中药灌肠联合胃管注入治疗肠梗阻疗效的系统评价

目的系统评价中药灌肠联合胃管注入治疗肠梗阻的临床疗效。方法计算机检索PubMed、Web of Science、EMbase、The Cochrane Library(2013年第4期)、CBM、CNKI、VIP和WanFang Data,查找关于中药灌肠联合胃管注入治疗肠梗阻的随机对照试验(RCT)或半随机对照试验(quasi-RCT),检索时限均为从建库至2013年7月。由2位评价员按照纳入与排除标准独立筛选文献、提取资料和评价纳入研究的方法学质量后,采用RevMan5.1软件进行Meta分析。结果最终纳入27个RCT,3个quasi-RCT,共计3 074例患者。Meta分析结果显示:中药灌肠联合胃管注入组在提高肠梗阻总有效率[OR=4.69,95%CI(3.70,5.94),P<0.00001],缩短住院时间[SMD=–1.19,95%CI(–1.42,–0.96),P<0.00001]、肛门排气时间[SMD=–1.52,95%CI(–1.76,–1.28),P<0.00001]、肛门排便时间[SMD=–2.27,95%CI(–3.43,–1.11),P=0.0001]、胃管留置时间[SMD=–1.56,95%CI(–1.86,–1.27),P<0.00001]和症状完全消失时间[SMD=–0.74,95%CI(–1.11,–0.37),P<0.000 1]方面均优于对照组,其差异均有统计学意义。结论现有证据显示,中药灌肠联合胃管注治疗肠梗阻疗效优于单纯西医治疗。由于纳入研究的质量不高,上述结论尚需开展更多高质量的随机双盲对照试验加以验证。     

火针治疗带状疱疹后遗神经痛有效性和安全性的系统评价

目的系统评价火针治疗带状疱疹后遗神经痛(PHN)的有效性和安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、CNKI、WanFang Data、CBM和VIP数据库,搜集有关火针治疗PHN有效性和安全性的随机对照试验(RCT),检索时限均从建库至2021年6月5日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行Meta分析。结果共纳入31个RCT,包括2755例患者。Meta分析结果显示:火针与西药相比可降低PHN患者的VAS评分[SMD=-1.00,95%CI(-1.36,-0.63),P<0.00001];火针联合西药与单用西药相比,可提高总有效率[RR=1.15,95%CI(1.06,1.23),P=0.0003],降低VAS评分[SMD=-1.92,95%CI(-2.87,-0.97),P<0.0001]、SAS评分[SMD=-0.89,95%CI(-1.20,-0.59),P<0.00001]。火针与常规针刺相比,可降低VAS评分[SMD=-1.37,95%CI(-2.35,-0.39),P=0.006],缩短即刻止痛时间[SMD=-0.64,95%CI(-0.88,-0.39),P<0.00001]。与中药相比,火针联合中药可降低VAS评分[SMD=-1.00,95%CI(-1.53,-0.47),P=0.0002]、SDS评分[SMD=-1.59,95%CI(-1.18,-1.31),P<0.00001]、SAS评分[SMD=-1.79,95%CI(-2.08,-1.49),P<0.00001]。此外,试验组不良反应发生率明显低于对照组。结论现有证据表明,火针可明显减轻PHN患者的疼痛强度,缓解焦虑,提高生活质量。受纳入研究数量和质量的限制,上述结论尚待更多高质量研究予以验证。     

