and diastolic AP increased 39.0 ± 17.6 and 39.9 ± 22.8 mmHg from the baseline (P < 0.001) in the jaw-thrust group. HR was also 32.5 ± 19.4 beats/min from the baseline (P < 0.001) in the jaw-thrust group. These remained high at all time points, compared with the control group (P < 0.01). The force magnitude applied for jaw-thrust was not correlated to the AP and HR changes (P > 0.05).
Conclusions
Performing the jaw-thrust maneuver induces significant sympathetic responses, irrespective of the force magnitude.
doi:10.4097/kjae.2013.65.2.127
PMCID: PMC3766777  PMID: 24023994
Force; Jaw-thrust; Sympathetic
10.  Severe lingual tonsillar hypertrophy and the rationale supporting early use of wire-guided retrograde intubation 
Saudi Journal of Anaesthesia  2010;4(2):102-104.
An expanding body of literature exists which describes the airway challenges and management options for lingual tonsillar hypertrophy (LTH). The use of retrograde intubation to secure a patient‘s airway in the setting of LTH has been previously unreported and should be considered early in the event of a cannot intubate, cannot ventilate scenario. A 55-year-old man, who had previously been described as an easy intubation, presented an unexpected cannot intubate, cannot ventilate scenario secondary to LTH. Various noninvasive airway maneuvers were attempted to restore ventilation without success. We describe the advantages of early use of wire-guided retrograde intubation as an alternative to a surgical airway for obtaining a secure airway in a patient with LTH, in whom noninvasive airway management maneuvers have failed. Multiple different noninvasive approaches to management of LTH have been previously described including the laryngeal tube, laryngeal mask airway, and fiberoptic bronchoscopy. Unfortunately, none of these noninvasive airway maneuvers successfully ventilated this patient and an invasive airway became necessary. Retrograde intubation is a less invasive alternative to the surgical airway with potentially less risk for complications. Retrograde intubation may be particularly effective in the setting of LTH as it may stent open an otherwise occluded airway and allow passage of an endotracheal tube. Skillful use of this technique should be considered early as a viable option in any case of unexpected difficult intubation due to LTH.
doi:10.4103/1658-354X.65120
PMCID: PMC2945505  PMID: 20927270
Lingual tonsillar hypertrophy; retrograde intubation; difficult intubation
11.  Initial Management and Evaluation of the Multisystem Injured Patient, Part 2 
Trauma is the fourth leading cause of death for all Americans, with a mortality rate of 61 deaths per 100,000 people. Although the definitive place for the management of major abdominal or thoracic hemorrhage, as well as neurologic or orthopedic problems, is the operating room in a tertiary care hospital, trauma is a time-related disease, and the more quickly hemorrhage is controlled and appropriate management initiated, the better the outcome.
The author outlines a systematic approach to prehospital management of the trauma patient that includes a primary survey and a secondary survey. The primary survey (Part 1) focuses on life-threatening conditions that affect the airway and methods to clear the airway immediately. Once the airway is cleared, any anatomical or physiologic compromise that limits ventilation is identified and corrected, hemorrhage is controlled, and the cervical spine, if injury is suspected, is protected. The secondary survey (Part 2) is a comprehensive examination.
PMCID: PMC2625465  PMID: 3586045
12.  Initial Management and Evaluation of the Multisystem Injured Patient, Part 1 
Trauma is the fourth leading cause of death for all Americans, with a mortality rate of 61 deaths per 100,000 people. Although the definitive place for the management of major abdominal or thoracic hemorrhage, as well as neurological or orthopedic problems, is the operating room in a tertiary care hospital, trauma is a time-related disease, and the more quickly hemorrhage is controlled and appropriate management initiated, the better the outcome.
The author outlines a systematic approach to prehospital management of the trauma patient that includes a primary survey and a secondary survey. The primary survey (Part 1) focuses on life-threatening conditions that affect the airway and methods to clear the airway immediately. Once the airway is cleared, any anatomical or physiologic compromise that limits ventilation is identified and corrected, hemorrhage is controlled, and the cervical spine, if injury is suspected, is protected. The secondary survey (Part 2) is a comprehensive examination.
