Review article: Video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

Awake Tracheal Intubation: An Update

Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills.

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

The i-view® Video Laryngoscope Compared With the Macintosh Laryngoscope Does Not Enhance the Endotracheal Intubation Skills of Dental Students

Background A disposable i-view® video laryngoscope (Intersurgical Limited, Berkshire, United Kingdom) is yet to be used to educate medical and dental students, who must learn endotracheal intubation skills. Additionally, the advantage of the i-view® use for the purpose, compared with the Macintosh laryngoscope, is unknown. We aimed to first determine whether the i-view® video laryngoscope enhances endotracheal intubation skills among dental students compared with the Macintosh laryngoscope. Methodology A prospective, observational, simulation study was conducted among 67 dental students in their sixth clinical year of education. Intubation skills were evaluated on a computer-assisted simulator with a standardized manikin. Each student was asked to intubate using the conventional Macintosh laryngoscope and the i-view® video laryngoscope in the trachea of the simulator's manikin. We collected objective data, including the retroflection angle of the manikin, the maxillary incisor contact pressure, time from picking up the laryngoscope to ventilation, intubation success, and intubation delay. Each student was further asked to grade their subjective evaluation concerning the visual field, Cormack and Lehane classification, operability, stability, needed force for intubation, and easiness during intubation. Results Enrolled dental students quoted that the i-view® video laryngoscope demonstrated better visual field, Cormack and Lehane classification, operability, and stability than the Macintosh laryngoscope. However, they felt intubation easiness could have been better using Macintosh than i-view®. Intubation time, failure rate, and delay rate did not differ between the two laryngoscopes. Nevertheless, the maxillary incisor contact pressure (median interquartile range (IQR)) during the intubation increased in the i-view® intubation compared with Macintosh (32 (24 to 41) vs. 25 (18 to 35) N, p = 0.010). Conclusions We first demonstrated that the i-view® video laryngoscope compared with the Macintosh laryngoscope does not enhance the endotracheal intubation skills of dental students. However, the possible repeated use as an educational simulator training tool may add some advantages to the experience of video laryngoscope in both medical and dental students.

[Recommendations of the new S1 guidelines on airway management]

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department

BACKGROUND

The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED.

METHODS

We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods.

RESULTS

Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events.

CONCLUSION

The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.

Airway Management: The Current Role of Videolaryngoscopy

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Effect of head and neck positions on tracheal intubation using a McGRATH MAC video laryngoscope: A randomised, prospective study

BACKGROUND

Different head and neck positions may affect video laryngoscopy in terms of laryngeal exposure, intubation difficulty, advancement of the tracheal tube into the glottis and the occurrence of palatopharyngeal mucosal injury.

OBJECTIVE

We investigated the effects of simple head extension, head elevation without head extension and the sniffing position on tracheal intubation using a McGRATH MAC video laryngoscope.

DESIGN

A randomised, prospective study.

SETTING

Medical centre governed by a university tertiary hospital.

PATIENTS

A total of 174 patients undergoing general anaesthesia.

METHODS

Patients were randomly allocated to one of three groups: simple head extension (neck extension without a pillow), head elevation only (head elevation with a pillow of 7 cm and no neck extension) and sniffing position (head elevation with a pillow of 7 cm and neck extension).

MAIN OUTCOMES

During tracheal intubation using a McGRATH MAC video laryngoscope in three different head and neck positions, we assessed intubation difficulty by several methods: a modified intubation difficulty scale score, time taken for tracheal intubation, glottic opening, number of intubation attempts, requirements for other manoeuvres (lifting force or laryngeal pressure) for laryngeal exposure and advancement of the tracheal tube into the glottis. The occurrence of palatopharyngeal mucosal injury was evaluated after tracheal intubation.

RESULTS

Tracheal intubation was significantly easier in the head elevation group than in the simple head extension (P = 0.001) and sniffing positions (P = 0.011). Intubation difficulty did not differ significantly between the simple head extension and sniffing positions (P = 0.252). The time taken for intubation in the head elevation group was significantly shorter than that in the simple head extension group (P < 0.001). A lifting force or laryngeal pressure was required less frequently for tube advancement into the glottis in the head elevation group than in the simple head extension (P = 0.002) and sniffing position groups (P = 0.012). The need for a lifting force or laryngeal pressure for tube advancement into the glottis was not significantly different between the simple head extension and sniffing positions (P = 0.498). Palatopharyngeal mucosal injury occurred less frequently in the head elevation group than in the simple head extension group (P = 0.009).

CONCLUSION

The head elevation position facilitated tracheal intubation using a McGRATH MAC video laryngoscope compared with a simple head extension or sniffing position.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov (NCT05128968).

Ramped versus sniffing position in the videolaryngoscopy-guided tracheal intubation of morbidly obese patients: a prospective randomized study

BACKGROUND

Ramped positioning is recommended for intubating obese patients undergoing direct laryngoscopy. However, whether the use of the ramped position can provide any benefit in videolaryngoscopy-guided intubation remains unclear. This study assessed intubation time using videolaryngoscopy in morbidly obese patients in the ramped versus sniffing positions.

