Among the symptoms presented by patients with SARS-Cov-2 infection, we can find various otorhinolaryngological alterations. Dysphonia appears in up to 79% of infected patients during the acute phase. Dysphonia can also occur as a sequelae, often underestimated, possibly due to its appearance along with other symptoms, also in patients after prolonged intubation or tracheostomy. We present a systematic review of the literature with a bibliographic search in PubMed, Cochrane and Google Scholar, with MESH terms including studies in English and Spanish. The results of the studies found and the vocal manifestations in patients during COVID-19 disease and the consequences produced are analysed. Dysphonia is an acute manifestation of COVID-19 with alterations in aerodynamic and acoustic analysis and in fibrolaryngoscopy. Post-COVID dysphonia can be a persistent symptom that is often underestimated, requiring multidisciplinary management and speech therapy intervention. Laryngeal sequelae are common in post-intubation or post-tracheostomy patients and are related to intubation time, tube number, pronation and respiratory sequelae.

Unplanned invasive mechanical ventilation (IMV) is associated with high mortality in lung cancer patients. We aimed to identify factors associated with weaning from IMV, intensive care unit (ICU) survival and 1-year survival in lung cancer patients requiring unplanned IMV.
Retrospective observational study (2007-2017).
University-affiliated ICU.
Lung cancer patients requiring unplanned IMV.
None.
Weaning from IMV, ICU and 1-year survival.
Of the 136 patients included in the analysis (age 64 (9) years, male 110 (81%), metastatic disease 97 (62%)), 52 (38%) were weaned from IMV, 51 (38%) were discharged from ICU and 22 (16%) were alive at 1year. The main indication for intubation was acute respiratory failure. In multivariate analysis, PaO2/FiO2 >175mmHg at ICU admission and intubation before ICU admission were associated with successful weaning from IMV while intubation for cardiac arrest was associated with weaning failure. Same factors were associated with ICU survival. Absence of metastasis at ICU admission and lung resection surgery were independently associated with 1-year survival.
A significant proportion of patients with lung cancer treated with unplanned IMV could be weaned from IMV and survived to ICU discharge, especially in the absence of severe hypoxemia at ICU admission. The low one-year survival was mostly driven by metastatic status.

We describe a series of 11 cases in which we used the new flexible tip (FlexTip) bougie as a rescue device following first-attempt failure at intubation with the C-MAC D-Blade video laryngoscope in our UCI. We collected data from all intubations performed using the C-MAC D-Blade video laryngoscope over a 16-month period. Ninety six patients were included in the study: 79 (86.8%) were intubated at the first attempt; 11 (12.1%) required 2 attempts; and 1 patient required 3 attempts. The Frova Intubating Introducer was used in 1 of the 12 patients requiring more than 1 intubation attempt, and the FlexTip was used in the remaining 11. This study shows that the new FlexTip bougie is a good rescue device when the first attempt at video laryngoscope intubation fails.

Nasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation. The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients.
We conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit.
A total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay.
In critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients.
An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.
1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.
Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

UNASSIGNED: The goal of the study was to compare the incidence of complications, technical difficulty of intubation and physiologic pre-intubation status between the first intubation and reintubation performed on the same patient in an ICU.
METHODS: The study was approved by the ethics committee of Galicia (Santiago-Lugo, code No. 2015-012). Due to the observational, noninterventional, and noninvasive design of this study, the need for written consent was waived by the ethics committee of Galicia. Patients requiring tracheal intubation and reintubation in the ICU were included in this prospective observational study. Main endpoint was to compare the incidence of complications, physiologic pre-intubation status, and the rate of technical difficulty of intubation between the first intubation and reintubation performed on the same patient in an ICU.
CONCLUSIONS: 504 patients were intubated in our ICU during the study period, and 82 (16%) required reintubation. There was no difference between the first intubation and reintubation regarding number of total complication (35% vs 33%; P = ,86), hypotension (24% vs 24%; P = 1), hypoxia (26% vs 26%; P = 1), esophageal intubation (1% vs 1%; P = 1), and bronchoaspiration (2% vs 1%; P = ,86). Physiologic pre-intubation status and technical difficulty of intubation did not differ between the first intubation and reintubation.
CONCLUSIONS: In our ICU patients requiring tracheal reintubation, incidence of complications, physiologic pre-intubation status, and technical difficulty of intubation did not differ between the first intubation and reintubation.

