Share
array:23 [ "pii" => "S2341192922000397" "issn" => "23411929" "doi" => "10.1016/j.redare.2022.02.002" "estado" => "S300" "fechaPublicacion" => "2022-02-01" "aid" => "1302" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2022;69:65-70" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "S0034935621001092" "issn" => "00349356" "doi" => "10.1016/j.redar.2021.01.006" "estado" => "S300" "fechaPublicacion" => "2022-02-01" "aid" => "1302" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2022;69:65-70" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Entorno prehospitalario y manejo en UCI de epiglotitis en un adulto" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "65" "paginaFinal" => "70" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Approaching the airway in prehospital emergency is a common and potentially life-saving practice" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 805 "Tamanyo" => 44936 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Día 0. Epiglotitis aguda - Imagen prehospitalaria de Airtraq®.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">1: Epiglotis inflamada; 2: Área glótica inflamada.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.R. Fernandes-Teles, J.M. Pina-Amado, J.M. Pereira, J.A. Paiva, S. Rocha-Silva" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A.R." "apellidos" => "Fernandes-Teles" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Pina-Amado" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Pereira" ] 3 => array:2 [ "nombre" => "J.A." "apellidos" => "Paiva" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Rocha-Silva" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192922000397" "doi" => "10.1016/j.redare.2022.02.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922000397?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621001092?idApp=UINPBA00004N" "url" => "/00349356/0000006900000002/v1_202201260835/S0034935621001092/v1_202201260835/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192922000336" "issn" => "23411929" "doi" => "10.1016/j.redare.2022.02.001" "estado" => "S300" "fechaPublicacion" => "2022-02-01" "aid" => "1319" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2022;69:71-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "71" "paginaFinal" => "78" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neurólisis del plexo celiaco intraoperatoria directa frente a percutánea guiada por tomografía computarizada en el cáncer de páncreas no operable: estudio aleatorizado, controlado y de no inferioridad" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2382 "Ancho" => 2499 "Tamanyo" => 364072 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CONSORT diagram.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Abdelbaser, T. Shams, A.A. El-giedy, M. Elsedieq, M.A. Ghanem" "autores" => array:5 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Abdelbaser" ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Shams" ] 2 => array:2 [ "nombre" => "A.A." "apellidos" => "El-giedy" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Elsedieq" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Ghanem" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621001419" "doi" => "10.1016/j.redar.2020.12.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621001419?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922000336?idApp=UINPBA00004N" "url" => "/23411929/0000006900000002/v1_202203120614/S2341192922000336/v1_202203120614/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Approaching the airway in prehospital emergency is a common and potentially life-saving practice" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "65" "paginaFinal" => "70" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A.R. Fernandes-Teles, J.M. Pina-Amado, J.M. Pereira, J.A. Paiva, S. Rocha-Silva" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A.R." "apellidos" => "Fernandes-Teles" "email" => array:1 [ 0 => "anarita_teles@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Pina-Amado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.M." "apellidos" => "Pereira" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.A." "apellidos" => "Paiva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Rocha-Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anaesthesiology, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Faculty of Medicine, University of Porto, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Entorno prehospitalario y manejo en UCI de epiglotitis en un adulto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 805 "Ancho" => 805 "Tamanyo" => 55008 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Day 13 of orotracheal intubation - Airtraq® image prior to extubation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Emergency prehospital airway management, a common practice that potentially saves lives, is required in 1 out of every 5 emergency patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. It is a challenge, even for experienced professionals.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Tracheal intubation (TI) is currently the gold standard approach to airway management. Prehospital TI must be performed safely and to the same standards demanded in the hospital setting, despite the additional difficulties encountered in the former<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–6</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prehospital airway management is a complex procedure in which there is little time to optimize patients or position them properly. This is further aggravated by poor oxygenation, poor staff training, and lack of material, and may explain why the incidence of difficult intubation in the prehospital setting ranges from 6% to 17.7%, a rate far higher than that encountered in hospital operating rooms<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are few guidelines that specifically address prehospital TI. Management of the supraglottic region (which is defined as a difficult airway) in a hypoxemic patient is particularly complex.