PMCID: PMC2625502  PMID: 3586032
13.  A nationwide postal questionnaire survey: the presence of airway guidelines in anaesthesia department in Sweden 
BMC Anesthesiology  2014;14:25.
Background
In Sweden, airway guidelines aimed toward improving patient safety have been recommended by the Swedish Society of Anaesthesia and Intensive Care Medicine. Adherence to evidence-based airway guidelines is known to be generally poor in Sweden. The aim of this study was to determine whether airway guidelines are present in Swedish anaesthesia departments.
Methods
A nationwide postal questionnaire inquiring about the presence of airway guidelines was sent out to directors of Swedish anaesthesia departments (n = 74). The structured questionnaire was based on a review of the Swedish Society of Anaesthesia and Intensive Care voluntary recommendations of guidelines for airway management. Mean, standard deviation, minimum/maximum, percentage (%) and number of general anaesthesia performed per year as frequency (n), were used to describe, each hospital type (university, county, private). For comparison between hospitals type and available written airway guidelines were cross tabulation used and analysed using Pearson’s Chi-Square tests. A p- value of less than 0 .05 was judged significant.
Results
In total 68 directors who were responsible for the anaesthesia departments returned the questionnaire, which give a response rate of 92% (n 68 of 74). The presence of guidelines showing an airway algorithm was reported by 68% of the departments; 52% reported having a written patient information card in case of a difficult airway and guidelines for difficult airways, respectively; 43% reported the presence of guidelines for preoperative assessment; 31% had guidelines for Rapid Sequence Intubation; 26% reported criteria for performing an awake intubation; and 21% reported guidelines for awake fibre-optic intubation. A prescription for the registered nurse anaesthetist for performing tracheal intubation was reported by 24%. The most frequently pre-printed preoperative elements in the anaesthesia record form were dental status and head and neck mobility.
Conclusions
Despite recommendations from the national anaesthesia society, the presence of airway guidelines in Swedish anaesthesia departments is low. From the perspective of safety for both patients and the anaesthesia staff, airway management guidelines should be considered a higher priority.
doi:10.1186/1471-2253-14-25
PMCID: PMC3996174  PMID: 24708670
Airway guidelines; Airway management; Patient safety
14.  Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center 
Anesthesia and analgesia  2012;116(1):112-117.
Background
Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting.
Methods
We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories, and compared these cases to those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same time period (control group), were collected via review of medical records.
Results
Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (p=0.04, odds ratio 10, 95% confidence interval 1.1 to 482). Tongue or soft tissue bite occurred in two cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure.
Conclusion
The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.
doi:10.1213/ANE.0b013e31826f9125
PMCID: PMC3530138  PMID: 23223101
15.  Airway and Esophageal Stenting in Patients with Advanced Esophageal Cancer and Pulmonary Involvement 
PLoS ONE  2008;3(8):e3101.
Background
Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC.
Methods and Findings
The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases.
Conclusion
Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.
doi:10.1371/journal.pone.0003101
PMCID: PMC2518104  PMID: 18769726
16.  Clinical review: Management of difficult airways 
Critical Care  2006;10(6):243.
Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway.
doi:10.1186/cc5112
PMCID: PMC1794480  PMID: 17184555
17.  Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012 
PLoS Medicine  2014;11(6):e1001667.
Sukhmeet Panesar and colleagues classified reports of patient-safety-related hospital deaths in England to identify patterns of cases where improvements might be possible.
Please see later in the article for the Editors' Summary
Background
Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced.
Methods and Findings
The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement.