METHODS

This is a prospective randomized study in patients with morbid obesity (n = 82; body mass index [BMI] ≥ 35 kg/m2). Patients were randomly allocated to either the ramped or the standard sniffing position groups. During the induction of general anesthesia, difficulty in mask ventilation was assessed using the Warters scale. Tracheal intubation was performed using a C-MAC® D-Blade videolaryngoscope, and intubation difficulty was assessed using the intubation difficulty scale (IDS). The primary endpoint was the total intubation time calculated as the sum of the laryngoscopy and tube insertion times.

RESULTS

The percentage of difficult mask ventilation (Warters scale ≥ 4) was significantly lower in the ramped (n = 40) than in the sniffing group (n = 41) (2.5% vs. 34.1%, P < 0.001). The percentage of easy intubation (IDS = 0) was significantly higher in the ramped than in the sniffing group (70.0% vs. 7.3%, P < 0.001). The total intubation time was significantly shorter in the ramped than in the sniffing group (22.5 ± 6.2 vs. 40.9 ± 9.0, P < 0.001).

CONCLUSIONS

Compared with the sniffing position, the ramped position reduced intubation time in morbidly obese patients and effectively facilitated both mask ventilation and tracheal intubation using videolaryngoscopy.

Factors Influencing the Time of Intubation Using C-MAC D-Blade® Video Laryngoscope: An Observational Cross-Sectional Study

Purpose C-MAC D-Blade® (Karl Storz, Tuttlingen, Germany) video laryngoscope (VL) has proved to be of immense utility in difficult intubation. But unfortunately, in an urgent situation, the predictable correct curvature of the endotracheal tube for effortless intubation is not met. We hypothesized that expertise is the most important variable in intubation and that novice students will be unable to intubate if the angle of curvature is incorrect. Methods An observational cross-sectional study was planned with 30 anesthesia residents, categorized into three groups based on their expertise in laryngoscopy. Students had to intubate an airway mannequin using the C-MAC D-Blade® VL with three different stylet angulations. The curvatures were 80, 100, and 120 degrees, which are commonly encountered in routine day-to-day practice. The time to get a stable glottic view, time to intubate, and ease of intubation were measured. Results The mean time to intubate was the least with 100-degree angulation in group C (19.60 ± 0.97) while the maximum time was in group A with 80-degree angulation (61.49 ± 3.69). A significant difference was noted in time to get a stable glottic view when compared between the groups. There was no difference in time to intubate with different stylet angulations when compared between groups. Conclusions Novices and experts could intubate even if the angle of curvature was incorrect taking more time. The time to laryngoscopy is significantly dependent on experience, but the time to intubate is influenced by the angle of curvature of the stylet.

Mask R-CNN based multiclass segmentation model for endotracheal intubation using video laryngoscope

Objective

Endotracheal intubation (ETI) is critical to secure the airway in emergent situations. Although artificial intelligence algorithms are frequently used to analyze medical images, their application to evaluating intraoral structures based on images captured during emergent ETI remains limited. The aim of this study is to develop an artificial intelligence model for segmenting structures in the oral cavity using video laryngoscope (VL) images.

Methods

From 54 VL videos, clinicians manually labeled images that include motion blur, foggy vision, blood, mucus, and vomitus. Anatomical structures of interest included the tongue, epiglottis, vocal cord, and corniculate cartilage. EfficientNet-B5 with DeepLabv3+, EffecientNet-B5 with U-Net, and Configured Mask R-Convolution Neural Network (CNN) were used; EffecientNet-B5 was pretrained on ImageNet. Dice similarity coefficient (DSC) was used to measure the segmentation performance of the model. Accuracy, recall, specificity, and F1 score were used to evaluate the model's performance in targeting the structure from the value of the intersection over union between the ground truth and prediction mask.

Results

The DSC of tongue, epiglottis, vocal cord, and corniculate cartilage obtained from the EfficientNet-B5 with DeepLabv3+, EfficientNet-B5 with U-Net, and Configured Mask R-CNN model were 0.3351/0.7675/0.766/0.6539, 0.0/0.7581/0.7395/0.6906, and 0.1167/0.7677/0.7207/0.57, respectively. Furthermore, the processing speeds (frames per second) of the three models stood at 3, 24, and 32, respectively.

Conclusions

The algorithm developed in this study can assist medical providers performing ETI in emergent situations.

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Video-Twin Technique for Airway Management, Combining Video-Intubating Stylet with Videolaryngoscope: A Case Series Report and Review of the Literature

Direct laryngoscopy (DL) and videolaryngoscopy (VL) have been the most commonly used airway management modalities in the last several decades. Meanwhile, various optional airway tools (e.g., supraglottic devices, fiberoptic bronchoscopes) have been used for alternative rescue modalities when anticipated or unexpected difficulties in airway management has occurred. In recent decades, optical stylets and video-assisted intubating stylets have become another option for difficult airway scenarios. In contrast to other approaches, we have adopted the Shikani video-assisted intubating stylet technique (VS) for both routine and difficult airway management scenarios. In this case series report, we present the video-twin technique, combining a videolaryngoscope with a video-assisted intubating stylet in various clinical case scenarios. We propose that such a combination is easy to learn and employ and is particularly beneficial in situations where an expected difficult airway (EDA) is encountered.