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Emergency intubation is one of the most high-risk procedures in critical care. Failed intubation, or multiple or prolonged intubation attempts, can occur in 22%–54% of all emergency intubations performed in critical patients, and are associated with poor outcomes and serious complications, such as hypoxaemia, airway trauma, aspiration of gastric contents, haemodynamic instability, cerebral hypoxia, cardiopulmonary arrest, and death<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,8</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Successful TI is a common measure of the quality of airway management in prehospital emergency medicine (PHEM) teams<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. Acute epiglottitis is a life-threatening upper respiratory tract disorder that is classified as a medical emergency due to its sudden and potentially lethal evolution. As it involves oedema of the arytenoids, aryepiglottic folds, and epiglottis, the term supraglottitis should be used instead of acute epiglottitis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Among children, the incidence of epiglottitis has been reduced due to vaccination against <span class="elsevierStyleItalic">Haemophilus influenzae type B</span> and group A <span class="elsevierStyleItalic">Streptococcus</span><a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a>. Epiglottitis is rare in adults<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a>. Vigilance and familiarity with the clinical presentation of this disorder are essential for prompt identification and treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Emergency personnel must be able to distinguish epiglottitis from other possible diagnoses, and successfully intubate the patient in a complex setting that requires advanced technical competence and training.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We describe the case of an adult patient who presented in the prehospital setting with stridor caused by acute epiglottitis. We hope to draw attention to this unusual injury and its prehospital management from admission to discharge, describing severity, current treatment options, and outcomes.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 36-year-old man with a history of high blood pressure (controlled with Olsar 20 [olmesartan + hydrochlorothiazide]) and smoking (9 pack-years) presented with sudden onset myalgia, sore throat and fever. He reported increased difficulty in talking and breathing over the course of the day. The PHEM team was activated.</p><p id="par0055" class="elsevierStylePara elsevierViewall">On arrival, the PHEM team (doctor and nurse) performed a physical examination that revealed tachypnoea (27 breaths/min), intercostal and supraclavicular retraction, dyspnoea, and peripheral oxygen saturation of 76% on room air. A facemask was placed to deliver high-flow oxygen at a rate of 15 L/min. Blood gases showed respiratory alkalosis (pH 7.489, PaO2 121 mmHg, and pCO2 30.6 mmHg).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient presented audible inspiratory stridor and severe dyspnoea that worsened when lying supine. Tympanic membrane temperature was 38.7 °C, heart rate was 102 beats/min, and blood pressure was 178/94 mmHg. Inspection of the oral cavity showed no abnormalities, no pathologically enlarged nodes in the neck, and no rash. Pulmonary auscultation was normal.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient’s tachypnoea, dyspnoea, and stridor were treated with opioids and inhaled and intravenous corticosteroids. Due to an increase in respiratory effort followed by a reduction in stridor, the team decided to perform advanced prehospital airway management consisting of intubation with a video laryngoscope (Airtraq® Wi-Fi Camera, blade size 3).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patient’s head was raised for 3 min and he was pre-oxygenated using a bag valve face mask (15 L flow rate). After induction with propofol (2 mg/kg) and fentanyl (2 ug/kg), the he presented cardiac arrest due to pulseless electrical activity. Advanced life support using an Ambu™ self-inflating bag was started immediately; however, lung expansion was poor, even though the tracheal tube was correctly sized.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Video laryngoscopy performed during chest compressions revealed severe epiglottitis, with a film of mucous at the level of the cricoid cartilage and imminent obstruction of the upper airway (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The team then performed advanced intubation by inserting a latex-free, #8 polyvinyl chloride endotracheal tube over a frova introducer. The high-volume-low-pressure cuff was inflated, and capnography recorded.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Spontaneous circulation was restored after 2 min of advanced life support.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The patient was transferred to the hospital and admitted to the intensive care unit (ICU) under sedation and analgesia with propofol, fentanyl, and midazolam (under bispectral index guidance) and invasive mechanical ventilation (volume controlled ventilation with a tidal volume of 6 mL/kg of ideal weight).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Neuromuscular blockade with intermittent boluses of rocuronium was administered during prehospital transport and over the first 24 h in the ICU to improve mechanical ventilation and prevent patient-ventilator asynchrony.