Articles: intubation.
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Editorial Comment
Preventing difficult facemask ventilation in children: all is well that starts well.
Difficult facemask ventilation at induction of general anaesthesia can trigger hypoxaemia and inadequate ventilation if not immediately identified and adequately treated. For this reason, identification of predisposing conditions before induction of anaesthesia and causes of poor facemask ventilation are critical to avoid the subsequent complications. In a recently published secondary analysis of the Paediatric Difficult Intubation (PeDI) registry, the incidence and risk factors for difficult facemask ventilation in children with difficult tracheal intubation was described, as highlighted in the editorial.
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Prolonged intubation is a common cause of injury to the posterior larynx often resulting in cricoarytenoid joint (CAJ) fixation and posterior glottic stenosis (PGS). We present a case of respiratory failure due to acute bilateral CAJ fixation and PGS following only 2 days of intubation for routine cardiac surgery. ⋯ Clinicians should remain vigilant for laryngeal injury presenting as CAJ fixation and PGS. Prompt surgical consultation is advised as early intervention is associated with reduced morbidity.
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Am. J. Respir. Crit. Care Med. · Jun 2023
Individualized Treatment Effects of Bougie vs Stylet for Tracheal Intubation in Critical Illness.
Rationale: A recent randomized trial found that using a bougie did not increase the incidence of successful intubation on first attempt in critically ill adults. The average effect of treatment in a trial population, however, may differ from effects for individuals. Objective: We hypothesized that application of a machine learning model to data from a clinical trial could estimate the effect of treatment (bougie vs. stylet) for individual patients based on their baseline characteristics ("individualized treatment effects"). ⋯ In the validation cohort, individualized treatment effects predicted by the model significantly modified the effect of trial group assignment on the primary outcome (P value for interaction = 0.02; adjusted qini coefficient, 2.46). The most important model variables were difficult airway characteristics, body mass index, and Acute Physiology and Chronic Health Evaluation II score. Conclusions: In this hypothesis-generating secondary analysis of a randomized trial with no average treatment effect and no treatment effect in any prespecified subgroups, a causal forest machine learning algorithm identified patients who appeared to benefit from the use of a bougie over a stylet and from the use of a stylet over a bougie using complex interactions between baseline patient and operator characteristics.