Video Laryngoscopy Using King Vision™ aBlade™ and Direct Laryngoscopy in Paediatric Airway Management: A Randomized Controlled Study about Device Learning by Anaesthesia Residents

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5−10] s, the median TTP was 28 [19−44] s, and the median TTV was 51 [39−66] s. DL-mediated intubation was significantly faster (TTP: 17 [13−23] s; p < 0.0001 and TTV: 34 [28−44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

Videolaryngoscopy versus direct laryngoscopy for endotracheal intubation of cardiac arrest patients in hospital: A systematic literature review

Aims

Airway management during cardiopulmonary resuscitation may involve endotracheal intubation complicated by associated difficulties. Videolaryngoscopy may help to ease these difficulties and increase success rates by removing the need to achieve a direct line of sight required by standard direct laryngoscopy. This literature review aims to establish if there is an overall benefit in using videolaryngoscopy over direct laryngoscopy when intubating patients during cardiac arrest in the non-theatre hospital environment.

Methods

The review was registered on PROSPERO (record ID 329987). A systematic search was conducted of EMBASE, MEDLINE, CINAHL and Web of Science for literature comparing the use of videolaryngoscopy to direct laryngoscopy during intubation of cardiac arrest patients in hospital up until 4th May 2022. The Cochrane Central Register of Controlled Trials (CENTRAL) database was accessed, and reference lists of relevant systematic reviews were analysed for further papers. Forward and backward citation tracking was carried out of the shortlisted papers to hand-search for any further relevant studies. Papers were included in the review if they used adult patients, the patients were intubated during cardiac arrest in hospital and if the papers were in English language or had an accessible translation. Papers were excluded if patients were intubated not during cardiac arrest, the studies were based outside of a hospital setting or in the operating theatre, the patients were paediatric or if the study used a simulation or manikin. The Critical Appraisal Skills Programme checklists were used to assess risk of bias. Odds ratios, confidence intervals and probability values were used to synthesise results.

Results

Six studies were identified that collectively analysed 4525 patients who were intubated during cardiac arrest in the non-theatre hospital environment; five studies were observational and one a randomised controlled trial. Most of the studies being observational in nature led to a significant bias in their methodology which is a limitation to this review. The studies all measured first pass success rate as the primary outcome. First pass success rate only improved with videolaryngoscopy compared to direct laryngoscopy when the intubator was a less experienced clinician. Videolaryngoscopy also reduced some endotracheal intubation related complications and improved glottic visualisation when compared to direct laryngoscopy.

Conclusion

The limited data suggests that use of videolaryngoscopy improved first pass success rates compared to direct laryngoscopy when the clinician was less experienced.

Evidence-based airway management protocol for a critical ill patient in medical intensive care unit: Systematic review

Background

Airway management outside the theatre is performed either to resuscitate a physiologically unstable critically ill patients or to secure an emergency airway in the absence of essential equipments. It is a life saving procedure for critically ill and injured patients. Delaying in securing airway or awaking the patient is not an option in case of difficult airway in intensive care unit. Therefore, developing and implementation of an evidence-based airway management protocol is important.

Objective

This review was conducted to develop a clear airway management protocol for a critical ill patient in medical intensive care unit.

Methods

After formulating the key questions, scope, and eligibility criteria for the evidences to be included, a comprehensive search strategy of electronic sources was conducted. The literatures were searched using advanced searching methods from data bases and websites to get evidences on airway management of a critical ill patient. Duplication of literatures was avoided by endnote. Screening of literatures was conducted based on the level of significance with proper appraisal. This review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement.

Results

A total of 626 articles were identified from data bases and websites using an electronic search. Of these articles, 95 were removed for duplication and 305 studies were excluded after reviewing their titles and abstracts. At the screening stage, 79 articles were retrieved and evaluated for the eligibility. Finally, 40 studies related to airway management of a critical ill patient in medical ICU were included in this systematic review.

Conclusion

A critical ill patient needs oxygenation and ventilation support. A focused and rapid assessment, with special attention of the airway and hemodynamic status of the critical ill patient is paramount. An appropriate airway management option should be employed to resuscitate or to control an emergency airway of a critical ill patent. This could be non invasive ventilation or invasive airway intervention.