Conclusions
Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Being admitted to the hospital is worrying for patients and for their relatives. Will the patient recover or die in the hospital? Some seriously ill patients will inevitably die, but in an ideal world, no one should die in the hospital because of inadequate or unsafe care (an avoidable death). No one should die, for example, because healthcare professionals fail to act on signs that indicate a decline in a patient's clinical condition. Hospital mortality (death) is often regarded as a key indicator of patient safety in hospitals, and death rate indicators such as the “hospital standardized mortality ratio” (the ratio of the actual number of acute in-hospital deaths to the expected number of in-hospital deaths) are widely used to monitor and improve hospital safety standards. In England, for example, a 2012 report that included this measure as an indicator of hospital performance led to headlines of “worryingly high” hospital death rates and to a review of the quality of care in the hospitals with the highest death rates.
Why Was This Study Done?
Hospital standardized mortality ratios and other measures of in-patient mortality can be misleading because they can, for example, reflect the burden of disease near the hospital rather than the hospital's quality of care or safety levels. Moreover, comparative data on hospital mortality rates are of limited value in identifying areas of risk to patients or solutions to the problem of avoidable deaths. In this study, to identify areas of service failure amenable to improvement through strengthened clinical policies, procedures, and practices, the researchers undertake a thematic analysis of deaths in hospitals in England that were reported by healthcare staff to a mandatory patient-safety-related incident reporting system. Since 2004, staff in the UK National Health Service (the NHS comprises the publicly funded healthcare systems in England, Scotland, Wales, and Northern Ireland) have been encouraged to report any unintended or unexpected incident in which they believe a patient's safety was compromised. Since June 2010, it has been mandatory for staff in England and Wales to report deaths due to patient-safety-related incidents. A thematic analysis examines patterns (“themes”) within nonnumerical (qualitative) data.
What Did the Researchers Do and Find?
By searching the NHS database of patient-safety-related incidents, the researchers identified 2010 incidents that occurred between 1 June 2010 and 31 October 2012 that resulted in the death of adult patients in acute hospital settings. By scrutinizing the structured information in each incident report and the associated free text in which the reporter described what happened and why they think it happened, the researchers classified the reports into 18 incident categories. These categories fell into six broad areas of systemic failure—mismanagement of deterioration (35% of incidents), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%, incidents where the problem underlying death was unclear). Management of deterioration, for example, included the incident categories “failure to act on or recognize deterioration” (23% of reported incidents), “failure to give ordered treatment/support in a timely manner,” and “failure to observe.” Failure of prevention included the incident categories “falls” (10% of reported incidents), “healthcare-associated infections” (also 10% of reported incidents), “pressure sores,” “suicides,” and “deep vein thrombosis/pulmonary embolism.”
What Do These Findings Mean?
Although the accuracy of these findings may be limited by data quality and by other aspects of the study design, they reveal patterns of patient-safety-related deaths in hospitals in England and highlight areas of healthcare that can be targeted for improvement. The finding that the mismanagement of deterioration of acutely ill patients is involved in a third of patient-safety-related deaths identifies an area of particular concern in the NHS and, potentially, in other healthcare systems. One way to reduce deaths associated with the mismanagement of deterioration, suggest the researchers, might be to introduce a standardized early warning score to ensure uniform identification of this population of patients. The researchers also suggest that more effort should be put into designing programs to prevent falls and other incidents and into ensuring that these programs are effectively implemented. More generally, the classification system developed here has the potential to help hospital boards and clinicians identify areas of patient care that require greater scrutiny and intervention and thereby save the lives of many hospital patients.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001667.
The NHS provides information about patient safety, including a definition of a patient safety incident and information on reporting patient safety incidents
The NHS Choices website includes several “Behind the Headlines” articles that discuss patient safety in hospitals, including an article that discusses the 2012 report of high hospital death rates in England, “Fit for the Future?” and another that discusses the Keogh review of the quality of care in the hospitals with highest death rates
The US Agency for Healthcare Research and Quality provides information on patient safety in the US
Wikipedia has pages on thematic analysis and on patient safety (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001667
PMCID: PMC4068985  PMID: 24959751
18.  Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol 
BMJ Open  2013;3(2):e002467.
Introduction
Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA.
Methods and analysis
The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study.
Ethics and dissemination
Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field.
