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INTRODUCTION: Patients requiring emergent endotracheal intubation are at higher risk of post-intubation hypotension due to altered physiology in critical illness. Post-intubation hypotension increases mortality and hospital length of stay, however, the impact of vasopressors on its incidence and outcomes is not known. This scoping review identified studies reporting hemodynamic data in patients undergoing emergent intubation to provide a literature overview on post-intubation hypotension in cohorts that did and did not receive vasopressors. METHODS: A systematic search of CINAHL, Cochrane, EMBASE and PubMed-Medline was performed from database inception until September 28, 2023. Two independent reviewers completed the title and abstract screen, full text review and data extraction per PRISMA guidelines. Studies including patients < 18 years or intubations during cardiac arrest were excluded. Primary outcome was the presence of hypotension within 30 min of emergent intubation. Secondary outcomes included mortality at 1 h and in-hospital. RESULTS: The systematic search yielded 13,126 articles, with 61 selected for final inclusion. There were 24,547 patients with a mean age of 57.2 years and a slight male predominance (63.8%). Respiratory failure was the most common intubation indication. Across 18 studies reporting on vasopressor use prior to intubation, 1171/7085 patients received vasopressors pre-intubation. Post-intubation hypotension occurred in 22.2% of patients across all studies, and in 34.3% of patients in studies where vasopressor administration pre-intubation was specifically reported. One-hour mortality of patients across all studies and within the vasopressor use studies was 1.2% and 1.6%, respectively. In-hospital mortality across studies was 21.5%, and 13.1% in studies which reported on vasopressor use pre-intubation. CONCLUSION: Patients requiring emergent intubation have a high rate of post-intubation hypotension and in-hospital mortality. While there is an intuitive rationale for the use of vasopressors during emergent intubation, current evidence is limited to support a definitive change in clinical practice at this time.
RéSUMé: INTRODUCTION: Les patients nécessitant une intubation endotrachéale en émergence présentent un risque plus élevé d'hypotension post-intubation en raison de la physiologie altérée de la maladie grave. L'hypotension post-intubation augmente la mortalité et la durée du séjour à l'hôpital, mais on ne connaît pas l'impact des vasopresseurs sur son incidence et ses résultats. Cette revue de la portée a identifié des études qui ont rapporté des données hémodynamiques chez des patients soumis à une intubation d'urgence afin de fournir un aperçu de la littérature sur l'hypotension post-intubation dans les cohortes ayant reçu et n'ayant pas reçu des vasopresseurs. MéTHODES: Une recherche systématique de CINAHL, Cochrane, EMBASE et PubMed-Medline a été effectuée depuis la création de la base de données jusqu'au 28 septembre 2023. Deux examinateurs indépendants ont complété le titre et l'écran des résumés, la révision du texte intégral et l'extraction des données selon les lignes directrices de PRISMA. Les études incluant des patients de moins de 18 ans ou des intubations pendant un arrêt cardiaque ont été exclues. Le principal critère de jugement était la présence d'hypotension dans les 30 minutes suivant l'intubation. Les critères de jugement secondaires comprenaient la mortalité à l'heure et en milieu hospitalier. RéSULTATS: La recherche systématique a donné lieu à 13126 articles, dont 61 ont été sélectionnés pour inclusion finale. On a recensé 24547 patients avec un âge moyen de 57,2 ans et une légère prédominance masculine (63,8 %). L'insuffisance respiratoire était la plus fréquente indication d'intubation. Dans 18 études sur l'utilisation de vasopresseurs avant l'intubation, 1171/7085 patients ont reçu des vasopresseurs avant l'intubation. Une hypotension post-intubation est survenue chez 22,2 % des patients dans toutes les études et chez 34,3 % des patients dans les études où l'administration de vasopresseurs avant l'intubation a été spécifiquement signalée. La mortalité d'une heure des patients dans toutes les études et dans le cadre des études sur l'utilisation de vasopresseurs était respectivement de 1,2 % et 1,6 %. La mortalité en milieu hospitalier dans l'ensemble des études était de 21,5 %, et de 13,1 % dans les études qui ont fait état d'un recours à un vasopresseur avant intubation. CONCLUSION: Les patients nécessitant une intubation d'urgence ont un taux élevé d'hypotension post-intubation et de mortalité en milieu hospitalier. Bien qu'il existe une justification intuitive pour l'utilisation de vasopresseurs pendant l'intubation en phase émergente, les preuves actuelles sont limitées pour soutenir un changement définitif dans la pratique clinique à ce moment-ci.