Various modifications of the Macintosh blade and direct laryngoscopy have been incorporated into practice to improve the intubation success rate and avoid complications while ensuring patient safety. This study evaluates the usefulness of two different direct laryngoscopy methods used by operators with various level of experience in the Intensive Care Unit.
In a single centre prospective study, C-MAC and Macintosh laryngoscopes were compared in terms of laryngoscopy and intubation outcomes such as glottic visualization, number of intubation attempts, intubation success and satisfaction score.
During the one-year study period, 263 patients were evaluated and data of 218 patients were analyzed. The rate of successful first attempt intubation was higher in the video laryngoscope group (VL) (84% vs 57%; P<0.001). A significantly greater number of patients in the Macintosh laryngoscopy group had difficult visualization of the glottis in terms of the modified Cormack and Lehane classification and Percentage of Glottic Opening scale.
The use of video laryngoscope for intubation in ICU settings results in better visualization of the glottis and a higher incidence of successful intubation attempts.

The aim of this study was to compare the intubating laryngeal mask (iLM) airway and the new intubating laryngeal tube (iLTS-D) in use by residents with minimal previous intubation experience during simulated conditions of reduced cervical spine mobility.
Thirty first-year residents in anesthesiology participated in the study (18 women). All participants had minimal intubation experience (fewer than 10 previously performed intubations) and were novices in the specialty. Both devices were used by each participant after random assignment of order. We recorded the time required to insert the device and start to ventilate through it (T1) and the time from insertion and intubation to successful ventilation (T2). Efficacy of intubation and each resident\'s assessment of ease of use were also assessed.Observational study using biomechanical inertial sensors to detect movement in the spinal column during removal of helmets.
The residents\' mean (SD) T1 values were similar for the 2 devices (iLMA, 15.3 [5.5] seconds; iLTS-D, 15.4 [5.5] seconds; P=.938). T2 was shorter with the iLTS-D (25.4 [8.6] seconds vs 31.9 [8.8] seconds with the iLMA; P=.005). There were no failed intubation attempts with the iLTS-D.
The new iLTS-D may be a good alternative to the iLMA because a patient can be intubated and successfully ventilated in less time. The rate of successful intubation is also better with the iLTS-D.
El objetivo de este estudio fue evaluar el uso de la mascarilla de intubación laríngea y el reciente tubo de intubación laríngea en manos de residentes con poca experiencia previa en intubación, simulando condiciones de movilidad reducida en la columna cervical.
Treinta residentes de anestesia de primer año participaron en el estudio (18 mujeres). Todos ellos tenían una experiencia mínima en intubación (< 10 intubaciones realizadas previamente). Los dos dispositivos fueron utilizados por cada participante con asignación al azar del orden. Se registró tanto el tiempo requerido para insertar el dispositivo supraglótico y ventilar a través de él (T1), como el tiempo de colocación del tubo hasta la intubación y ventilación con éxito (T2). También se evaluó la eficacia de la intubación y la facilidad de su uso.
El tiempo medio requerido para insertar el dispositivo de vía aérea supraglótica y ventilar a través de él fue similar para ambos dispositivos estudiados (15,3 s [DE 5,5] vs 15,4 s [DE 5.5]; p = 0,938). El tubo de intubación laríngea se asoció con un menor tiempo desde su inserción hasta la intubación y ventilación exitosa (25,4 s [DE 8,6] vs 31,9 s [SD 8,8], p = 0,005). No hubo intubaciones fallidas con el uso del tubo de intubación laríngea.
El nuevo tubo laríngeo puede ser una buena alternativa a la mascarilla laríngea, ya que acorta el tiempo requerido para intubar y ventilar con éxito el paciente. También mejora la tasa de intubaciones exitosas.

To know organization, management and training in airway (AW) in Spanish Intensive Care Units (ICUs), with special interest in difficult airway (DAW).
Descriptive cross-sectional study and χ2 subanalysis, conducted through a national survey from november 1th to december 15th, 2016. With the SEMICYUC\'s support, an online questionnaire of 27 items was sent to 179 ICUs.
ICUs of public, private centers, and consortia.
In total, 101 units responded (56.4%), corresponding to 1,827 beds and almost 95,000 incomes/year. The 85.1% are public hospitals, and 83.2% had residents. Of the responders, 22.8% don\'t use routinely AW assessment scales, being the most frequently used the Cormack-Mallampati association (35.6%). There\'s not intubation (IOT) protocol in 77.2%, nor DAW protocol in 75.2%. An 82.2% have a DAW cart. The 48.5% have training in IOT, and in VAD 53.5%. Having a DAW expert is significantly associated with greater training in IOT (60% vs. 39.3%; P=.03), DAW (64.4% vs. 44.6%; P=.04), and more AW protocols (73.4% vs. 37.5%; P=.000). Having an specific guideline for DAW management in UCI is considered necessary in 99%.
There is room for improvement in AW management. It\'s necessary to identify an expert in DAW in each Unit, and the development of an specific guideline for DAW management in critical care.