Trial registration
ISRCTN: 18528625.
doi:10.1136/bmjopen-2012-002467
PMCID: PMC3586153  PMID: 23408081
Out of hospital cardiac arrest (OHCA); cardiopulmonary resuscitation (CPR); airway management; tracheal intubation; supraglottic airway devices (SADs)
19.  Obstructive sleep apnoea syndrome in children and anaesthesia 
Indian Journal of Anaesthesia  2010;54(1):18-23.
Obstructive sleep apnoea syndrome (OSAS) is a common medical disorder among adults, which is increasingly being recognized in children too. It is a breathing disorder characterized by upper airway obstruction with or without intermittent complete obstruction that disrupts normal breathing during sleep. Anatomical and neuromuscular disorders are mainly responsible for this disorder. This disorder leads to a state of chronic hypoxemia, which has significant cardiac, pulmonary and central nervous system implications. Diagnosis of OSAS is based on thorough history and clinical examination along with appropriate sleep studies including polysomnography. The mainstay of treatment of paediatric OSAS is adenotonsillectomy. Good anaesthetic practice in Paediatric patients with OSAS revolves around good and ideal airway management. Early detection of airway obstruction, intense monitoring to warn of impending airway problems and appropriate and early intervention of airway compromise are good anaesthetic practices. Coexisting medical problems should be adequately addressed and safe analgesic techniques in the perioperative period go towards improving outcomes in patients with paediatric OSAS.
doi:10.4103/0019-5049.60491
PMCID: PMC2876895  PMID: 20532066
Anaesthesia; children; OSAS
20.  SWIVIT - Swiss video-intubation trial evaluating video-laryngoscopes in a simulated difficult airway scenario: study protocol for a multicenter prospective randomized controlled trial in Switzerland 
Trials  2013;14:94.
Background
Video-laryngoscopes are marketed for intubation in difficult airway management. They provide a better view of the larynx and may facilitate tracheal intubation, but there is no adequately powered study comparing different types of video-laryngoscopes in a difficult airway scenario or in a simulated difficult airway situation.
Methods/Design
The objective of this trial is to evaluate and to compare the clinical performance of three video-laryngoscopes with a guiding channel for intubation (Airtraq™, A. P. Advance™, King Vision™) and three video-laryngoscopes without an integrated tracheal tube guidance (C-MAC™, GlideScope™, McGrath™) in a simulated difficult airway situation in surgical patients. The working hypothesis is that each video-laryngoscope provides at least a 90% first intubation success rate (lower limit of the 95% confidence interval >0.9). It is a prospective, patient-blinded, multicenter, randomized controlled trial in 720 patients who are scheduled for elective surgery under general anesthesia, requiring tracheal intubation at one of the three participating hospitals. A difficult airway will be created using an extrication collar and taping the patients’ head on the operating table to substantially reduce mouth opening and to minimize neck movement. Tracheal intubation will be performed with the help of one of the six devices according to randomization. Insertion success, time necessary for intubation, Cormack-Lehane grade and percentage of glottic opening (POGO) score at laryngoscopy, optimization maneuvers required to aid tracheal intubation, adverse events and technical problems will be recorded. Primary outcome is intubation success at first attempt.
Discussion
We will simulate the difficult airway and evaluate different video-laryngoscopes in this highly realistic and clinically challenging scenario, independently from manufacturers of the devices. Because of the sufficiently powered multicenter design this study will deliver important and cutting-edge results that will help clinicians decide which device to use for intubation of the expected and unexpected difficult airway.
Trial registration
NCT01692535
doi:10.1186/1745-6215-14-94
PMCID: PMC3651724  PMID: 23556410
Video-laryngoscope; Difficult airway; Airtraq; A. P. Advance; C-MAC; Glidescope; King vision; Mcgrath
21.  The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway 
Canadian Journal of Anaesthesia  2013;60:1119-1138.
Background
Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.
Methods
To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.
Principal findings
Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician’s experience, must also be considered in deciding the appropriate strategy.