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Cateterismo , Epistaxis , Humanos , Manejo de la Vía Aérea , Catéteres , Epistaxis/terapia , Intubación Intratraqueal , SucciónRESUMEN
PURPOSE: Although maxillomandibular advancement (MMA) surgery is highly efficacious for the management of obstructive sleep apnea (OSA), little information exists regarding the subjective effect of this treatment modality. The present study was undertaken to investigate the effect of MMA on patient-perceived quality of life (QOL) in OSA. PATIENTS AND METHODS: A retrospective cohort study of patients treated with MMA for OSA from May 2010 to April 2015 was performed. The primary outcome measure was a change in the QOL detected using the Ottawa Sleep Apnea Questionnaire (OSA-Q), which assesses the MMA-related changes in QOL with a 5-point Likert scale. The secondary outcome measure was a change in the apnea hypopnea index (AHI). RESULTS: Twenty-two patients participated in the present study. The mean maxillary and mandibular advancement were 8.36 and 11.08 mm, respectively. The AHI decreased from 42.4 to 6.9 events per hour postoperatively (P < .001). The QOL improved significantly after MMA (OSA-Q score 3.98 ± 0.35; P < 001). The sleep quality (4.35 ± 0.63), daytime function (4.13 ± 0.46), physical health (4.19 ± 0.45), mental and emotional health (4.02 ± 0.55), and sexual health (3.78 ± 0.62) categories all improved postoperatively (P < .001). The MMA-related side effects did not adversely affect the QOL. CONCLUSIONS: MMA for OSA significantly improves patient's subjective overall QOL, with few MMA-related side effects.
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Avance Mandibular , Calidad de Vida , Apnea Obstructiva del Sueño/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteotomía Le Fort , Osteotomía Sagital de Rama Mandibular , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
PURPOSE: Maxillomandibular advancement (MMA) surgery is a well-established treatment of obstructive sleep apnea (OSA). Although many studies have assessed the efficacy of MMA in treating OSA, very few studies have quantified the magnitude of its changes to airway morphology. Therefore, the present study investigated the linear and volumetric morphologic changes that occur in the pharyngeal airway after treatment of OSA using MMA. MATERIALS AND METHODS: A retrospective cohort study of patients with OSA treated from May 2010 to February 2014 was performed. Each patient underwent preoperative clinical and fiberoptic nasopharyngoscopic examinations. Pre- and postoperative polysomnograms, lateral cephalograms, and cone-beam computed tomography scans were acquired. The radiographic images were used to determine the linear and volumetric airway measurements. The time and magnitude of skeletal movement were used as the independent variables. The dependent variables included assessment of success or cure, apnea hypopnea index (AHI), cephalometric changes, Epworth score, rapid eye movement sleep, body mass index, and various airway morphologic parameters. RESULTS: A total of 15 patients (13 men and 2 women) participated in the present study. The surgical success and cure rate was 73.33% and 40.00%, respectively. Statistically significant improvements were found in the airway total volume, minimal cross-sectional area, anteroposterior and lateral dimensions, airway index, airway length, posterior airway space morphology, AHI, and Epworth sleepiness score. CONCLUSIONS: MMA is a highly successful surgical treatment of OSA that improves airway morphology and sleep quality. MMA results in a shorter and broader airway and associated improvements in the AHI.
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Avance Mandibular/métodos , Osteotomía Le Fort/métodos , Osteotomía Sagital de Rama Mandibular/métodos , Faringe/anatomía & histología , Apnea Obstructiva del Sueño/cirugía , Adulto , Anatomía Transversal/métodos , Índice de Masa Corporal , Cefalometría/métodos , Estudios de Cohortes , Tomografía Computarizada de Haz Cónico/métodos , Endoscopía/métodos , Femenino , Estudios de Seguimiento , Humanos , Imagenología Tridimensional/métodos , Masculino , Persona de Mediana Edad , Nasofaringe/anatomía & histología , Tamaño de los Órganos , Orofaringe/anatomía & histología , Polisomnografía/métodos , Estudios Retrospectivos , Fases del Sueño/fisiología , Sueño REM/fisiología , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: This study investigated the differences in airway morphology between control patients and those with obstructive sleep apnea (OSA) treated with maxillomandibular advancement (MMA) to gain better insight into the beneficial effects of MMA on airway morphology and OSA severity. STUDY DESIGN: This retrospective case-control study included preoperative radiographic data gathered for all patients; postoperative radiographic data were gathered for the OSA group. Statistical analysis, including the Student t test, and simple linear regression was performed to identify differences in cephalometric and airway variables among the three groups and to associate airway morphology to disease severity. RESULTS: Twenty-four patients (12 with OSA; 12 controls) treated at the same clinic were included in this study. Statistically significant differences versus control values were found for preoperative total airway volume, postoperative airway length, and both pre- and postoperative airway minimum cross-sectional areas. In general, the untreated OSA airway was anatomically compromised in comparison with controls, whereas the treated airway showed significant morphologic improvements, comparable with the control group values. CONCLUSIONS: MMA produces statistically significant airway improvements for OSA patients, producing airway morphology comparable with that of the controls. However, some degree of residual OSA may still exist. Therefore, factors other than static airway morphology contribute to OSA pathogenesis.