BACKGROUND: Evaluate the possibility of retromolar intubation for general anesthesia in patients with maxillofacial fractures.
METHODS: The medical records of 54 patients with maxillofacial fractures who visited the Oral and Maxillofacial Surgery Department of Nantong First People\'s Hospital from January 2020 to August 2022 were collected. The retromolar areas of each patient were measured from the coronal CT images, and correlated with the patient\'s age, sex, type of fracture (i.e., maxillary fracture, mandibular fracture, or complex fracture of multiple maxillofacial bones), and the presence of the third molar (verified from 3D CT). The dimensions of the retromolar areas were finally compared with the outer diameter (OD) of standard endotracheal tubes (ETTs), most importantly the size 7.5 ETT (OD 10.3 mm) for male and the size 7.0 ETT (OD 9.8 mm) for female.
RESULTS: The survey included 38 male and 16 female patients, with an average age of 44.1 and 54.3 years, respectively. The dimensions of the retromolar area (height × width) were as follows: male, (9.39 ± 1.77) mm × (12.08 ± 0.98) mm on the left and (9.81 ± 2.23) mm × (11.77 ± 1.08) mm on the right; female, (8.82 ± 1.53) mm × (10.51 ± 1.00) mm on the left and (9.73 ± 1.60) mm × (10.63 ± 1.58) mm on the right. The width was always larger than the OD of the routinely used ETT, but the height could be smaller by less than 1 mm. However, the oral mucosa can be compressed to allow the ETT to fit in the retromolar area.
CONCLUSIONS: The retromolar area provided appropriate space to place a reinforced ETT for patients with maxillofacial fractures needing general anesthesia that must not interfere with intermaxillary ligation. Retromolar intubation can help maxillofacial fracture surgeries that focus on occlusal restoration.

To evaluate the effects of our self-developed endotracheal tube fixation device in mechanically ventilated patients.
In a dual-centre randomised controlled trial, patients who were expected to require mechanical ventilation for over 48 h were assigned to the observation group (using self-developed device) or the control group (using the traditional device). The primary endpoint was the incidence of endotracheal intubation-related pressure injury (EIRPI).
Fifty-one patients in the observation group and 54 patients in the control group were analysed. The incidence of EIRPI was 7.8% in the observation group and 33.3% in the control group (p = 0.001). Lip pressure injury (PI) occurred in 0 versus 14 (25.9%) patients in the observation versus control groups (p < 0.001). Both oral-mucosal and facial PIs were similar between the two groups.
The use of the novel device reduced the incidence of EIRPI, especially lip PI. Trial registration Chinese Clinical Trial Registry ChiCTR2300078132. Registered on 29 November 2023.

Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiber-optic intubation (AFOI) is often impeded. Various maneuvers and tracheal tubes designed to overcome this obstruction may also be unsuccessful or costly.
The current study aimed to assess how the novel double configuration ETT affected AFOI success rates on the first attempt.
A randomized controlled experiment including 40 individuals receiving awake fiber-optic orotracheal intubation was performed in a 1:1 ratio with a single ETT railroaded with its bevel posteriorly (ST) or railroading with a double setup ETT (DT) over a flexible videoscope (FVS) for tracheal intubation. The number of intubation attempts, time spent intubating, and adverse events were examined and compared between the two groups.
Twenty patients received a single ETT railroaded with the bevel posteriorly, and 20 patients received railroading with the double setup ETT during AFOI. Intubation on the first attempt was significantly greater in the DT group (90%) than in the ST group (35%). The intubation time was considerably shorter for the DT group (12.8 [7.8-16.9] s) when compared with the ST group (27.9 [16.3-91.0] s). Five patients were intubated by the alternative technique after failure to intubate for several attempts, and 3 cases were found to have a crease in the FVS after intubation in group ST. During topical anesthetic, three individuals in each group experienced transient oxygen desaturation.
Our study discovered that the novel double setup tube could significantly improve the intubation success rate on the first attempt during AFOI for patients with challenging airway when a strategy based on a reduced gap between ETT and FB could not be applied.