Conclusions
With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.
doi:10.1007/s12630-013-0020-x
PMCID: PMC3825645  PMID: 24132408
22.  Evaluation of the new supraglottic airway S.A.L.T to aid blind orotracheal intubation: A pilot study 
Background and Objective:
Supraglottic Airway Laryngopharyngeal Tube (S.A.L.T) is a new airway gadget conceived as an effective device to facilitate blind oro-tracheal intubation. Literature review showed no available clinical study on human subjects. The aim of our study was to evaluate S.A.L.T as an adjunct to blind oro-tracheal intubation.
Methods:
Study design: Single centre, Single group, Open label, Prospective, Interventional pilot study. Study Group: 30 adult patients of either sex belonging to ASA I and II, scheduled for elective surgery under General anaesthesia. Patients were pre-medicated with inj. Glycopyrrolate 0.2 mg and inj. Midazolam 2 mg and induced with Inj. Propofol 2 mg/kg IV. After inj. Suxamethonium 1.5 mg/kg IV, S.A.L.T was inserted and a size 7.0 ID cuffed ETT was inserted through it immediately. The time period, from insertion of the S.A.L.T to the insertion of the ETT was noted. A successful intubation was defined as to insert SALT and intubate through it within 2 minutes irrespective of the number of attempts. Airway trauma, if any was recorded.
Results:
Only 40% of the patients were successfully intubated [(20.4% to 59.6% with 95% confidence interval (CI)]. The mean number of attempts required for intubation was 1.4 ± 0.67 (CI - 0.99 to 1.8) and the mean time for intubation was 26.3 ± 19.0 seconds (CI - 14.3 to 38.4 sec). Mallampati class I had more success rate than class III (P < 0.05). No airway trauma was recorded.
Conclusion:
S.A.L.T shows limited usefulness as an adjunct for aided blind oro-tracheal intubation.
doi:10.4103/2229-5151.124112
PMCID: PMC3891189  PMID: 24459620
Airway management; emergencies; intubation; laryngoscopy
23.  Delayed Complications of Emergency Airway Management: A Study of 533 Emergency Department Intubations 
Objectives
Airway management is a critical procedure performed frequently in emergency departments (EDs). Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs).
Methods
All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9%) were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI), stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period.
Results
The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553). Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553) of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 – 8.5%]) developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 – 5.1%]) had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway management. Three patients (0.5% [95% CI 0.1 – 1.6%]) suffered an acute MI, but none appeared to be related to the intubation. One patient was having an acute MI at the time of intubation and the other two patients had MIs more than 24 hours after the intubation. No patient suffered a stroke (0% [95% CI 0 – 0.6%]). No patients suffered any serious airway trauma such as a laryngeal or vocal cord injury.
Conclusions
Emergency tracheal intubation in the ED is associated with an extremely high success rate and a very low rate of delayed complications. Complication rates identified in this study compare favorably to reports of emergency intubations in other hospital settings. Tracheal intubation can safely be performed by trained EPs.
PMCID: PMC2672279  PMID: 19561743
24.  Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy 
Critical Care  2002;6(6):531-535.
Introduction
To assess the value of elective cricothyroidotomy for airway management in critically ill trauma patients with technically challenging neck anatomy.
Materials and methods
A retrospective chart review of patients admitted to the Trauma Service at a Level I Trauma Center who underwent cricothyroidotomy for elective airway management over a 40-month period from January 1997 to April 2000. Comparison was made with a cohort of Trauma Service patients who received a tracheostomy.
Results
Eighteen patients met study criteria, and an unpaired t test revealed significance (P < 0.05) for age only. There was no difference with Injury Severity Score, number of days in the intensive care unit, number of days requiring ventilation post procedure or number of days intubated prior to procedure. The major difference was the more technically challenging neck anatomy in the patients undergoing cricothyroidotomy. Five out of 18 patients undergoing cricothyroidotomy died prior to discharge and two out of 18 died after discharge from complications unrelated to their airway. Two out of 18 patients undergoing tracheostomy died prior to discharge from complications unrelated to their airway. For a period of 1 week–15 months (average, 5.5 months), notes in subsequent clinic appointments were reviewed for subjective assessment of wound healing, breathing and swallowing difficulties, and voice changes. One patient with a cricothyroidotomy required silver nitrate to treat some granulation tissue. Otherwise, no complications were identified. Telephone interviews were conducted with eight of the 11 surviving cricothyroidotomy patients and nine of the 16 surviving tracheostomy patients. One tracheostomy patient required surgical closure 3 months after discharge; otherwise, the only noted change was minor voice changes in three patients in each group. All six of these patients denied that this compromised them in any way.