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Due to distributive shock, vasopressor support with norepinephrine (maximum dose of 0.5 mcg/kg/min) was started to achieve a mean arterial pressure of 70 mmHg during the first day of ICU stay.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Blood tests revealed a C-reactive protein level of 101 mg/dL (normal range 0.05–1 mg/dL), leucocytosis of 20,630, and a neutrophil count of 90.7%. Microbiological samples (blood, tracheal aspirate, urine, and peritonsillar and periepiglottic exudate) were collected for testing, and treatment with ceftriaxone and clindamycin was started.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The chest X-ray was normal and computed tomography (CT) of the neck performed on the second day showed exuberant supraglottic oedema and bilateral cervical lymphadenomegaly; no thumb sign was observed and no samples were collected.</p><p id="par0110" class="elsevierStylePara elsevierViewall">An ENT specialist performed fibreoptic laryngoscopy every day to monitor the patient’s progress. Due to the persistence of exuberant supraglottic oedema, treatment with dexamethasone (8 mg, 8/8 h) was started on the 6th day of admission to the ICU, which led to progressive, significant improvement.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The urinary antigen test was negative for <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, the peritonsillar sample was positive for <span class="elsevierStyleItalic">Streptococcus parasanguinis</span> and <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>, and <span class="elsevierStyleItalic">Streptococcus gordonni</span> was grown in the periepiglottic exudate culture. Antibiotic treatment continued for 10 days.</p><p id="par0120" class="elsevierStylePara elsevierViewall">After 13 days in the ICU, awake intubation was performed after video laryngoscopy had confirmed the normality of airway structures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and the cuff leak test—performed with the cuff deflated—confirmed the absence of significant obstruction.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Fibreoptic bronchoscopy was not performed after extubation, since the patient remained asymptomatic, with good ventilation dynamics and no symptoms. No clinical or neurological imaging (CT) abnormalities were observed, and the patient was transferred to the ward 2 days later, and finally discharged home 20 days after admission.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Difficult intubation</span><p id="par0130" class="elsevierStylePara elsevierViewall">Airway management in the prehospital setting can be complex. As shown by this case report, TI can be both mandatory and urgent in patients with significant physiological deterioration, such as hypoxia and shock. When this occurs in an uncontrolled environment in which access to the patient or their airway is difficult, for example, when the airway is anatomically altered due to facial trauma or possible pharyngeal obstruction, intubation can be extremely challenging, and the best approach must be determined quickly to avoid delays that could lead to cardiac arrest, as occurred in our patient.</p><p id="par0135" class="elsevierStylePara elsevierViewall">It might be useful to recap on the concept of difficult airway in relation to our patient. According to airway management guidelines, 3 of the factors associated with intubation difficulty (both emergency and scheduled) are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0140" class="elsevierStylePara elsevierViewall">Hypoxemic patient (which will determine pre-oxygenation, induction and short apnoea time).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0145" class="elsevierStylePara elsevierViewall">Supraglottic pathology (epiglottitis) with airway obstruction.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0150" class="elsevierStylePara elsevierViewall">Prehospital setting (shortage of material, difficult access to the airway, and poor training).</p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">To this should be added the difficulty involved in making an accurate airway evaluation in this situation (due to lack of collaboration, altered level of consciousness, hypoxaemia or anatomical abnormalities).</p><p id="par0160" class="elsevierStylePara elsevierViewall">Preoxygenation before anaesthesia induction and tracheal intubation is a widely accepted manoeuvre that is designed to increase the body oxygen stores and thereby delay the onset of arterial haemoglobin desaturation during apnoea<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. It should be performed in all patients, but is particularly important when difficulty with ventilation or TI is anticipated, and when the subject has limited oxygen reserves, as was the case in our patient<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. Simple pre-oxygenation strategies can be used, even in the prehospital setting, such as elevation of the head, apnoeic diffusion oxygenation, or, if available and feasible, delivery of Boussignac continuous positive airway pressure (CPAP).</p><p id="par0165" class="elsevierStylePara elsevierViewall">Following this, and given the time limit in these situations, the team can begin to stratify the airway management plan and make a basic checklist of the necessary and available material.</p><p id="par0170" class="elsevierStylePara elsevierViewall">In our case, as we anticipated difficult intubation and had access to a video laryngoscope, we chose this as our first intubation strategy (plan A). We did not administer a muscle relaxant. Despite the lack of consensus in this regard, we believe that muscle relaxants improve intubation conditions, and can be used safely even in the prehospital setting, provided the team is following an airway management algorithm and are prepared to perform an emergency surgical access without delay, if necessary<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0175" class="elsevierStylePara elsevierViewall">A well-defined airway management algorithm for critical patients, as suggested and recently revised by the <span class="elsevierStyleItalic">Difficult Airway Society</span>, can and must be adapted to the pre-hospital setting<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>. Such an algorithm would need to take into account the special circumstances of PHEM teams while ensuring that intubation in the prehospital setting is performed to the same standards that apply in the hospital.