Aerosol drug delivery during high flow nasal oxygen (HFNO) and invasive mechanical ventilation (IMV) are key respiratory care strategies available for the treatment of pediatric patients. We aimed to quantify the impact of different HFNO and IMV set-ups on tracheal drug delivery via a vibrating mesh nebuliser (VMN).
Percent tracheal dose via VMN was quantified during HFNO therapy and IMV in a benchtop model of a 9-month-old infant. Under HFNO, 3 cannula sizes were used at 3 flow rate settings with the VMN placed at the dry side of the humidifier. Under IMV, tracheal dose when VMN was placed at the dry side of the humidifier, 15 cm from the wye and between the wye and endotracheal tube (ETT) was assessed. Salbutamol at 2.5 mg/2.5 ml (1 mg/ml) was used for each test (N = 5). The impact of VMN refill on circuit pressure under HFNO and IMV was also assessed.
Tracheal dose was highest during HFNO with the largest cannula size (OPT318) set to the lowest flow rate setting of 2 L/min (liter per minute) (5.80 ± 0.17%). Increasing flow rate reduced tracheal drug delivery for all cannulas. For IMV, VMN on the dry side of the humidifier and between the wye and ETT gave optimal drug delivery (4.49 ± 0.14% vs. 4.43 ± 0.26% respectively). VMN refill did not impact circuit pressure for either HFNO therapy or IMV.
Gas flow rate and cannula size during HFNO and VMN position during IMV has a significant effect on tracheal drug delivery in a pediatric setting.

Anesthesia for patients with mucopolysaccharidoses (MPS) is quite challenging due to vital systemic dysfunction following progressive accumulation of lysosomal glycosaminoglycans. Previous studies focused on perioperative difficult airway management under general anesthesia but rarely depicted the concern of choosing the size of the endotracheal tube (ETT) as well as neuraxial anesthesia. This study aimed to analyze the overall anesthetic management and related complications for a thorough anesthetic strategy. Within the study period from 2002 to 2021, each record of the anesthetic and perioperative quality assurance/improvement system for patients with a diagnosis of MPS at MacKay Memorial Hospital was retrospectively reviewed. A total of 51 individuals with 151 anesthesia for 163 interventions were cohort studied, and there were 136 general anesthesia and 15 neuraxial anesthesia. We found that the most common interventions for MPS patients were otolaryngological surgeries (49.6%). Additionally, a secured airway played a marked preference for the most general anesthesia (87.1%). The incidence of difficult intubation was 12.5%. In view of ETT size, a smaller than estimated size was used in MPS type II, III, IV, and VI patients and also in patients who received intubation with multiple attempts. However, a larger than estimated size of ETT was adopted whilst choosing cuffed ones. For neuraxial anesthesia, two failed spinal anesthesia procedures were converted to general anesthesia and 73 percent of the patients received perioperative sedation. In conclusion, through the individualized anesthetic strategy and build-up of an experienced team for airway management, high-quality anesthesia can be ensured in each patient.