腹内压监测在危重症患者肠内营养中应用效果的Meta分析

目的用系统评价的方法对腹内压监测在危重症患者肠内营养中的应用效果进行Meta分析,为今后临床实践和研究提供参考。方法计算机检索PubMed、The Cochrane Library、中国知网(CNKI)等数据库,搜集关于腹内压监测用于危重患者肠内营养的随机对照试验(RCT),检索时间均从建库到2021年3月。根据预先设定的纳入及排除标准进行筛选文献,提取相关数据,然后采用RevMan 5.4进行Meta分析。结果共纳入10个RCT,包括1249例患者,其中实验组628例,对照组621例。与常规肠内营养相比,在腹内压的指导下进行肠内营养可以降低血乳酸SMD=-2.23,95%CI(-2.49,-1.97),P<0.00001]、内毒素SMD=-1.09,95%CI(-1.40,-0.77),P<0.00001]、APACHE-Ⅱ评分SMD=-2.46,95%CI(-2.74,-2.18),P<0.00001],通过监测腹内压指导肠内营养使患者腹胀RR=0.5,95%CI(0.45,0.61),P<0.00001]、腹泻RR=0.51,95%CI(0.37,0.69),P<0.0001]、胃潴留RR=0.34,95%CI(0.19,0.63),P<0.0005]和恶心呕吐RR=0.43,95%CI(0.30,0.62),P<0.00001]的发生率降低。结论在腹内压的指导下给予肠内营养可降低血乳酸、内毒素、APACHE-Ⅱ评分,使腹胀、腹泻、呕吐、胃潴留等肠内营养不耐受症状的发生率有效下降。     

长期小剂量红霉素对慢性阻塞性肺疾病稳定期作用的Meta分析

目的系统评价小剂量红霉素治疗慢性阻塞性肺疾病(COPD)稳定期的临床疗效。方法计算机检索PubMed、EMbase、CBM、The Cochrane Library(2013年第4期)、CNKI、VIP和WanFang Data,查找小剂量红霉素+常规治疗与常规治疗或安慰剂加常规治疗比较治疗COPD稳定期患者疗效的随机对照试验(RCT)。检索时限均从建库至2013年5月。由2位评价员按照纳入与排除标准独立筛选文献、提取资料和评价纳入研究的方法学质量后,采用RevMan 5.2软件进行Meta分析。结果最终纳入8个RCT,共计526例患者。Meta分析结果显示:①与对照组相比,小剂量红霉素可显著改善COPD稳定期患者6分钟步行距离[SMD=0.30,95%CI(0.05,0.55),P=0.02],减少患者急性发作频率[RR=0.44,95%CI(0.25,0.78),P=0.005],降低痰中IL-8[SMD=–1.63,95%CI(–2.17,–1.09),P<0.00001]、TNF-α[SMD=–1.49,95%CI(–2.36,–0.62),P=0.0008]及中性粒细胞弹性蛋白酶[SMD=–0.94,95%CI(–1.36,–0.51),P<0.0001]水平。②两组在改善COPD稳定期患者第一秒用力呼气容积(FEV1)值方面无明显差异[SMD=0.19,95%CI(–0.19,0.58),P=0.32]。结论在COPD稳定期,小剂量红霉素的应用可改善患者运动耐量、减少急性加重频率、减轻气道炎症,但不能较常规治疗显著改善患者的肺功能。受纳入研究数量和质量限制,上述结论尚有赖于进一步开展更多大样本、多中心、高质量的RCT加以验证。     

喉罩在小儿先天性心脏病介入治疗麻醉中的应用

目的探索喉罩在小儿先天性心脏病介入治疗麻醉中应用的可行性和安全性。方法选择ASAⅠ～Ⅱ级,择期先天性心脏病介入治疗的患儿60例,随机分为喉罩组和气管插管组,每组各30例。喉罩组麻醉诱导,静脉注射丙泊酚1.5mg/kg、雷米芬太尼2μg/kg,药物达峰效应后置入喉罩;气管插管组麻醉诱导时加用罗库溴铵0.6mg/kg。麻醉维持采用丙泊酚和雷米芬太尼持续输注。分别记录两组患儿手术时间、苏醒时间、麻醉诱导前、麻醉诱导后及喉罩或导管置入前、置入后、拔除前、拔除后的平均动脉压(MAP)、心率(HR)、血氧饱和度(SpO2)值,并对置入喉罩和气管插管的一次成功率进行比较。监测术毕麻醉后恢复情况。结果两组患儿手术时间、苏醒时间、麻醉诱导前及喉罩或导管置入前、拔除前MAP、HR、SpO2值比较差异无统计学意义(P>0.05);喉罩或导管置入后及术后拔除时喉罩组MAP、HR低于气管插管组(P<0.05);术后呼吸系统并发症喉罩组少于气管插管组(P<0.05)。结论喉罩应用于小儿先天性心脏病介入治疗全麻,患儿血流动力学平稳、呼吸道并发症少,安全可靠性优于全麻插管,值得临床推广。     