Video-Assisted Stylet Intubation with a Plastic Sheet Barrier, a Safe and Simple Technique for Tracheal Intubation of COVID-19 Patients

As the COVID-19 pandemic evolves, infection with the Omicron variants has become a serious risk to global public health. Anesthesia providers are often called upon for endotracheal intubations for COVID patients. Expedite and safe intubation can save patient’s life, while minimizing the virus exposure to the anesthesia provider and personnel involved during airway intervention is very important to protect healthcare workers and conserve the medical work force. In this paper, we share clinical experience of using a video-assisted intubating stylet technique combined with a simple plastic sheet barrier placed over the patients’ mouth for tracheal intubation during the Omicron crisis in Taiwan. We demonstrated that the use of an intubating stylet combined with plastic sheet barrier is swift, safe, and accurate in securing the airway in patients with COVID-19.

Video-Assisted Intubating Stylet Technique for Difficult Intubation: A Case Series Report

Induction of anesthesia can be challenging for patients with difficult airways and head or neck tumors. Factors that could complicate airway management include poor dentition, limited mouth opening, restricted neck motility, narrowing of oral airway space, restricted laryngeal and pharyngeal space, and obstruction of glottic regions from the tumor. Current difficult airway management guidelines include awake tracheal intubation, anesthetized tracheal intubation, or combined awake and anesthetized intubation. Video laryngoscopy is often chosen over direct laryngoscopy in patients with difficult airways because of an improved laryngeal view, higher frequency of successful intubations, higher frequency of first-attempt intubation, and fewer intubation attempts. In this case series report, we describe the video-assisted intubating stylet technique in five patients with difficult airways. We believe that the intubating stylet is a feasible and safe airway technique for anesthetized tracheal intubation in patients with an anticipated difficult airway.

Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery

The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.

Comparison of VividTrac, King Vision and Macintosh laryngoscopes in normal and difficult airways during simulated cardiopulmonary resuscitation among novices

Introduction

Early endotracheal intubation improves neurological outcomes in cardiopulmonary resuscitation, although cardiopulmonary resuscitation is initially carried out by personnel with limited experience in a significant proportion of cases. Videolaryngoscopes might decrease the number of attempts and time needed, especially among novices. We sought to compare videolaryngoscopes with direct laryngoscopes in simulated cardiopulmonary resuscitation scenarios.

Materials and methods

Forty-four medical students were recruited to serve as novice users. Following brief, standardized training, students executed endotracheal intubation with the King Vision^®, Macintosh and VividTrac^® laryngoscopes, on a cardiopulmonary resuscitation trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction.

Results

In the normal airway scenario, significantly shorter intubation times were achieved using the King Vision^® than the Macintosh laryngoscope. In the difficult airway scenario, we found that the VividTrac^® was superior to the King Vision^® and Macintosh laryngoscopes in the laryngoscopy time. In both scenarios, we noted no difference in the first-attempt success rate, but the best view of the glottis and dental trauma, esophageal intubation and bougie use were more frequent with the Macintosh laryngoscope than with the videolaryngoscopes. The shortest tube insertion times were achieved using the King Vision^® in both scenarios.

Conclusion

All providers achieved successful intubation within three attempts, but we found no device superior in any of our scenarios regarding the first-attempt success rate. The King Vision^® was superior to the Macintosh laryngoscope in the intubation time in the normal airway scenario and noninferior in the difficult airway scenario for novice users. We noted significantly less esophageal intubation using the videolaryngoscopes than using the Macintosh laryngoscope in both scenarios. Based on our results, the KingVision^® might be recommended over the VividTrac^® and Macintosh laryngoscopes for further evaluation.

Global distribution of publications in anesthesiology : A bibliometric analysis from 1999 to 2018

PURPOSE

Only few studies have analyzed the global distribution of anesthesia research. This study was designed to reveal the current global research status of anesthesiology.

METHODS

Articles published between 1999 and 2018 in international journals in the field of anesthesiology were retrieved from the PubMed database. The top 20 ranked countries were identified. The gross domestic product (GDP) of each country was also retrieved to reveal the correlation between research outputs and the economy. The total outputs and outputs per 10 million inhabitants in each country were calculated and compared. To analyze the quality of publications among the top 10 ranked countries, the impact factor (IF), article influence score (AIS), and immediacy index (ImI) were calculated and analyzed. In addition, the keywords of publications were retrieved to conduct co-occurrence analysis in order to determine the research focus in anesthesiology.

RESULTS

A total of 112,918 articles were published in 30 selected journals from 1999 to 2018. There was a positive correlation between research outputs and GDP of 10 countries (p < 0.001, r = 0.825). The USA ranked 1st with 21,703 articles, followed by the UK (8393 articles) and Germany (6504 articles). Canada had the highest number of publications per 10 million inhabitants in 2018. The UK had the highest average IF (4.70), average AIS (1.16), and average ImI (1.64) among the 10 countries. The research highlights in the field of anesthesiology included "mechanism and management of pain", "cardiac anesthesia", "pediatric anesthesia and airway management", "analgesia" and "anesthetic agents".

CONCLUSION

Regarding quantity trend, the output of global production in anesthesiology increased continuously as the number of articles from the high-output countries showed an increasing trend; however, there was still a gap between developing and developed countries in research quality. High-quality research should be encouraged in developing countries.

Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting

Aim: Compared with direct laryngoscopy (DL), video laryngoscopy (VL) offers clinical benefits in routine and difficult airways. The health economic benefit of VL versus DL for routine tracheal intubation remains unknown. Materials & methods: This analysis compared VL and DL health economic outcomes, including total inpatient costs, length of hospital stay (LOS), postoperative intensive care unit (ICU) admission and incidence of procedurally associated complications. Results: Patients with VL had decreased inpatient cost (US$1144-5891 across eight major diagnostic categories [MDC]); >1-day LOS reduction in five MDC; reduced odds for postoperative ICU admission (0.04-0.68) and reduced odds of respiratory complications in three MDC (0.43-0.90). Conclusion: Video laryngoscopy may lower total costs, reduce LOS and decrease the likelihood of postoperative ICU admission.

Difficult airway management practice changes after introduction of the GlideScope videolaryngoscope: A retrospective cohort study

BACKGROUND

Introduction of the GlideScope videolaryngoscope caused a change in use of other devices for difficult airway management.

OBJECTIVE

The influence of the GlideScope videolaryngoscope on changes in the indications for and the frequency of use of flexible fibreoptic-assisted intubation and other difficult airway management techniques.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care referral centre.

METHODS

Two periods of equal length (647 days each) before and after introducing the GlideScope were compared. Information about patients who were intubated using nondirect laryngoscopic techniques were analysed. Data were retrieved from the anaesthesia and hospital information management systems.

RESULTS

Difficult airway management techniques were used in 235/8306 (2.8%) patients before and in 480/8517 (5.6%) (P < 0.0001) patients after the introduction of the GlideScope. There was an overall 44.4% reduction in use of flexible fibreoptic bronchoscopy after GlideScope introduction [before 149/8306 (1.8%); after 85/8517 (1.0%), P < 0.0001]. The GlideScope replaced flexible fibreoptic bronchoscopy in most cases with expected and unexpected difficult intubation. In patients with limited mouth opening, flexible fibreoptic bronchoscopy was still mostly the first choice after the introduction of the GlideScope. There was a 70% reduction in the use of other difficult intubation techniques after the introduction of the GlideScope [before 84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)].

CONCLUSION

The GlideScope videolaryngoscope replaced flexible fibreoptic bronchoscopy for most patients with expected and unexpected difficult intubation. In the case of limited mouth opening, flexible fibreoptic bronchoscopy was still the first choice after the introduction of the GlideScope. The reduced use of flexible fibreoptic bronchoscopy raises concerns that residents may not be adequately trained in this essential airway management technique. GlideScope use was disproportionately greater than the reduction in the use of flexible fibreoptic bronchoscopy and other difficult intubation techniques. This may be attributed to resident teaching and use in patients with low-to-moderate suspicion of difficult intubation.

Evolution of videolaryngoscopy in pediatric population

Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.

Endotracheal intubation in patients undergoing open abdominal surgery in the lateral position: a comparison between the intubating video stylet and fiberoptic intubating bronchoscopy

BACKGROUND

Some situations compel anesthetists to execute endotracheal intubation in the lateral position. We compared elective endotracheal intubation in the lateral decubitus position using the video stylet (VS) device with the fiberoptic (FO) bronchoscope device in patients undergoing abdominal surgery.

METHODS

Overall, 50 patients were enrolled in this prospective, randomized study. They were randomly classified into the VS intubation or FO intubating bronchoscope group. After anesthesia induction, patients were placed in the lateral decubitus position, and a single investigator well-versed with the use of the VS and FO bronchoscope performed the intubation. The primary outcome was the time taken for intubation. Secondary outcomes included the intubation success rate, hemodynamic response at specific time points and perioperative complications.

RESULTS

The average time taken for intubation was significantly lesser in the VS group than in the FO group, with values of 39.5 ± 10.0 and 75.6 ± 16.2 s, respectively (P < 0.001). Incidences of a successful first attempt of intubation in the VS and FO groups were 88% and 100%, respectively, showing no significant difference. There was a negligible difference in complications between the groups, except sore throat, which showed a higher incidence in the VS group than in the FO group (P = 0.002).

CONCLUSIONS

In laterally positioned patients, elective endotracheal intubation with VS provides less intubation time; however, its use is accompanied by a significant increase in the hemodynamic response after intubation and an increased incidence of sore throat.

A manikin study comparing the performance of the GlideScope®, the Airtraq® and the C-MAC® in endotracheal intubation using suction-assisted laryngoscopy airway decontamination techniques in a simulated massive haematemesis scenario by emergency doctors

Background:

The suction-assisted laryngoscopy and airway decontamination (SALAD) techniques (level 1, SALAD-1 and level 2, SALAD-2) are newly proposed airway management skills to facilitate endotracheal intubation in patients with massive haematemesis. A pilot study using GlideScope® demonstrated the superior performance of SALAD-1 technique in massive haematemesis simulation.