OBJECTIVE: Little information about the performance of videolaryngoscopes outdoors is available. We aimed to test the hypothesis that a Macintosh direct laryngoscope would perform less well than videolaryngoscopes under difficult environmental conditions (high-altitude glacier, sun-reflecting snow).
METHODS: After local research ethics committee approval, this randomized controlled trial enrolled 20 physicians who intubated manikins with limited cervical extension mouth opening under 5 conditions: 1) in hospitals (indoors), 2) indoors at a high altitude, 3) outdoors on a glacier in sunlight without sunglasses, 4) outdoors on a glacier with sunglasses, and 5) outdoors on a glacier with the physician and manikin covered with a blanket. The following devices were compared to the Macintosh laryngoscope, McGrath, Airtraq-SP, GlideScope, KingVision, C-MAC-D-Blade, AP Advance Difficult Airway Blade and Bonfils. The main outcome was first-attempt intubation success; secondary outcomes were intubation time, visibility on the screen, and view of the glottis.
RESULTS: The best intubation success rates were observed indoors asnd on the glacier under a blanket. The Macintosh performed better than the videolaryngoscopes under bright sunlight. We observed significant differences in the performance of devices with built-in screens under varying conditions. Wearing sunglasses improved performance with some but not all devices. Intubation times differed significantly between devices, regardless of the environmental condition (P<0.01). Screen visibility differed significantly between conditions and devices.
CONCLUSIONS: Successful intubation with videolaryngoscopes is less likely under bright sunlight conditions. The Macintosh laryngoscope performs better than videolaryngoscopes. Covering the heads of both the physician and the patient with a dark blanket sufficiently overcomes the detrimental effects of sunlight during intubation.
UNASSIGNED: Existe muy poca información sobre la realización de videolaringoscopias al aire libre. Investigamos el rendimiento de una variedad de dispositivos de intubación en comparación con la laringoscopia directa y bajo condiciones ambientales difíciles (glaciar de gran altitud, nieve con efecto reflectante).
UNASSIGNED: Tras la aprobación por el comité local de ética, este estudio aleatorizó a 20 médicos que intubaron maniquíes con limitación en la apertura bucal y en la extensión cervical, bajo cinco circunstancias: 1) en el interior de hospitales, 2) en interiores a la altitud del glaciar, 3) en un glaciar a plena luz solar, 4) en un glaciar con gafas de sol, y 5) en un glaciar, con el médico y el maniquí cubiertos por una manta. Los dispositivos evaluados fueron: laringoscopio Macintosh y los videolaringoscopios McGrath, Airtraq-SP, GlideScope, KingVision, C-MAC-D-blade, APAdvancedifficult- airway-blade y Bonfils. El resultado principal a analizar fue el éxito de intubación al primer intento; y los resultados secundarios el tiempo de intubación, la visibilidad de de la glotis en la pantalla.
UNASSIGNED: Se observó un mayor índice de éxito de intubación en el interior, así como al aire libre en el glaciar cuando se cubría con una manta. El rendimiento a plena luz del día del Macintosh fue superior a la de los videolaringoscopios. En los dispositivos con pantallas incorporadas se percibieron diferencias significativas en condiciones ambientales cambiantes. El uso de gafas de sol mejoró el rendimiento de algunos dispositivos, pero no de todos. El tiempo de intubación difirió sustancialmente entre los dispositivos, independientemente de las condiciones ambientales (p < 0,01). La calidad de visibilidad de la pantalla varió significativamente según las condiciones y los dispositivos.
UNASSIGNED: El laringoscopio Macintosh se comporta mejor que los videolaringoscopios. Las posibilidades de éxito en la intubación con videolaringoscopios es menor en condiciones de luz solar brillante. Cubrir la cabeza con una manta oscura bloquea suficientemente los efectos perjudiciales de la luz solar durante la intubación a pleno sol.