The impact of tube replacement timing during LCIG therapy on PEG-J associated adverse events: a retrospective multicenter observational study

Background Levodopa–carbidopa intestinal gel (LCIG) treatment, a unique drug delivery system for patients with advanced Parkinson’s disease (PD), is covered by health insurance in Japan since September 2016. Various LCIG procedure/device-associated adverse events (AEs) have been reported; however, reports on their treatment have been limited. This is the first multicenter study to clarify the frequency and timing of device-related AEs. Methods Between September 2016 and December 2018, 104 patients introduced to the LCIG treatment for advanced PD in 11 hospitals were included. The patients’ characteristics, AEs incidence, AEs time, and tube exchange time were investigated. Results The median follow-up period was 21.5 months. Minor AE cases were 29.4%, whereas major AE cases were 43.1%. Majority of major AEs (n = 55, 94.8%) were managed with endoscopic treatment, such as tube exchange. Few severe AEs required surgical treatment (n =3, 5.2%). The mean (range) exposure to percutaneous endoscopic gastrojejunostomy (PEG-J) was 14.7 (0–33) months. One year after the LCIG treatment introduction, 55 patients (54.0%) retained the original PEG-J tube. The mean PEG-J tube exchange time was 10.8 ± 7.0 months in all patients, 11.6 ± 4.7 and 10.5 ± 7.7 months in patients with scheduled exchange and who underwent exchange due to AEs, respectively. Conclusions Some device-related AEs occurred during the LCIG treatment; however, only few were serious, most of which could be treated with simple procedures or tube replacement with endoscopy. Therefore, the LCIG treatment is feasible and safe and is a unique treatment option for PD, requiring endoscopists’ understanding and cooperation.

Conversion of an oral to nasal intubation in difficult nasal anatomy patients: two case reports

Background Nasal intubation is indispensable for some cases that require intraoral surgical access, and the fiberoptic bronchoscope is the best tool for difficult airways. However, fiberoptic bronchoscopy is not always possible in cases with altered pharyngeal anatomy. Case presentation In this report, we introduce a novel technique for retrograde endotracheal oral-to-nasal conversion with an ordinary endotracheal tube exchange catheter. A 49-year-old male with a fractured mandible angle and symphysis was scheduled to undergo mandible reconstruction. Secondly, a 45-year-old male who had a bone defect in the mandible angle and ramus was scheduled for mandible and oral cavity reconstruction. We chose to intubate orally first and successfully converted the endotracheal tube from oral to nasal retrogressively using a tube exchange catheter. Conclusions Our simple and safe technique, which use a tube exchange catheter retrogressively, provides an alternative method for a difficult airway in which the fiberscope is not helpful.

Clinical Use of Preformed Microcuff® Pediatric Endotracheal Tubes in Japan

Preformed cuffed oral endotracheal tubes are widely used to intubate children undergoing oral surgery. To evaluate the efficacy and safety of oral Ring-Adair-Elwyn (RAE) Microcuff® pediatric endotracheal tubes, we retrospectively investigated the endotracheal tube exchange rate and associated complications in Japanese children younger than 2 years of age undergoing cheiloplasty or palatoplasty. The exchange rate was 3.5%, and although unplanned extubations occurred in 2 patients, no severe complications were observed. Our results suggest that oral RAE Microcuff® tubes are effective and safe for intubating Japanese children younger than 2 years of age, with a low tube exchange rate and minor complications.

The impact of tube replacement timing during LCIG therapy on PEG-J associated adverse events: a retrospective multicenter observational study

Background Levodopa–carbidopa intestinal gel (LCIG) treatment, a new drug delivery system for patients with advanced Parkinson’s disease (PD), is covered by the health insurance in Japan since September 2016. Various LCIG procedure/device-associated adverse events (AEs) have been reported; however, reports on their treatment have been limited. This is the first multicenter study to clarify the frequency and timing of device-related AEs. Methods Between September 2016 and December 2018, 104 patients introduced to the LCIG treatment for advanced PD in 11 hospitals were included. The patients’ characteristics, AEs incidence, AEs time, and tube exchange time were investigated. Results The median follow-up period was 21.5 months. Minor AE cases were 29.4%, whereas major AE cases were 43.1%. Majority of major AEs (n = 55, 96.5%) were managed with endoscopic treatment, such as tube exchange. Few severe AEs required surgical treatment (n = 2, 3.5%). The mean (range) exposure to percutaneous endoscopic gastrojejunostomy (PEG-J) was 14.7 (0–33) months. One year after the LCIG treatment introduction, 55 patients (54.0%) retained the original PEG-J tube. The mean PEG-J tube exchange time was 10.8 ± 7.0 months in all patients, 11.6 ± 4.7 and 10.5 ± 7.7 months in patients with scheduled exchange and who underwent exchange due to AEs, respectively. Conclusions Some device-related AEs occurred during the LCIG treatment; however, only few were serious, most of which could be treated with simple procedures or tube replacement with endoscopy. Therefore, the LCIG treatment is feasible and safe and is a unique treatment option for PD, requiring endoscopists’ understanding and cooperation.