</p><p id="par0180" class="elsevierStylePara elsevierViewall">After adapting the 2018 guidelines for the management of TI in critically ill adults<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> to the prehospital context, the basic steps to follow are:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1</span><p id="par0185" class="elsevierStylePara elsevierViewall">Preparation: pre-oxygenation of the patient, definition of the strategy, preparation of the patient and the material.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2</span><p id="par0190" class="elsevierStylePara elsevierViewall">Plan A TI attempt<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">No more than 3 attempts/laryngoscopies, always improving conditions.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Consider using a bougie or stylet.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Consider neuromuscular blockade: there is a broad consensus in the literature that the use of muscle relaxants in both rapid sequence and normal induction increases the success of IT at the first attempt, since it improves intubation conditions. Some authors even argue that these drugs should always be used to ensure optimal intubation conditions before the first attempt because they “maximise the success strategy of the first attempt”<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,8</span></a>. However, it is important to bear in mind that there is no contingency plan in the prehospital setting, and that neuromuscular blockade can be fatal.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">3</span><p id="par0210" class="elsevierStylePara elsevierViewall">Plan B/C: Second-generation supraglottic airway devices (SAD), or bag-valve-mask for rescue ventilation.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">If face mask ventilation and oxygenation is effective, consider making a final attempt with laryngoscope if there is nothing that can considerably improve the probability of success.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Intubation via SAD, if possible.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Transfer to the nearest hospital/location of additional airway management resources</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">4</span><p id="par0230" class="elsevierStylePara elsevierViewall">Plan D: Front of neck or surgical airway. Only in “can’t intubate, can’t ventilate” situations Preferred method: scalpel cricothyrotomy.</p></li></ul></p><p id="par0235" class="elsevierStylePara elsevierViewall">In addition to creating and implementing algorithms, PHEM personnel also need training in the surgical environment, since it is difficult to achieve competence in airway management exclusively in the context of prehospital emergencies<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0240" class="elsevierStylePara elsevierViewall">A standardised approach to airway approach in the prehospital setting would allow authors to perform evidence-based, less biased studies.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathology: epiglottitis</span><p id="par0245" class="elsevierStylePara elsevierViewall">Epiglottitis is an acute inflammatory condition that involves the epiglottis and other supraglottic structures that, in severe cases, such as the one reported here, can cause airway obstruction.</p><p id="par0250" class="elsevierStylePara elsevierViewall">The incidence of acute epiglottitis in adults ranges from 0.97 to 3.1 cases per 100,000 adults, with a mortality rate of approximately 7.1%<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,14</span></a>.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Characteristic clinical symptoms, such as dysphagia, fever, malaise, respiratory distress when lying down, shortness of breath, which may be more severe as inflammation increases, and stridor, with no obvious laryngeal abnormalities on gross examination, should prompt clinicians to include epiglottitis in their differential diagnosis, and are of primary importance for referral to an emergency unit. Patients with progressive signs of upper airway obstruction should be treated as a medical emergency, since clinical deterioration occurs within hours in patients presenting stridor, hoarseness, drooling, dyspnoea, and fever<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Respiratory distress and stridor are common physical signs in children, but less frequent in adults<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. Stridor in adults is a typical indication of upper airway obstruction, and is regarded as a warning sign of progressive airway occlusion. Audible reduction of stridor in early clinical presentation indicates occlusion rather than recovery. This was well illustrated in our case, so we quickly decided to perform an advanced airway procedure after observing these signs of severity, despite the unfavourable (pre-hospital) context.</p><p id="par0265" class="elsevierStylePara elsevierViewall">The use of video laryngoscopy in our case was an added advantage, not only because it facilitated diagnosis, but also because it helped decide the best airway approach, which included using the <span class="elsevierStyleItalic">frova</span> introducer to facilitate insertion of the orotracheal tube in the prehospital setting.