紫杉类联合顺铂+氟尿嘧啶治疗局部晚期头颈部鳞癌效果的系统评价

目的系统评价紫杉类联合顺铂+氟尿嘧啶与顺铂+氟尿嘧啶比较治疗局部晚期头颈鳞癌的有效性和安全性。方法计算机检索h e Cochrane Library(2013年第1期)、PubMed、EMbase、Web of Science、CBM、CNKI、VIP和WanFang Data数据库,收集所有紫杉类联合顺铂+氟尿嘧啶与顺铂+氟尿嘧啶比较诱导化疗治疗局部晚期头颈鳞癌的随机对照试验(RCT),检索时限均从建库至2013年4月1日。由2位评价员按纳入与排除标准独立筛选文献、提取资料并评价质量后,采用RevMan 5.2软件进行Meta分析。结果共纳入7个RCT,2088例患者,其中紫杉类联合顺铂+氟尿嘧啶诱导化疗组(TPF组)1051例,顺铂+氟尿嘧啶诱导化疗组(PF组)1037例。Meta分析结果显示:TPF组与PF组在1年总生存率[RR=1.12,95%CI(1.02,1.23),P=0.02]、2年总生存率[RR=1.20,95%CI(1.11,1.29),P<0.00001]、3年总生存率[RR=1.18,95%CI(1.07,1.31),P=0.0007]、1年无进展生存率[RR=1.18,95%CI(1.08,1.28),P=0.0002]、2年无进展生存率[RR=1.20,95%CI(1.06,1.36),P=0.003]、3年无进展生存率[RR=1.48,95%CI(1.25,1.74),P<0.00001]、完全缓解率[RR=1.67,95%CI(1.26,2.23),P=0.0004]和总反应率[RR=1.18,95%CI(1.11,1.27),P<0.00001]方面差异均有统计学意义,TPF组均优于PF组。在不良反应方面,与PF相比,TPF组中性粒细胞减少症发生率[RR=1.42,95%CI(1.24,1.63),P<0.00001]、脱发发生率[RR=16.09,95%CI(4.59,56.38),P<0.0001]和中性粒细胞减少性发热发生率[RR=2.21,95%CI(1.29,3.80),P<0.004]更高。结论紫杉类联合顺铂+氟尿嘧啶诱导化疗治疗局部晚期头颈鳞癌具有较好的治疗效果,但不良反应较多。     