BACKGROUND:  In perioperative care or intensive care units, the expansion lines of endotracheal tubes (ETTs) or laryngeal mask airways (LMAs) may be accidentally cut off during medical procedures. We designed a simple method for repairing damaged ETT and LMA expansion lines.
METHODS:  In this in vitro study, ETT (n = 20) or LMA (n = 20) models were each categorized into experimental (n = 10) and control (n = 10) groups. In the experimental groups, the expansion lines were cut in the middle, and a 22G intravenous catheter was inserted into the broken end of each expansion line. The time taken to repair the expansion lines was recorded in both experimental groups. The repaired expansion lines in both groups were tested for visible underwater air leakage with cuffs under high pressure (120 cm H2O). After 15 h, the cuff pressure and tensile strength of the expansion lines were measured.
RESULTS:  The overall time required to repair the expansion line was 27.8 ± 1.5 s in the ETT group and 20.4 ± 1.1 s in the LMA group. When the cuff pressure was increased to 120 cmH2O, no air leakage was observed in the experimental LMA and ETT groups. The mean difference in the cuff pressures of the control and experimental groups was insignificant for both, ETT (9.50 ± 1.29 vs. 9.50 ± 1.08 cmH2O, 95% CI =  - 1.11 to 1.11 cmH2O, P = 1.00) and LMA (34.1 ± 1.10 cmH2O vs. 34.5 ± 0.97 cmH2O, 95% CI =  - 0.57 to 1.37 cmH2O, P = 0.40) groups, The tensile strength and the force required to pull apart the expansion lines in the experimental groups were lower than those in the control groups for ETTs (3.32 ± 0.37 N vs. 35.03 ± 4.47 N, 95% CI =  - 34.69 to - 28.72 N, P < 0.0001) and LMAs (36.55 ± 2.20 N vs. 26.18 ± 1.67 N, 95% CI =  - 12.21 to - 8.53 N, P < 0.0001).
CONCLUSIONS:  An intravenous catheter can be directly inserted into the damaged ETT or LMA expansion lines; it is a simple, rapid, and effective repair method.

Cough caused by endotracheal tube (ETT) placement is ubiquitous and correlates with adverse outcomes. Remifentanil administration via target-controlled infusion (TCI) is one of the cough prevention measures used during recovery. In a pilot study, lidocaine administered via the perforated outer cuff of a dual-cuff endotracheal tube was also found to prevent cough due to ETT placement. We therefore compared these two cough prevention approaches during recovery after thyroidectomy in a single-centre, double-blind, randomised study conducted in China during the period from 09/10/2020 to 30/04/2021.
Ninety-eight female patients aged 18-65 years with American Society of Anaesthesiologists Physical Status scores of I and II were scheduled to undergo thyroidectomy. The ETT contained an internal cuff covered by a perforated outer cuff to allow for lidocaine delivery. Patients were randomised to receive either 4 ml of saline solution (Group R, n = 49) or 4 ml of 2% lidocaine in the outer cuff (Group L, n = 49) at the beginning of skin suturing. Remifentanil (2 ng/ml) was maintained in Group R until extubation, while remifentanil was maintained in Group L until the end of skin suturing. The primary outcome was cough during patient transfer, at 1 min before extubation, and at extubation. The secondary outcomes were haemodynamics and other recovery parameters.
Primary outcomes were compared between remifentanil vs. lidocaine application, namely, the incidence of cough during patient transfer (0% in Group R vs. 0% in Group L), at 1 min before extubation (22.45% in Group R vs. 4.08% in Group L; P = 0.015), and at extubation (61.22% in Group R vs. 20.41% in Group L; P < 0.001). Compared with remifentanil, lidocaine more effectively decreased heart rate elevation and hypoxemia at 5 min after extubation, the spontaneous respiration recovery time, the extubation time, the duration of post-anaesthesia care unit (PACU) stay, Richmond Agitation-Sedation Scale scores in the agitated range and Critical-Care Pain Observation Tool scores.
Lidocaine administered via the perforated outer cuff of the ETT significantly improved recovery from general anaesthesia compared to remifentanil in female patients after thyroidectomy.
Chinese Clinical Trial Registry (No. ChiCTR2000038653), registered on 27/09/2020.

BACKGROUND: During the perianesthesia period, emergency situations threatening the life and safety of patients can occur at any time. When dealing with some emergencies, occasional confusion is inevitable.
METHODS: This case report describes the rare situation wherein a surgeon inadvertently detached the inflatable tube of an endotracheal tube during a tonsillectomy, and positive pressure ventilation could not be provided. While reintubation may increase the risk of respiratory tract infection and aspiration, patients with a difficult airway might die due to apnea. The best treatment method is to optimize the damaged tracheal tube junction to avoid secondary intubation and ensure patient safety. An intravenous needle and cannula were used to repair the damaged gap in the current case. Following the repair, the anesthesia machine showed no indication of low tidal volume, and there was no deflation of the endotracheal tube cuff. Subsequently, the patient was transferred to the post-anesthesia recovery room, and the tracheal tube was removed with satisfactory results.
CONCLUSIONS: Using an intravenous needle to repair a break in the inflatable tube surrounding an endotracheal tube is safe and reliable.