</p><p id="par0270" class="elsevierStylePara elsevierViewall">Direct laryngoscopy and visualization of the swollen, red epiglottis support the diagnosis of epiglottitis. Epiglottitis can also be diagnosed with radiography of the soft tissues of the neck, although this is seldom used<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>.</p><p id="par0275" class="elsevierStylePara elsevierViewall">In many cases, epiglottitis has a bacterial or viral origin, or a combination of both. <span class="elsevierStyleItalic">H. influenzae</span> used to be a common cause, but the introduction of the influenza vaccine has considerably reduced the number of cases of <span class="elsevierStyleItalic">H. influenzae</span>-related epiglottitis<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,15,16</span></a>. Other agents implicated in epiglottitis are <span class="elsevierStyleItalic">S. pneumoniae,</span> other species of <span class="elsevierStyleItalic">Streptococcus, Staphylococcus aureus, Moraxella catarrhalis</span> and <span class="elsevierStyleItalic">Pseudomonas</span> spp. Super-infection by viruses such as Herpes simplex, Parainfluenza and Epstein Barr, among others, has also been described<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a>.</p><p id="par0280" class="elsevierStylePara elsevierViewall">Non-infectious causes of epiglottitis may include trauma due to foreign bodies, inhalation and chemical burns, systemic disease, or reaction to chemotherapy. The presence of dysphagia, drooling, and stridor following thermal or caustic injury should alert the clinician to the possibility of injury to the supraglottic structures resulting in epiglottitis. Epiglottic injuries of this type should be suspected in patients with mental disorders or communication difficulties. In young adults, acute epiglottitis has been described as being caused by inhalation of heated objects when smoking illicit drugs<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>.</p><p id="par0285" class="elsevierStylePara elsevierViewall">We only collected microorganisms from exudate and fluid samples from the oral cavity. Both <span class="elsevierStyleItalic">S. parasanguinis</span> and <span class="elsevierStyleItalic">S. gordonii</span> are oral commensal bacteria that are capable of promoting the development of a microbial community that exists in harmony with the host<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>. Nonetheless, those very same colonization capabilities can confer upon <span class="elsevierStyleItalic">sanguinis</span>-group streptococci the ability to promote systemic disease<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>. We believe that <span class="elsevierStyleItalic">S. parasanguinis</span> and <span class="elsevierStyleItalic">S. gordonii</span>, as previously described in the literature<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>, were the causative pathogens in our patient.</p><p id="par0290" class="elsevierStylePara elsevierViewall">ENT units should be involved in treating the patient, and therapy should start with intravenous antibiotics such as third-generation cephalosporin that covers <span class="elsevierStyleItalic">H. influenzae</span><a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,22</span></a>. Treatment with clindamycin or metronidazole should also be started if anaerobic organisms are suspected<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>. Due to the severity of the clinical presentation, we decided to start empirical antibiotic therapy with ceftriaxone and clindamycin.</p><p id="par0295" class="elsevierStylePara elsevierViewall">The use of corticosteroids is controversial, and their benefit has not been proven in any prospective trials<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,14,23–26</span></a>. In our case, we decided to start corticosteroid therapy when daily fibreoptic laryngoscopy examination showed no improvement in the supraglottic oedema after 6 days of antibiotics. The introduction of corticosteroids appeared to accelerate the healing process and was crucial for resolution of the oedema and safe extubation.</p><p id="par0300" class="elsevierStylePara elsevierViewall">There is evidence to suggest that TI should be maintained for 2–3 days when epiglottitis is caused by <span class="elsevierStyleItalic">H. influenzae</span>, and for 6 days on average when it is caused by other pathogens<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>. Our patient was on mechanical ventilation for 13 days with persistent severe oedema. Tracheostomy was not performed because tracheotomised patients trend to present more complications and require a longer sick leave than intubated patients<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>. As mentioned above, we believe that <span class="elsevierStyleItalic">S. parasanguinis</span> and <span class="elsevierStyleItalic">S. gordonii</span> were the pathogens involved in this supraglottitis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Simulation and training</span><p id="par0305" class="elsevierStylePara elsevierViewall">Studies show that training programmes in advanced airway access and difficult airway management and the use of algorithms reduce the risk of TI-related complications, and are therefore a prerequisite for optimising prehospital management of the difficult airway<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,11</span></a>.</p><p id="par0310" class="elsevierStylePara elsevierViewall">Training in airway management skills could include simulation of these rare but life-threatening situations.