两种扁桃体切除术临床疗效对比的Meta分析

[目的]评价扁桃体切除术电刀凝切术和常规剥离术对病人临床效果的影响。[方法]计算机检索PubMed、EMbase、the Cochrane Library、CINAHL、CBM、CNKI、WanFang Data、VIP数据库、SUMsearch和Google搜索引擎,查找自建库以来至2019年2月1日关于电刀凝切术与常规剥离术的随机对照试验(RCT)。由2名评价员独立筛选文献、提取资料和评价纳入研究偏倚风险后,采用RevMan 5.3软件进行Meta分析。[结果]纳入32个RCT,共3203例病人。Meta分析结果显示:电刀凝切组病人扁桃体手术切除时间[SMD=-2.88,95%CI(-3.28,-2.48),P<0.00001]、术中出血量[SMD=-3.82,95%CI(-4.43,-3.21),P<0.00001]、术后平均疼痛时间[MD=-0.73,95%CI(-1.30,-0.17),P=0.01]、术后6 h疼痛[SMD=-2.17,95%CI(-3.06,-1.28),P<0.00001]、24 h疼痛[SMD=-1.49,95%CI(-2.13,-0.85),P<0.00001]、48 h疼痛[SMD=-1.60,95%CI(-1.85,-1.34),P<0.00001]和72 h疼痛[SMD=-1.72,95%CI(-2.30,-1.13),P<0.00001]均明显小于常规剥离组;而术后恢复正常饮食时间[MD=2.06,95%CI(0.90,3.23),P=0.0005]和术后白膜脱落时间[MD=1.51,95%CI(0.41,2.61),P=0.007]明显长于常规剥离组;两组病人术后原发性出血发生率[OR=0.35,95%CI(0.12,1.07),P=0.07]和继发性出血发生率[OR=1.74,95%CI(0.91,3.34),P=0.10]差异无统计学意义。[结论]当前证据显示,与常规剥离术相比,电刀凝切术可明显缩短病人手术时间,减少术中出血量,缩短术后平均疼痛时间,减轻术后6 h、24 h、48 h、72 h疼痛程度,但术后较晚恢复正常饮食,且白膜脱落时间延迟。鉴于受纳入文献限制,上述研究结果尚需更多高质量的RCT加以验证。     

术后早期经口进食对非胃肠道手术患者胃肠功能及术后住院时间影响的Meta分析

目的通过Meta分析评价术后早期经口进食对非胃肠道手术患者胃肠功能及术后住院时间的影响。方法计算机检索PubMed、The Cochrane Library、Embase、CBM、CNKI、万方数据库,同时追溯纳入研究的参考文献。运用RevMan 5.3软件进行数据处理。结果共纳入13篇随机对照试验,包括5 243例患者。Meta分析结果显示,术后早期经口进食组与常规进食组相比,恶心发生率RR=1.04,95%CI(0.79,1.38),P=0.76;呕吐发生率RR=1.00,95%CI(0.69,1.45),P=0.99;腹胀发生率RR=0.68,95%CI(0.44,1.03),P=0.07;术后便秘发生率RR=0.20,95%CI(0.12,0.32),P0.00001;术后首次排气SMD=-0.67,95%CI(-0.91,-0.42),P0.00001,首次排便时间SMD=-0.56,95%CI(-0.76,-0.36),P0.00001;术后住院时间SMD=-0.20,95%CI(-0.30,-0.10),P=0.0001。结论术后早期经口进食有利于非胃肠道手术患者胃肠功能的恢复,缩短术后住院时间。     

思维导图式健康教育对患者出院准备度干预效果的Meta分析

目的 通过Meta分析,评价思维导图式健康教育在患者出院准备中的应用效果。方法 检索PubMed、Cochrane Library、Web of Science、JBI、中国知网、中国生物医学文献数据库、万方数据库中关于使用思维导图对出院患者进行健康教育的随机对照试验,检索时间为建库至2022年4月,由2名研究者独立筛选文献、提取资料并进行质量评价,使用RevMan 5.4软件进Meta分析。结果 最终纳入12篇,1181例患者。Meta分析显示:与常规健康教育相比,应用思维导图式健康教育可以提高患者出院准备度[SMD=2.12,95%CI(1.24,3.00),P<0.00001],提高出院指导质量[SMD=1.66,95%CI(1.09,2.23),P<0.00001]和护理满意度[OR=4.42,95%CI(2.20,8.87),P<0.0001],增强患者自护能力[SMD=1.56,95%CI(0.08,3.04),P=0.04],但对降低术后并发症的发生率,差异无统计学意义[OR=0.63,95%CI(0.27,1.48),P=0.29]。结论 运用思维导图...     