Conclusion
Elective cricothyroidotomy has a low complication rate and is a reasonable, technically less demanding option in critically ill patients with challenging neck anatomy requiring a surgical airway.
PMCID: PMC153438  PMID: 12493076
airway; cricothyroidotomy; tracheotomy; trauma
25.  Airway Clearance Devices for Cystic Fibrosis 
Executive Summary
Objective
The purpose of this evidence-based analysis is to examine the safety and efficacy of airway clearance devices (ACDs) for cystic fibrosis and attempt to differentiate between devices, where possible, on grounds of clinical efficacy, quality of life, safety and/or patient preference.
Background
Cystic fibrosis (CF) is a common, inherited, life-limiting disease that affects multiple systems of the human body. Respiratory dysfunction is the primary complication and leading cause of death due to CF. CF causes abnormal mucus secretion in the airways, leading to airway obstruction and mucus plugging, which in turn can lead to bacterial infection and further mucous production. Over time, this almost cyclical process contributes to severe airway damage and loss of respiratory function. Removal of airway secretions, termed airway clearance, is thus an integral component of the management of CF.
A variety of methods are available for airway clearance, some requiring mechanical devices, others physical manipulation of the body (e.g. physiotherapy). Conventional chest physiotherapy (CCPT), through the assistance of a caregiver, is the current standard of care for achieving airway clearance, particularly in young patients up to the ages of six or seven. CF patients are, however, living much longer now than in decades past. The median age of survival in Canada has risen to 37.0 years for the period of 1998-2002 (5-year window), up from 22.8 years for the 5-year window ending in 1977. The prevalence has also risen accordingly, last recorded as 3,453 in Canada in 2002, up from 1,630 in 1977. With individuals living longer, there is a greater need for independent methods of airway clearance.
Airway Clearance Devices
There are at least three classes of airway clearance devices: positive expiratory pressure devices (PEP), airway oscillating devices (AOD; either handheld or stationary) and high frequency chest compression (HFCC)/mechanical percussion (MP) devices. Within these classes are numerous different brands of devices from various manufacturers, each with subtle iterations. At least 10 devices are licensed by Health Canada (ranging from Class 1 to Class 3 devices).
Evidence-Based Analysis of Effectiveness
Research Questions
Does long-term use of ACDs improve outcomes of interest in comparison to CCPT in patients with CF?
Does long-term use of one class of ACD improve outcomes of interest in comparison to another class of ACD in CF patients?
Literature Search
A comprehensive literature search was performed on March 7, 2009 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from January 1, 1950 to March 7, 2009.
Inclusion Criteria
All randomized controlled trials including those of parallel and crossover design,
Systematic reviews and/or meta-analyses. Randomized controlled trials (RCTs), systematic reviews and meta-analyses
Exclusion Criteria
Abstracts were generally excluded because their methods could not be examined; however, abstract data was included in several Cochrane meta-analyses presented in this paper;
Studies of less than seven days duration (including single treatment studies);
Studies that did not report primary outcomes;
Studies in which less than 10 patients completed the study.
Outcomes of Interest
Primary outcomes under review were percent-predicted forced expiratory volume (FEV-1), forced vital capacity (FVC), and forced expiratory flow between 25%-75% (FEF25-75). Secondary outcomes included number of hospitalizations, adherence, patient preference, quality of life and adverse events. All outcomes were decided a priori.