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="par0315" class="elsevierStylePara elsevierViewall">This case shows that timely diagnosis and intervention in epiglottitis can prevent serious morbidity and mortality in this rare but potentially lethal disorder. Epiglottitis is a real difficult airway emergency. Airway management in the prehospital setting can be difficult, and physicians must be well trained and fully prepared for this procedure, given its impact on patient outcomes. Physicians must maintain a high index of clinical suspicion of epiglottitis, due to the wide range of possible symptoms. Physical examination can be unreliable, and delay in diagnosis can have catastrophic consequences. Antibiotic therapy is the cornerstone of treatment, and further studies are needed to clarify the role of corticosteroids in epiglottitis.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patient consent for publication</span><p id="par0320" class="elsevierStylePara elsevierViewall">The patient gave his informed consent for the publication of this case report. Consent was also obtained to access his clinical records and images.</p><p id="par0325" class="elsevierStylePara elsevierViewall">The consent forms are attached as an annex to this article.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0330" class="elsevierStylePara elsevierViewall">This study did not receive any financial support.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1679093" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1489821" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1679094" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1489820" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Difficult intubation" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Pathology: epiglottitis" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Simulation and training" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient consent for publication" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-04" "fechaAceptado" => "2021-01-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1489821" "palabras" => array:4 [ 0 => "Prehospital emergency" 1 => "Acute epiglottitis" 2 => "Difficult airway" 3 => "Videolaryngoscope" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1489820" "palabras" => array:4 [ 0 => "Urgencia prehospitalaria" 1 => "Epiglotitis aguda" 2 => "Vía aérea difícil" 3 => "Vídeolaringoscopio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El abordaje de la vía aérea en la unidad de urgencias prehospitalarias es una práctica común que potencialmente salva vidas. El manejo es complejo debido al entorno, lo cual significa un porcentaje mucho más elevado de vías aéreas difíciles que en un ambiente regulado, como en el caso del quirófano.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El intento fallido o prolongado de intubación traqueal está asociado a resultados desfavorables y complicaciones graves.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La epiglotitis aguda es un trastorno potencialmente letal, clasificado como urgencia médica dentro de las enfermedades de la vía aérea respiratoria superior, que se caracteriza por una evolución repentina y mortal si no se logra una intubación rápida que permita la oxigenación del paciente.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Describimos el caso de un paciente de 36 años con estridor, disnea e hipoxemia debido a la obstrucción total de la vía aérea, causada por una epiglotitis aguda. Nuestro objetivo es subrayar esta lesión infrecuente y su manejo desde la unidad prehospitalaria hasta el alta, ilustrando la gravedad de la presentación clínica, el tratamiento actual y el resultado.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernandes-Teles AR, Pina-Amado JM, Pereira JM, Paiva JA, Rocha-Silva S. Entorno prehospitalario y manejo en UCI de epiglotitis en un adulto. Rev Esp Anestesiol Reanim. 2022;69:65–70.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Header: Epiglottitis in an adult: more than an airway difficulty.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 805 "Tamanyo" => 44936 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Day 0 Acute epiglottitis - Airtraq® prehospital image.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">1: Epiglottic inflammation; 2: Inflammation of the area surrounding the glottis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 805 "Ancho" => 805 "Tamanyo" => 55008 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Day 13 of orotracheal intubation - Airtraq® image prior to extubation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of difficult airway situations during prehospital airway management by emergency physicians—a retrospective analysis of 692 consecutive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Thoeni" 1 => "T. Piegeler" 2 => "M. Brueesch" 3 => "S. Sulser" 4 => "T. Haas" 5 => "S.M. Mueller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.resuscitation.2015.02.010" "Revista" => array:6 [ "tituloSerie" => "Resuscitation." "fecha" => "2015" "volumen" => "90" "paginaInicial" => "42" "paginaFinal" => "45" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25708959" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scandinavian SSAI clinical practice guideline on pre-hospital airway management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Rehn" 1 => "P.K. Hyldmo" 2 => "V. Magnusson" 3 => "J. Kurola" 4 => "P. Kongstad" 5 => "L. Rognås" ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1111/aas.12746" "Revista" => array:6 [ "tituloSerie" => "Acta Anaesthesiol Scand." "fecha" => "2016" "volumen" => "60" "paginaInicial" => "852" "paginaFinal" => "864" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27255435" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1111/aas.12746" "WWW" => array:1 [ "link" => "https://doi.org/10.1093/bja/aeu205" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in prehospital airway management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Jacobs" 1 => "A. Grabinsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/2229-5151.128014" "Revista" => array:6 [ "tituloSerie" => "Int J Crit Illn Inj Sci." "fecha" => "2014" "volumen" => "4" "paginaInicial" => "57" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24741499" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Ono" 1 => "K. Shinohara" 2 => "A. Goto" 3 => "T. Yano" 4 => "L. Sato" 5 => "H. Miyazaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00540-015-2124-7" "Revista" => array:6 [ "tituloSerie" => "J Anesth." "fecha" => "2016" "volumen" => "30" "paginaInicial" => "205" "paginaFinal" => "214" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26715428" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prehospital standardization of medical airway management: incidence and risk factors of difficult airway" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. Combes" 1 => "P. Jabre" 2 => "C. Jbeili" 3 => "B. Leroux" 4 => "S. Bastuji-Garin" 5 => "A. Margenet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1197/j.aem.2006.02.016" "Revista" => array:6 [ "tituloSerie" => "Acad Emerg Med." "fecha" => "2006" "volumen" => "13" "paginaInicial" => "828" "paginaFinal" => "834" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16807397" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. Combes" 1 => "P. Jabre" 2 => "A. Margenet" 3 => "J.C. Merle" 4 => "B. Leroux" 5 => "M. Dru" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e318201c42e" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology." "fecha" => "2011" "volumen" => "114" "paginaInicial" => "105" "paginaFinal" => "110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21169803" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Ono" 1 => "K. Shinohara" 2 => "A. Goto" 3 => "T. Yano" 4 => "L. Sato" 5 => "H. Miyazaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00540-015-2124-7" "Revista" => array:6 [ "tituloSerie" => "J Anesth." "fecha" => "2016" "volumen" => "30" "paginaInicial" => "205" "paginaFinal" => "214" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26715428" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strategies to improve first attempt success at intubation in critically ill patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B.S. Natt" 1 => "J. Malo" 2 => "C.D. Hypes" 3 => "J.C. Sakles" 4 => "J.M. Mosier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aew061" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth." "fecha" => "2016" "volumen" => "117" "paginaInicial" => "i60" "paginaFinal" => "i68" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27221259" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Airway infections disease emergencies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Rafei" 1 => "R. Lichenstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.pcl.2005.10.001" "Revista" => array:6 [ "tituloSerie" => "Pediatr Clin North Am." "fecha" => "2006" "volumen" => "53" "paginaInicial" => "215" "paginaFinal" => "242" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16574523" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The rising incidence of adult acute epiglottitis and epiglottic abscess" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Berger" 1 => "T. Landau" 2 => "S. Berger" 3 => "Y. Finkelstein" 4 => "J. Bernheim" 5 => "D. Ophir" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Otolaryngoscopy." "fecha" => "2003" "volumen" => "24" "paginaInicial" => "374" "paginaFinal" => "383" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute infectious epiglottitis in children and adults: annual incidence and mortality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Carenfelt" 1 => "A. Sobin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2273.1989.tb00410.x" "Revista" => array:6 [ "tituloSerie" => "Clin Otolaryngol Allied Sci." "fecha" => "1989" "volumen" => "14" "paginaInicial" => "489" "paginaFinal" => "493" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2612027" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoxygenation: physiologic basis, benefits, and potential risks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "U. Nimmagadda" 1 => "M.R. Salem" 2 => "G.J. Crystal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000001589" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg." "fecha" => "2017" "volumen" => "124" "paginaInicial" => "507" "paginaFinal" => "517" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28099321" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Trimmel" 1 => "C. Beywinkler" 2 => "S. Hornung" 3 => "J. Kreutziger" 4 => "W.G. Voelckel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12245-018-0178-7" "Revista" => array:5 [ "tituloSerie" => "Int J Emerg Med." "fecha" => "2018" "volumen" => "11" "paginaInicial" => "19" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29549460" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of tracheal intubation in critically ill adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Higgs" 1 => "B.A. McGrath" 2 => "C. Goddard" 3 => "J. Rangasami" 4 => "G. Suntharalingam" 5 => "R. Gale" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bja.2017.10.010" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth." "fecha" => "2018" "volumen" => "120" "paginaInicial" => "323" "paginaFinal" => "352" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29406182" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute epiglottitis in adults: an eight year experience in Rhode Island" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.F. Mayo-Smith" 1 => "P.J. Hirsch" 2 => "S.F. Wodzinski" 3 => "F.J. Schiffman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM198605013141801" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med." "fecha" => "1986" "volumen" => "314" "paginaInicial" => "1133" "paginaFinal" => "1139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3515191" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Haemophilus