院前与入院后气管插管对重型颅脑损伤患者预后影响的Meta分析

目的评价院前急救中气管插管与入院后插管对重型颅脑损伤患者预后的影响。方法计算机检索PubMed、EMbase、The Cochrane Library、Ovid、CNKI、CBM、万方和维普数据库中有关院前急救中气管插管对重型颅脑损伤患者预后影响的研究,追溯纳入文献和相关综述的参考文献,检索时限均由建库至2017年12月。由2位研究员独立筛选文献、提取资料和评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行Meta分析,使用STATA 12.0软件进行敏感性分析,绘制漏斗图分析纳入文献的发表偏倚。结果最终纳入8篇文献,共17 604例患者。Meta分析结果显示:与入院后气管插管组相比,对重型颅脑损伤患者院前急救进行气管插管后,增加患者的病死率[RR=1.15,95%CI(1.09～1.20),P0.00001]及ICU住院时间[SMD=0.56,95%CI(0.12～1.00),P=0.01];其次,对肺炎发生率[RR=1.28,95%CI(0.95～1.71),P=0.10]及机械通气时间[SMD=0.15,95%CI(-0.08～0.37),P=0.20]差异无统计学意义。敏感性分析显示结果较为稳健,发表偏倚检测显示无明显发表偏倚。结论院前急救中对重型颅脑损伤患者行气管插管可能增加患者病死率,延长ICU住院时间,但对患者入院后肺炎发生率和机械通气时间无显著影响。受纳入研究质量和数量的限制,上述结论有待更多高质量的研究验证。     

Dual Reporter Comparative Indexing of rAAV Pseudotyped Vectors in Chimpanzee Airway

Selecting the most efficient recombinant adeno-associated virus (rAAV) serotype for airway gene therapy has been difficult due to cross-specific differences in tropism and immune response between humans and animal models. Chimpanzees—the closest surviving genetic relative of humans—provide a valuable opportunity to select the most effective serotypes for clinical trials in humans. However, designing informative experiments using this protected species is challenging due to limited availability and experimental regulations. We have developed a method using Renilla luciferase (RL) and firefly luciferase (FL) reporters to directly index the relative transduction and immune response of two promising rAAV serotypes following lung coinfection. Analysis of differential luciferase activity in chimpanzee airway brushings demonstrated a 20-fold higher efficiency for rAAV1 over rAAV5 at 90 days, a finding that was similar in polarized human airway epithelia. T-cell responses to AAV5 capsid were stronger than AAV1 capsid. This dual vector indexing approach may be useful in selecting lead vector serotypes for clinical gene therapy and suggests rAAV1 is preferred for cystic fibrosis.     

喉罩通气道与气管内插管在急救复苏中重建有效通气道的对比研究

目的检测喉罩通气道用于急救复苏中重建有效通气道的优越性.方法L组20例系各种因素导致呼吸衰竭或呼吸停止的患者,选择合适3～4型号的喉罩盲探插入正确位置,进行控制呼吸.E组20例手术麻醉患者,在静脉快诱导明视下行气管内插管机械通气,观察2组插管困难程度、插管成功次数、插管时间、插管后PetCO2波形、气道顺应性、SPO2、胸廓起伏状况、双肺呼吸音.结果L组盲探下插管全部1次成功,E组诱导明视下插管1次成功16例,3次以上4例.插管时间L组全部在30s内完成,E组在30s内完成16例,其余长达1min30s～3min20s(P＜0.05),相比差异有显著性.插管后两组气道顺应性,PetCO2、SPO2、双肺呼吸音判断导管位置均正确无误.结论应用喉罩通气道于急救复苏,与使用喉镜明视下快诱导行气管内插管相比,具有体位要求不高,操作简单,可盲探插管,为抢救此类患者赢得宝贵的抢救时间.     

