Video-intuboscopic assistance is a useful aid to tracheal intubation in pediatric patients

[Video laryngoscopy olé! Time to say good bye to direct and flexible intubation?]

A number of video laryngoscopy systems have been introduced into anesthetic practice in recent years. Due to the technical concepts of these systems exposure of the laryngeal structures is usually better than with direct laryngoscopy, both in normal airways as well as in those that are difficult to manage. With the increasing use of video laryngoscopy it seems as if direct laryngoscopy and flexible fibrescopic intubation are at risk of becoming redundant. This article describes current developments and discusses why expertise in direct laryngoscopy and flexible fibrescopic intubation should be maintained, particularly by experts in airway management.

Confirmation of correct tracheal tube placement in newborn infants

Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms "Infant, Newborn", "Endotracheal intubation", "Resuscitation", "Clinical signs", "Radiography", "Respiratory Function Tests", "Laryngoscopy", "Ultrasonography", and "Bronchoscopy". Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of newborn infants.

Pediatric airway management: current practices and future directions

Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.

An endotracheal intubation confirmation system based on carina image detection: a proof of concept

In this paper, a novel system for automatic confirmation of endotracheal intubation is proposed. The system comprises a miniature CMOS sensor and electric wires attached to a rigid stylet. Video signals are continuously acquired and processed by the algorithm implemented on a PC/DSP. The system is based on detection of the carina image as an anatomical landmark of correct tube positioning and it thus utilizes direct visual cues. Detection of the carina is performed based on unsupervised clustering, using a greedy-Gaussian mixture framework. The performance of the proposed system was initially evaluated using a mannequin model. A scientific prototype was assembled and used to perform repeated intubations on the model and collect a database of video signals which were processed off-line. The videos were categoried by a medical professional into carina, upper-trachea, and esophagus. An accuracy of 100% was achieved in discriminating between the carina and other anatomical structures including esophagus and upper-trachea. As an additional validation, the system was tested using a dataset of 231 video images recorded from five human subjects during intubation. The system correctly classified 120 out of 125 non-carina images (i.e. a sensitivity of 96.0%), and 100 out of 106 carina images (i.e. a specificity 94.3%). Using a 10th-order median filter, applied on the frame-based classification results, a 100% accuracy rate was obtained.

A videolaryngoscopy technique for the intubation of the newborn: preliminary report

OBJECTIVE

We describe videolaryngoscopy equipment and technique for endotracheal intubation and airway evaluation in the delivery room (DR) and NICU for endotracheal intubation and airway evaluation. We report our first experience of 47 patients.

METHODS

Forty-seven infants who weighed 530 to 6795 g and required endotracheal intubation or airway evaluation were considered for intubation or assessment by using the modified Kaplan-Berci videolaryngoscope. We report quality-improvement data after initial introduction of newly approved technology.

RESULTS

We report results of 48 intubations in 42 patients and videolaryngoscopic inspection without intubation in 5 patients. Five intubation attempts were successful after failed attempts by experienced intubators; 6 attempts by residents were completed with video guidance rather than requiring an additional attempt. Only 3 intubations required more than 2 attempts. Enlarged panoramic view and recording assisted in correct diagnosis of vocal cord paralysis. The features and main advantages are discussed in detail. No complications or difficulties resulting from the technology occurred.

CONCLUSIONS

This new technique and technology show promise to improve airway management, evaluation, and teaching. Future research to validate improved intubation success in difficult airways and in teaching situations is warranted.

A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants

BACKGROUND

The Truview EVO2 laryngoscope is a recently introduced device with a unique blade that provides a wide and magnified laryngeal view at 46 degrees anterior refracted angle. An infant blade of the laryngoscope has recently become available.

AIMS AND OBJECTIVES

The aim of the study was to compare the Truview infant EVO2 laryngoscope with the Miller straight blade laryngoscope in order to determine whether the Truview EVO2 laryngoscope provided an improved laryngeal view at laryngoscopy and also to assess the time taken for intubation with the two devices.

MATERIALS AND METHODS

In this prospective randomized study, 60 neonates and infants of either sex undergoing surgery under general anesthesia were enrolled and divided into two groups: endotracheal intubation using a Truview infant blade (Group I) or with a Miller blade number 0 (Group II). The view of the glottis at laryngoscopy, time to intubation and the number of attempts required for intubation were recorded.

RESULTS

The average time for laryngoscopy in Group I was 18.18 s and in Group II was 16.30 s, which though not significant clinically, is statistically significant (P = 0.002). While eight patients (26.6%) had Cormack and Lehane grade 2 view on laryngoscopy in Group II, only two patients (6.6%) had such a view in Group 1 (P = 0.039). The number of attempts at laryngoscopy was comparable in the two groups.