Objectives:

To compare the performance of three different video laryngoscopes (the GlideScope®, the Airtraq® and the C-MAC®) in endotracheal intubation using SALAD techniques by emergency doctors in a manikin simulating massive haematemesis.

Methods:

Forty-eight emergency doctors were recruited. The participants’ performance of endotracheal intubation using the GlideScope®, the Airtraq® and the C-MAC® with the conventional and the two SALAD techniques in a manikin simulating massive haematemesis was evaluated. The time for intubation, number of attempts, rate of failed intubation, amount of aspirated fluid and the subjective ease of different devices and techniques were compared.

Results:

The C-MAC® had shorter intubation time compared with GlideScope® when using conventional (mean intubation time: 28.48 vs 47.00 s, p = 0.018) and SALAD-1 technique (mean intubation time: 29.35 vs 43.25 s, p < 0.039). The intubation time of all three video laryngoscopes was similar in SALAD-2 technique. There was no significant difference in the number of attempts and failed intubation rate among different video laryngoscopes in using different techniques. Intubation with the C-MAC® resulted in the least mean amount of aspiration in all the conventional (35.63 mL), SALAD-1 (14.06 mL) and SALAD-2 (18.13 mL) techniques. However, the results were not significantly different from the GlideScope® and the Airtraq®. The C-MAC® was rated the most favourable video laryngoscope for the SALAD-1 technique (p < 0.001). There was no significant preference for different video laryngoscopes in using the SALAD-2 technique (p = 0.111).

Conclusion:

All the video laryngoscopes have similar intubation performance with the SALAD-1 and SALAD-2 techniques. The C-MAC® performed better than GlideScope® in terms of intubation time. The C-MAC® was the most favourable video laryngoscope for the SALAD-1 technique.

Utility of videolaryngoscopy for diagnostic and therapeutic interventions in head and neck surgery

BACKGROUND

Videolaryngoscopy is commonly used by anesthesiologists to manage difficult airways. Recently otolaryngologists have reported use in select procedures; to date there is limited evaluation in head and neck surgery.

MATERIALS AND METHODS

Patients who underwent direct laryngoscopy (DL) with use of GlideScope videolaryngoscopy (GVL) were retrospectively identified from a tertiary care Veterans Affairs hospital. GVL was used to assist or replace traditional laryngoscopes for diagnostic and therapeutic procedures.

RESULTS

Nineteen patients (48-83 years old) underwent 21 procedures. Difficult endotracheal intubation was reported in 53% of patients. GVL replaced traditional DL in 76% of cases, assisted evaluation prior to traditional DL in 10%, and rescued failed traditional DL in 14%. No complications occurred. Three indications for GVL were identified.

DISCUSSION

GVL was safe in our experience and provides unique benefits in selected scenarios in head and neck surgery. Otolaryngologists can consider videolaryngoscopy as a complement to traditional DL.

A Comparison of Direct Laryngoscopy and Videolaryngoscopy for Endotracheal Intubation by Inexperienced Users: A Pediatric Manikin Study

OBJECTIVE

Direct laryngoscopy (DL) is the most common technique for endotracheal intubation, whereas videolaryngoscopy provides an indirect view of the glottis without the need to align the oral, pharyngeal, and tracheal axes. The current study compares videolaryngoscopy with DL among experienced and inexperienced users for endotracheal intubation using a pediatric manikin.

METHODS

Participants performed DL using Miller and Macintosh laryngoscopes and videolaryngoscopy using CMAC and GlideScope devices on a manikin (SimBaby; Laerdel, Wappingers Falls, NY). Time to endotracheal intubation, number of attempts, and successful intubation within 120 seconds were recorded.

RESULTS

Among 31 experienced users, time to endotracheal intubation with the CMAC (20 ± 13 seconds) did not differ from DL with either the Miller (30 ± 28 seconds) or Macintosh (27 ± 23 seconds) laryngoscopes. However, with the GlideScope, time to endotracheal intubation (85 ± 38 seconds) was longer. The results were similar among 12 inexperienced users, as time to endotracheal intubation with the CMAC (61 ± 34 seconds) was comparable with the Miller (72 ± 45 seconds) or Macintosh (72 ± 45 seconds) laryngoscopes but was longer with the GlideScope (118 ± 6 seconds) for each comparison.

CONCLUSIONS

The standard straight or curved laryngoscope blades including the CMAC were associated with shorter procedural time and higher success rate when compared with indirect videolaryngoscopy with an unconventional blade design such as the GlideScope in both experienced and inexperienced users. However, the current study demonstrates that results may be influenced by the anatomical design of the manikin.