Comparative Study of Airway Management Techniques with Restricted Access to Patient Airway

Objective. To determine which airway endotracheal tube (ET), Combitube (CT), or Laryngeal Mask Airway (LMA) has the shortest time to successful ventilation in three nontraditional prehospital airway scenarios. Methods. Prospective randomized cohort study of emergency medicine (EM) residents, faculty EM physicians, andparamedics (EMT-P). Subjects were instructed to place an airway in a mannequin in three scenarios: mannequin supine under a table with head abutting a wall, mannequin sitting upright with access from behind, andmannequin lying on its side with access facing the mannequin. The number of airway placement attempts andtime to successful ventilation were recorded. Results. Twenty-five resident physicians, 9 faculty physicians, and22 EMT-Ps participated. No significant difference was found between the different airways in the number of attempts to successfully ventilate. EMT-Ps demonstrated significantly faster times to successful ventilation for all scenarios versus physicians (e.g., supine scenario with ET, EMT-P median time 57 seconds, physician median time 96 seconds) except for the mannequin lying on its side where there was no significant difference. The time to ventilation for all scenarios was less with the LMA versus ET or CT versus ET, except in the sitting scenario where ET andCT were comparable Conclusions. In this mannequin model of restricted airway access, LMA resulted in significantly faster times to ventilation versus ET andCT in all but one scenario. Further consideration andstudy using airways other than ET are warranted for situations with restricted access to the patient's airway.     

Airway clearance applications in infants and children

The rationale for airway clearance therapy and basic principles of its application are identical for children and adults, but there are important differences in physiology (regarding airway mucus characteristics and airway mechanics) and pathological processes in children, as well as other considerations unique to the pediatric population. The major obstacle in reviewing the evidence for efficacy of airway clearance therapy in pediatrics is the lack of data from well-performed, adequately powered clinical trials. This problem is partially alleviated by the use of published meta-analyses. A review of pediatric studies suggests that airway clearance therapy is of clear and proven benefit in the routine care of cystic fibrosis, and that no specific airway-clearance technique is clearly superior, but for any individual patient the technique that is most likely to maximize patient adherence to treatment is preferred. Airway clearance therapy appears likely to be of benefit in the routine care of children with neuromuscular disease and cerebral palsy, and is probably of benefit in treating atelectasis in children on mechanical ventilation. Airway clearance therapy may be of benefit in preventing post-extubation atelectasis in neonates. Airway clearance therapy appears to be of minimal to no benefit in the treatment of children with acute asthma, bronchiolitis, hyaline membrane disease, and those on mechanical ventilation for respiratory failure in the pediatric intensive care unit, and it is not effective in preventing atelectasis in children immediately following surgery. All in all, however, given that these conclusions are based on very little data, future well-performed clinical trials might change the weight of evidence to contradict these current conclusions.     

Impact of Emergency Medicine Faculty and an Airway Protocol on Airway Management

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.     

插管型喉罩用于困难气道的临床研究

目的:观察插管型喉罩(intubating laryngeal mask airway,ILMA)在困难气道中应用的可行性。方法:25例Cormack与lehaneⅢ-Ⅳ级预测为困难气道的择期手术患者(Difficut组,简称D组),另匹配25例Cormack与lehaneⅠ-Ⅱ级的择期手术患者(Control组,简称C组),在静脉诱导后行ILMA插管。观察喉罩置入时间和次数、气管插管时间和次数、插管并发症以及成功率。结果:D组24例(96％)成功经ILMA插入气管导管,其中1次插管成功16例,成功率64％;2次插管成功6例;1例操作失败。C组25例(100％)全部经ILMA成功插入气管导管,其中1次插管成功23例,成功率92％。2次插管成功1例。D组和C组喉罩置入加插管总时间分别为(90．24±8．50)s和(81．26±7．20)s,插管时间分别为(41．73±7．86)s和(40．80±6．93)s。两组在气管导管插入时间、总的ILMA置入时间,成功率、术后并发症等方面无显著差异。结论:插管型喉罩是处理困难气道的有效应用工具之一。     