CONCLUSION

In this study, we found that in neonates and infants, the tracheal intubation using Truview infant EVO2 blade took almost as much time as miller blade and provided improved laryngoscopic view as compared to the Miller blade.

[Airway management]

Managing the difficult airway poses an enormous challenge for anaesthesiologists, intensivists and A&E physicians, particularly because of the high probability of a potentially fatal outcome. Development and (pre-) clinical distribution of supraglottic airway devices (e.g. LMA, LT) and their enhancements, as well as the broad acceptance of awake fibre-optic intubation, led to a profound change in the strategy for managing the difficult airway. This is reflected in the revised ASA guidelines, implementing the use of the laryngeal mask airway and fibre-optic intubation. In view of the utmost importance of this topic the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) framed an independent German guideline, considering German national terms and conditions. In analogy algorithms and guidelines of the ILCOR, ERC and ATLS were revised as well as those of many other national anaesthesiological boards. Nevertheless, massive national and international deficits exist in implementing these guidelines into practice and the implicated structural requirements with respect to education, reflection, team building and equipment concerning the individual institution.

Crisis management during anaesthesia: difficult intubation

BACKGROUND

Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation.

OBJECTIVES

To examine the role of a specific sub-algorithm for the management of difficult intubation.

METHODS

The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

RESULTS

There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors.

CONCLUSION

The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.

Seeing is believing: the importance of video laryngoscopy in teaching and in managing the difficult airway

Of the several million patients who undergo surgery in North America annually, a large proportion undergo intubation of the trachea. In approximately 90% of these patients, the endotracheal tube is introduced using a traditional laryngoscope with a battery in the handle and a small bulb near the tip of the blade. This bulb provides a limited and often dim view of the glottic structures. In about 10% of cases, the patient is intubated using a flexible fiberoptic intubating scope. The authors have developed a video laryngoscope that preserves the standard blade configuration with a modified handle. A 3-mm image light guide is built into the blade, replacing the bulb. A small TV camera with an incorporated light bundle is inserted into the handle. A wide-angle panoramic view of the upper airway anatomy is displayed on a TV screen, which can be positioned at a convenient working distance. The use of a TV monitor is a well-accepted standard during minimally invasive surgical procedures.

The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet

PURPOSE

To compare the ease of tracheal intubation facilitated by the gum elastic bougie or the malleable stylet while applying cricoid pressure.

METHODS

Sixty American Society of Anesthesiologists I-III adult patients undergoing elective surgeries participated in this study. After induction of anesthesia with 2.5 mg x kg(-1) propofol and vecuronium 0.1 mg x kg(-1), the laryngeal view was assessed without and with cricoid pressure. Patients were allocated randomly into two groups: a gum elastic bougie or stylet group. One of the two devices was used for tracheal intubation while applying cricoid pressure. The duration and ease of tracheal intubation was recorded.

MAIN RESULTS

In 58 patients, the trachea was intubated at the first attempt. In the stylet group, tracheal intubation was difficult and needed more time, especially when the glottic opening was not visible. In the bougie group, the duration and ease of intubation was not influenced by laryngeal view. In the remaining two patients with Cook's modified 3b laryngeal view, it was impossible to intubate the trachea with these devices.

CONCLUSIONS

Applying cricoid pressure worsened laryngeal view. The use of a gum elastic bougie was more effective than the use of a stylet to facilitate intubation.

A new video laryngoscope-an aid to intubation and teaching

In recent decades, video techniques have been employed in the majority of endoscopic procedures because of several distinct advantages provided. These include the following: The displayed anatomy is magnified. Recognition of the anatomical structures and anomalies is easier, and manipulation of airway devices is facilitated. When assistance is required, the operator and assistant can coordinate their movements because each sees exactly the same image on the video monitor. As a result, video techniques have become the method of choice in teaching. The Video Macintosh Intubating Laryngoscope System (VMS) was designed employing a standard Macintosh blade and laryngoscope handle. A camera was incorporated into the handle with a short image and light bundle. The magnified anatomy is displayed on an 8-inch monitor, which is attached to a swivel arm on a small cart. Observation and manipulation can be performed in one axis.A total of 235 patients were studied and were divided into two groups: Group A (n = 217), in whom intubation was thought unlikely to be difficult, and Group B (n = 18), in whom difficulty with intubation was anticipated. External laryngeal manipulation (ELM) was required in 22 of the 217 Group A patients (10%). All intubations but one in this group were successful. In the second group (B) of 18 patients who had anatomical conditions that suggested that direct laryngoscopy might be challenging, all 18 cases required ELM but all were successfully intubated using the VMS. The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthesiologist handling the laryngoscope results in a significant advantage over the conventional laryngoscope technique. As a consequence, the learning curve is short. In our view, video laryngoscopy will become the method of choice in teaching.