Summary of Findings
Literature searching and back-searching identified 13 RCTs meeting the inclusion criteria, along with three Cochrane systematic reviews. The Cochrane reviews were identified in preliminary searching and used as the basis for formulating this review. Results were subgrouped by comparison and according to the available literature. For example, results from Cochrane meta-analyses included abstract data and therefore, additional meta-analyses were also performed on trials reported as full publications only (MAS generally excludes abstracted data when full publications are available as the methodological quality of trials reported in abstract cannot be properly assessed).
Executive Summary Table 1 summarizes the results across all comparisons and subgroupings for primary outcomes of pulmonary function. Only two comparisons yielded evidence of moderate or high quality according to GRADE criteria–the comparisons of CCPT vs. PEP and handheld AOD vs. PEP–but only the comparison of CCPT vs. PEP noted a significant difference between treatment groups. In comparison to CCPT, there was a significant difference in favour of PEP for % predicted FEV-1 and FVC according to one long-term, parallel RCT. This trial was accepted as the best available evidence for the comparison. The body of evidence for the remaining comparisons was low to very low, according to GRADE criteria, being downgraded most often because of poor methodological quality and low generalizability. Specifically, trials were likely not adequately powered (low sample sizes), did not conduct intention-to-treat analyses, were conducted primarily in children and young adolescents, and outdated (conducted more than 10 years ago).
Secondary outcomes were poorly or inconsistently reported, and were generally not of value to decision-making. Of note, there were a significantly higher number of hospitalizations among participants undergoing AOD therapy in comparison to PEP therapy.
Summarization of results for primary outcomes by comparison and subgroupings
Bolding indicates significant difference
Positive summary statistics favour the former intervention
Abbreviations: AOD, airway oscillating device; CCPT, conventional chest physiotherapy; CI, confidence interval; HFCC, high frequency chest compression; MP, mechanical percussion; N/A: not applicable; PEP, positive expiratory pressure
Economic Analysis
Devices ranged in cost from around $60 for PEP and handheld AODs to upwards of $18,000 for a HFCC vest device. Although the majority of device costs are paid out-of-pocket by the patients themselves, their parents, or covered by third-party medical insurance, Ontario did provide funding assistance through the Assistive Devices Program (ADP) for postural drainage boards and MP devices. These technologies, however, are either obsolete or their clinical efficacy is not supported by evidence. ADP provided roughly $16,000 in funding for the 2008/09 fiscal year. Using device costs and prevalent and incident cases of CF in Ontario, budget impact projections were generated for Ontario. Prevalence of CF in Ontario for patients from ages 6 to 71 was cited as 1,047 cases in 2002 while incidence was estimated at 46 new cases of CF diagnosed per year in 2002. Budget impact projections indicated that PEP and handheld AODs were highly economically feasible costing around $90,000 for the entire prevalent population and less than $3,000 per year to cover new incident cases. HFCC vest devices were by far the most expensive, costing in excess of $19 million to cover the prevalent population alone.
Conclusions
There is currently a lack of sufficiently powered, long-term, parallel randomized controlled trials investigating the use of ACDs in comparison to other airway clearance techniques. While much of the current evidence suggests no significant difference between various ACDs and alternative therapies/technologies, at least according to outcomes of pulmonary function, there is a strong possibility that past trials were not sufficiently powered to identify a difference. Unfortunately, it is unlikely that there will be any future trials comparing ACDs to CCPT as withholding therapy using an ACD may be seen as unethical at present.
Conclusions of clinical effectiveness are as follows:
Moderate quality evidence suggests that PEP is at least as effective as or more effective than CCPT, according to primary outcomes of pulmonary function.
Moderate quality evidence suggests that there is no significant difference between PEP and handheld AODs, according to primary outcomes of pulmonary function; however, secondary outcomes may favour PEP.
Low quality evidence suggests that there is no significant difference between AODs or HFCC/MP and CCPT, according to both primary and secondary outcomes.
Very low quality evidence suggests that there is no significant difference between handheld AOD and CCPT, according to primary outcomes of pulmonary function.
Budget impact projections show PEP and handheld AODs to be highly economically feasible.
PMCID: PMC3377547  PMID: 23074531

Results 1-25 (623930)