Estimation of Appropriate Endotracheal Tube Size in Pediatric Patients: Use of Epiphyseal Diameter of the Distal Radius and Subglottic Diameter

INTRODUCTION: The aim of this study is to test the usefulness of epiphysis of distal radius measurement as a surrogate parameter for endotracheal tube (ETT) size prediction in children. METHODS: Seventy-three children were intubated with cuffed ETT selected according to age-based formula. Transvers diameter of epiphysis of distal radius and subglottic diameter of trachea were measured by ultrasound (US). Correlation between the outer diameter of best-fit endotracheal tube and transvers diameter of both radius epiphysis and subglottic diameter were calculated. The need for tube exchange, time for ultrasound (US) measurements and the ease level of measurements were compared. RESULTS: First attempt success at intubation was 83.6%. The correlation of the epiphysis diameter of the distal radius and best-fit ETT was significant (p<0.001, r= 0.619, r2=0.383, 95% CI=0.419-0.838). Similarly the correlation of subglottic tracheal diameter and best-fit ETT was significant (p<0.001, r=0.744, r2=0.553, 95% CI=0.678-825). Estimated ETT sizes according to radial epiphysis diameter and subglottic diameter were optimal in 82.2% and 94.5% respectively. Time for the US measurements of radial epiphysis and subglottic area were 38.3±9.6 and 24.9±4.6 seconds respectively (p<0.001). The level of ease of US measurements were rated for radial epiphysis as 6 (5-9) and for subglottic area as 8 (7-9) (p<0.001). DISCUSSION AND CONCLUSION: US measured transverse diameter of distal radius epiphysis resulted in similar success rate to age-based formula in our child population. Subglottic diameter measured by US estimates ETT size more accurately; it is also less time consuming and easier.

A Case of Successful Tracheal Tube Exchange With McGrath MAC for Tube Damage During Oral Surgery

A patient undergoing a bilateral sagittal split and LeFort 1 maxillary osteotomy performed under general anesthesia required emergent intraoperative exchange of a potentially damaged nasotracheal tube. This exchange was smoothly performed under constant indirect visualization using the McGrath MAC video laryngoscopy system. After the exchange, ventilation of the patient dramatically improved. The removed endotracheal tube was torn 19 cm from the distal tip. The McGrath MAC was useful for visualizing the glottis and confirming the entire course of the tube exchange despite the patient's having a difficult airway (Cormack-Lehane grade 3).

67 Airway Skills in Paediatrics: Infants are Not Just Little Children

Background Airway skills such as intubation and bag-valve-mask ventilation (BVM) have historically been considered necessary skills for all general paediatricians. Recently, evidence has driven practice toward goals of reduced invasive respiratory intervention and support. While patient outcomes have improved, implications include reduced airway skill training opportunities for paediatric residents, and possibly challenges in maintaining proficiency for practicing paediatricians. From postgraduate and continuing professional educational perspectives, the specific airway skill needs for Canadian paediatricians in contemporary practice are unclear. Objectives Identify those airway skills that are critical to general paediatric practice in Canada, and whether the skill needs differ by patient age. Design/Methods Data on general paediatric procedural practice was collected in 2018 via a one-time survey through the Canadian Paediatric Surveillance Program. A database was created from the 938 collected responses. The survey asked paediatricians to indicate the frequency of performance, opinion of importance, and challenges in maintaining proficiency of various airway procedures. Data was analyzed descriptively, and questions discriminating infant (age &lt; 2y) vs. child (age ≥ 2y) were compared by chi-square or Fisher’s exact test, as appropriate. Results In total, 481 (51.3%) respondents worked ≥ 50% in general paediatrics and formed the main analysis group. Responses represented broad ranges of career duration, national geography, and practice settings. BVM of infants was the most commonly performed procedure, with 196 (40.8%) performing this monthly. Infant intubation was performed monthly by 58 (12.1%). A total of 355 (73.8%) and 402 (83.6%) reported never performing laryngeal-mask airway insertion and tracheostomy tube exchange respectively. Both BVM and intubation were performed significantly more frequently in infants than in children (p &lt; 0.001). While many respondents considered BVM and intubation of children as essential skills, significantly more rated performing these skills on infants as essential to their practice (p &lt; 0.001). Of those paediatricians that performed procedures as part of their practice, 68/309 (22.0%) and 192/304 (63.2%) reported difficulty in maintaining proficiency in the skills of infant BVM and intubation respectively. Conclusion Although variably utilized, airway skills in infants and children remain a core aspect of practice for many general paediatricians. Specifically, skills related to infants were performed more frequently and were more often rated as essential. Most respondents felt it was challenging to maintain proficiency in several airway skills. Accordingly, airway skills, especially those involving infants, should be emphasized in paediatric residency programs and continuing professional development activities.