King Airway Use by Air Medical Providers

Background. In cases of difficult or failed endotracheal intubation (ETI), alternate airways are designed to provide adequate oxygenation andventilation until a definitive airway can be established. The King Laryngeal Tube Disposable (LTD) is a new superglottic alternate airway. Objective. To describe the use, rates of success, andoutcomes of the King airway by highly skilled prehospital providers. Method. In this retrospective analysis, we examined prehospital King airway use by a large regional air medical service for the period from March 2006 to December 2006. Rescuers used alternate airways after three unsuccessful ETI attempts or in situations of anticipated ETI difficulty. We identified clinical characteristics, described airway difficulties, anddetermined the success of airway placement. Where available, we evaluated the hospital course andoutcomes. Results. Of 575 ETI, alternate airways were used in 27 cases, including 26 King airway placements (4.5%, 95% CI: 3.0–6.6%). All were successfully placed; 24 required one attempt, andtwo required more than one attempt. No immediate complications were observed. No prehospital surgical airways were performed. Follow-up data were available for 15 of 26 patients. Five patients were in cardiac arrest anddid not survive to hospital admission. Many of the patients required specialized efforts from anesthesia or surgery for definitive airway management with 40% (4/10) requiring emergent tracheostomy. Conclusion. In this series of critically ill patients, air medical providers successfully used the King airway as an alternate airway device. Definitive airway management was complicated andrequired specialized efforts from surgery andanesthesia.     

Airway management for the uninitiated

The 21(st) century has witnessed burgeoning interest in airway management. Pertinent basic sciences are covered in numerous texts and lectures. This article presents clinical information required to perform airway management. It serves as a primer for those interested in learning airway management skills. It does not replace extensive practice under the tutelage of expert airway managers.     

Airway control in trauma patients with cervical spine fractures

INTRODUCTION: Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial. PURPOSE: This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma. HYPOTHESIS: The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma. METHODS: The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway--CSF--breathing spontaneously, stable vital signs; 2) Urgent airway--CSF--breathing spontaneously, unstable vital signs; and 3) Emergent airway--CSF--apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures. RESULTS: Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81%, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%. The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation. CONCLUSION: The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.     

Airway Management Proficiency Checklist for Assessing Paramedic Performance

Objective: To develop and derive an instrument for assessing airway management proficiency for paramedics. Methods: Using a validated difficult airway model simulation, we recorded responses to a standard traumatic brain injury scenario requiring airway management in 197 certified paramedics. Discrete items (N = 131) were developed by an expert panel, and referenced to three performance standard subscales (i.e., intubation, ventilation, and backup airway). Responses were scored and subjected to an iterative process to create a more practical number of items for the final Airway Management Proficiency Checklist (AMPC). Tetrachoric correlations were used to evaluate items for relevance. Kuder-Richardson Formula 20 reliabilities were used to assess internal consistency among checklist items. Finally, a Rasch analysis on each subscale was performed to evaluate items for measurement quality. Items were retained if they were determined to fit the Rasch Model. Results: Items were deleted from the final AMPC for lack of simulation fidelity (26 items), duplicity (15 items), and poor psychometric quality (39 items). In four additional iterations, items were dropped for lack of equipment options (e.g., single mask), lack of instructional clarity (e.g., calculation of GCS score), high inference on the part of the evaluator (6 items), or inadequate measurement of behavioral performance (e.g., passes blade through lips without contacting mouth or teeth). Thirty seven items and three outcome standards (first pass success of the endotracheal tube; assisted ventilation with no interruption of 30 seconds or greater; successful placement of a backup airway device within one attempt) were retained to form three hypothesized subscales. Conclusions: The AMPC represents a psychometrically derived instrument that identified important tasks required for comprehensive airway management. The 37-item instrument will contribute to improving training and measuring the performance of paramedic's airway management skills.