Videolaryngoscopy for transesophageal echocardiography probe insertion: a systematic review and meta-analysis of randomized controlled trials

Transesophageal echocardiography (TEE) is a well-established procedure, but serious complications may occur. This systematic review and meta-analysis assessed the utility of videolaryngoscopy-assisted technique in TEE probe insertion. We performed a systematic search in MEDLINE, EMBASE, CENTRAL, and ICTRP. We included RCTs comparing TEE probe insertion techniques assisted with videolaryngoscopy and with any other insertion technique in adult patients. Primary outcome measures were (1) the number of attempts before successful TEE probe insertion, and (2) the risk of any procedural injury to related structures. The secondary outcome measure was time to TEE probe insertion. In total, three studies (n = 266) were included in this systematic review. Overall, a significantly less number of attempts were required with videolaryngoscopy-assisted insertion (mean difference [MD] - 0.60; 95% confidence interval [CI] - 0.73, - 0.46; low quality of evidence). Videolaryngoscopy-assisted technique was also associated with smaller risk of complications (risk ratio [RR] 0.17; 95% CI 0.05, 0.62; low quality of evidence). There was no significant difference in time to probe insertion (MD - 8.57; 95% CI - 26.31, 9.16; very low quality of evidence). The use of videolaryngoscopy for TEE probe insertion is associated with a significant reduction in the number of attempts and complication rate.

Comparison of adverse events between video and direct laryngoscopes for tracheal intubations in emergency department and ICU patients-a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis was designed to determine whether video laryngoscope (VL) compared with direct laryngoscope (DL) could reduce the occurrence of adverse events associated with tracheal intubation in the emergency and ICU patients.

METHODS

The current issue of Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science (from database inception to October 30, 2018) were searched. The RCTs, quasi-RCTs, observational studies comparing VL and DL for tracheal intubation in emergency or ICU patients and reporting the rates of adverse events were included. The primary outcome was the rate of esophageal intubation (EI). Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible RCT. The ACROBAT-NRSi Cochrane Risk of Bias Tool was applied to assess the risk of bias for each eligible observational study.

RESULTS

Twenty-three studies (13,117 patients) were included in the review for data extraction. Pooled analysis showed a lower rate of EI by using VL (relative risk [RR], 0.24; P < 0.01; high-quality evidence for RCTs and very low-quality evidence for observational studies). Subgroup analyses based on the type of studies, whether a cardiopulmonary resuscitation study, or operators' expertise showed a similar lower rate of EI by using VL compared with DL in all subgroups (P < 0.01) except for experienced operators (RR, 0.44; P = 0.09). There were no significant differences between devices for other adverse events (P > 0.05), except for a lower incidence of hypoxemia when intubation was performed with VL by inexperienced operators (P = 0.03).

CONCLUSIONS

Based on the results of this analysis, we conclude that compared with DL, VL can reduce the risk of EI during tracheal intubation in the emergency and ICU patients, but does not provide significant benefits on other adverse events associated with tracheal intubation.

A national survey of videolaryngoscopes and alternative intubation devices in Hungary

INTRODUCTION

Videolaryngoscopy (VL) as a new airway management technique has evolved in recent decades, and a large number of videolaryngoscopes are now available on the market. Most recent major guidelines already recommend the immediate availability and use of VL in difficult airway management scenarios. However, national data on the availability of VL, introduction into practice and patterns of use are rarely published. Therefore, the current study aimed to provide data on VL in Hungary.

MATERIALS AND METHODS

An electronic survey was designed and popularized with the help of the Hungarian Society of Anaesthesiology and Intensive Therapy to explore the availability, use, and practice of and attitudes toward VL among Hungarian anesthesiologists. The survey was conducted between 01.01.2018 and 31.12.2018.

RESULTS

In total, 324 duly completed forms were returned and analyzed. Responders were mainly males (58%), specialists (80%) and those involved mainly in anesthesia practice (68%) in the public sector. Two hundred and ten (65%) responders had access to various videolaryngoscopes and were mainly from surgery, intensive care and traumatology units. No responders reported the availability of eight videolaryngoscopes out of the eighteen listed devices, and 32% of the responders had never used any videolaryngoscope in clinical settings. The most commonly available devices were KingVision, MacGrath Mac and Airtraq. Most of the responders reported using videolaryngoscopes mainly for difficult airway management and reported using a fiberscope as the first alternative device. Popular methods for selecting videolaryngoscopes included the following: short clinical trial (n = 67/324), decision of the departmental lead (n = 65/324) and price (n = 54/324). The majority of responders had some training prior to clinical application, but training was mainly voluntary. Overall, 98% of the responders considered videolaryngoscopes beneficial.

CONCLUSIONS

Approximately two-thirds of Hungarian anesthesiologists have immediate access to videolaryngoscopes, which are used mainly for difficult airway management. The overall attitude towards VL is positive, and many videolaryngoscopes are known and have been used by Hungarian anesthesiologists. However, only a few devices on the market are used commonly. Based on the results, further improvement might be recommended regarding VL training and availability.

Comparison between use of single lightwand and video laryngoscope-guided lightwand for tracheal intubation in simulated cervical spine-immobilized patients: a single-blind randomized study

Objective

This study was performed to compare the use of a video laryngoscope-guided lightwand versus a single lightwand for tracheal intubation performed by non-experts in cervical spine-immobilized patients.