BACKGROUND: Postoperative sore throat (POST) is a common complication following thyroid surgery with an endotracheal tube (ET). The I-gel® is a supraglottic airway device that has greater advantages in airway management compared with ET. This prospective trial aimed to explore the potential benefits of I-gel® compared with ET on POST.
METHODS: In this trial, 106 patients, classified using the American Society of Anesthesiologists (ASA) physical status classification system, belonging to classes I and II, aged 18-65 years old who were prearranged for elective radical thyroidectomy, were randomly divided into the ET and I-gel® groups. All patients underwent total intravenous anesthesia (propofol, sufentanil, and cisatracurium). The incidence and severity of POST and postoperative hoarseness (PH) at 1, 6, 24, and 48 h following the operation were assessed and compared between the two groups. Moreover, the hemodynamic data during anesthesia were recorded and compared. Opioid consumption (sufentanil, propofol, and remifentanil) and postoperative nausea and vomiting were recorded. The visual analog scale scores for pain at the incision site 1, 6, 24, and 48 h postoperatively and Ramsay Sedation Scale scores were also evaluated and recorded.
RESULTS: No significant difference was observed in the incidence of POST 1, 6, 24, and 48 h postoperatively (61.2% vs. 51.0%, P=0.309; 75.5% vs. 83.7%, P=0.316; 83.7% vs. 85.7%, P=0.779; and 12.2% vs. 22.4%, P=0.182, respectively) and the severity of sore throat (P=0.392) following surgery between the ET and I-gel® groups. The incidence of PH in the I-gel® group was significantly lower than that in the ET group 1, 6, 24, and 48 h postoperatively (all P<0.05). Compared with the ET group, a significantly less fluctuation in heart rate 1 min after intubation (P=0.045) and extubation (P=0.001) was observed in the I-gel® group.
CONCLUSIONS: Although the I-gel® cannot reduce the incidence and severity of POST in patients with normal BMIs following thyroid surgery, it can reduce the occurrence and severity of PH compared with ET. The I-gel® showed superior results in terms of insertion time and better hemodynamic condition during intubation.

OBJECTIVE: To evaluate the dynamic changes in tracheal cuff pressure before and after four clinical nursing procedures including sputum suction, oral care, atomisation inhalation, and turning over, and thus provide references for the adjustment time of cuff pressure in clinical practice.
BACKGROUND: Cuff pressure must be kept within the range of 25-30 cmH2 O to ensure effective ventilation and prevent aspiration, while maintaining tracheal blood flow perfusion.
METHODS: A prospective observational study.
METHODS: The cuff pressure of 56 intubated patients was adjusted to 28-30 cmH2 O. A cuff pressure monitor was used to continuously monitor cuff pressure changes before and after four clinical nursing procedures (sputum suction, oral care, atomisation inhalation, and turning over) and the cuff pressures at various time points were compared. The semi-quantitative cough strength score (SCSS) was used to evaluate cough strength during sputum suction and the effect of cough strength on cuff pressure during sputum suction. This study followed the STROBE checklist for cross-sectional studies.
RESULTS: The cuff pressures during the four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care, all temporarily increased (p < 0.001) and decreased to varying degrees 20 min later (p < 0.001). Among them, the cuff pressure rose the highest under a state of moderate or strong coughing during sputum suction (78.38 ± 12.13 cmH2 O) and dropped the most at 20 min after the procedure (21.71 ± 4.80 cmH2 O).
CONCLUSIONS: The four clinical nursing procedures of sputum suction, atomisation inhalation, turning over, and oral care can all cause different degrees of cuff pressure drop. The decision on whether the cuff pressure needs to be corrected depends on the specific situation.
CONCLUSIONS: During clinical practice, the cuff pressure can be individually corrected according to different clinical nursing procedures, which can increase the qualified rate of cuff pressure and reduce the workload of nurses.