influenzae</span> type b epiglottitis as a cause of acute upper airways obstruction in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Tanner" 1 => "G. Fitzsimmons" 2 => "E.D. Carrol" 3 => "T.J. Flood" 4 => "J.E. Clark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmj.325.7372.1099" "Revista" => array:6 [ "tituloSerie" => "BMJ." "fecha" => "2002" "volumen" => "325" "paginaInicial" => "1099" "paginaFinal" => "1100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12424174" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The dramatic change in the epidemiology of pediatric epiglottitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. Faden" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.pec.0000221347.42120.f8" "Revista" => array:6 [ "tituloSerie" => "Pediatr Emerg Care." "fecha" => "2006" "volumen" => "22" "paginaInicial" => "443" "paginaFinal" => "444" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16801849" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epiglottitis in the <span class="elsevierStyleItalic">Haemophilus influenzae</span> type B vaccine era: changing trends" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.K. Shah" 1 => "D.W. Roberson" 2 => "D.T. Jones" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00005537-200403000-00031" "Revista" => array:6 [ "tituloSerie" => "Laryngoscope." "fecha" => "2004" "volumen" => "114" "paginaInicial" => "557" "paginaFinal" => "560" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15091234" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute epiglottitis: trends, diagnosis and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C. Abdallah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/1658-354X.101222" "Revista" => array:6 [ "tituloSerie" => "Saudi J Anaesth." "fecha" => "2012" "volumen" => "6" "paginaInicial" => "279" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23162404" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric epiglottitis caused by group G beta-hemolytic <span class="elsevierStyleItalic">Streptococcus</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Isaacson" 1 => "D.M. Isaacson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.inf.0000086421.57385.b1" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J." "fecha" => "2003" "volumen" => "22" "paginaInicial" => "846" "paginaFinal" => "847" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14515840" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genetics of <span class="elsevierStyleItalic">sanguinis</span>-Group Streptococci in health and disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Nobbs" 1 => "J. Kreth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Microbiol Spectr." "fecha" => "2019" "volumen" => "7" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thum sign: acute epiglottitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Takata" 1 => "T. Fujikawa" 2 => "R. Goto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bcr-2016-214742" "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep." "fecha" => "2016" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute epiglottitis in adults: an under-recognized and life-threatening condition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Westerhuis" 1 => "M.G. Bietz" 2 => "J. Lindemann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "S D Med." "fecha" => "2013" "volumen" => "66" "paginaInicial" => "309" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24175495" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute adult supraglottitis: current management and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Al-Qudah" 1 => "S. Shetty" 2 => "M. Alomari" 3 => "M. Alqdah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SMJ.0b013e3181e538d8" "Revista" => array:6 [ "tituloSerie" => "South Med J." "fecha" => "2010" "volumen" => "103" "paginaInicial" => "800" "paginaFinal" => "804" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20622745" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and management of supraglottitis (epiglottitis)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Glynn" 1 => "J.E. Fenton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11908-008-0033-8" "Revista" => array:6 [ "tituloSerie" => "Curr Infect Dis Rep." "fecha" => "2008" "volumen" => "10" "paginaInicial" => "200" "paginaFinal" => "204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18510881" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epiglottitis: it hasn’t gone away" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.L. Lichtor" 1 => "M. Roche Rodriguez" 2 => "N.L. Aaronson" 3 => "T. Spock" 4 => "T.R. Goodman" 5 => "E.D. Baum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0000000000001125" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology." "fecha" => "2016" "volumen" => "124" "paginaInicial" => "1404" "paginaFinal" => "1407" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27031010" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of intubation and tracheotomy in adult patients with acute epiglottitis or supraglottitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.K. Tapiovaara" 1 => "K.L.S. Aro" 2 => "L.J.J. Bäck" 3 => "A.I.M. Koskinen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00405-019-05624-0" "Revista" => array:6 [ "tituloSerie" => "Eur Arch Otorhinolaryngol." "fecha" => "2019" "volumen" => "276" "paginaInicial" => "3173" "paginaFinal" => "3177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31489494" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006900000002/v1_202203120614/S2341192922000397/v1_202203120614/en/main.assets" "Apartado" => array:4 [ "identificador" => "34051" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006900000002/v1_202203120614/S2341192922000397/v1_202203120614/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922000397?idApp=UINPBA00004N" ]