Methods

In total, 318 patients under general anesthesia were assigned either to the single lightwand group (Group L) or the video laryngoscope-guided lightwand group (Group VL) at a 1:1 ratio. First- or second-grade residents performed tracheal intubation with the assigned device after applying semi-hard fitted cervical collars to the patients. Outcomes, including the success rate and airway complications, were compared between the two groups.

Results

There were no significant differences in demographics or airway-related characteristics between the two groups. The success rate of intubation on the first attempt was significantly higher in Group VL than in Group L (90% vs. 64%, respectively). Postoperative complications, including oral mucosal bleeding, hoarseness, and sore throat scores at 1 and 24 hours after surgery, were significantly lower in Group VL than in Group L.

Conclusions

The use of a video laryngoscope-guided lightwand for tracheal intubation can be useful for non-experts who encounter difficult airway situations.

Recent advances in laryngoscopy in adults

Recent advances in technology have made laryngoscopy less dependent upon a direct line of sight to achieve tracheal intubation. Whether these new devices are useful tools capable of increasing patient safety depends upon when and how they are used. We briefly consider the challenges in reviewing the emerging literature given the variety of devices, "experience" of the care providers, the clinical settings, and the definitions of outcome. We examine some of the limitations of conventional direct laryngoscopy, question the definitions we have used to define success, discuss the benefits of indirect (video) techniques, and review evidence pertaining to their use in the patients in the operating room, emergency department, and intensive care unit.

The teaching order of using direct laryngoscopy first may improve the learning outcome of endotracheal incubation: A preliminary, randomized controlled trial

BACKGROUND

Endotracheal intubation (ETI) is a life-saving procedure taught to medical students. We examined the influence of the order of teaching ETI through direct laryngoscopy (DL) and video laryngoscopy (VL) on learning by measuring the intubation time and learning curve of trainees, in order to explore ways to improve ETI performance.

METHODS

Twenty trainees were randomly divided into 2 groups. In the DL-first group, trainees used DL to perform ETI 10 times and then used VL 10 times, while the order was reversed in the VL-first group. Intubation time, number of intubation attempts, the Cormack-Lehane (CL) classification, and adverse events were recorded. The primary outcome was the cumulative summation (CUSUM). The CUSUM equation is defined as (Equation is included in full-text article.), where ct is the cumulative sum.

RESULTS

ETI was attempted on 400 patients. The difference in the mean times for the first 10 intubations between the 2 groups was not significant (P > .05). Mean intubation time for second series in the DL-first group was significantly shorter than that of the first series (P < .05), while there were no differences between the 2 series in the VL-first group (P > .05). The mean intubation time in the second series of the DL-first group was shorter than for the first series of the VL-first group (P < .05), while the mean intubation time of the first series by the DL-first group did not differ from the second series by the VL-first group (P > .05). Eighteen attempts were required to achieve an 80% intubation success rate for the DL-first group, while more than 20 attempts were required for the trainees in the VL-first group.

CONCLUSION

We consider that teaching trainees DL for tracheal intubation first.

CLINICAL TRIAL NUMBER

ChiCTR-OOR-16008364.

Prospective Trial to Compare Direct and Indirect Laryngoscopy Using C-MAC PM® with Macintosh Blade and D-Blade® in a Simulated Difficult Airway

Objective. Evaluation of C-MAC PM® in combination with a standard Macintosh blade size 3 in direct and indirect laryngoscopy and D-Blade® in indirect laryngoscopy in a simulated difficult airway. Primary outcome was defined as the best view of the glottic structures. Secondary endpoints were subjective evaluation and assessment of the intubation process. Methods. Prospective monocentric, observational study on 48 adult patients without predictors for difficult laryngoscopy/tracheal intubation undergoing orthopedic surgery. Every participant preoperatively received a cervical collar to simulate a difficult airway. Direct and indirect laryngoscopy w/o the BURP maneuver with a standard Macintosh blade and indirect laryngoscopy w/o the BURP maneuver using D-Blade® were performed to evaluate if blade geometry and the BURP maneuver improve the glottic view as measured by the Cormack-Lehane score. Results. Using a C-MAC PM® laryngoscope, D-Blade® yielded improved glottic views compared with the Macintosh blade used with either the direct or indirect technique. Changing from direct laryngoscopy using a Macintosh blade to indirect videolaryngoscopy using C-MAC PM® with D-Blade® improved the Cormack-Lehane score from IIb, III, or IV to I or II in 31 cases. Conclusion. The combination of C-MAC PM® and D-Blade® significantly enhances the view of the glottis compared to direct laryngoscopy with a Macintosh blade in patients with a simulated difficult airway. Trial Registration Number. This trial is registered under number NCT03403946.

C-MAC© videolaryngoscopy: The anaesthetic assistant's view

Although videolaryngoscopy plays a major role in the 2015 Difficult Airway Society guidelines, the impact on anaesthetic assistant working practices and training has not previously been reported. We surveyed anaesthetic assistants in our hospital to document their experience with using the C-MAC^© videolaryngoscope (48 practitioners, 100% response rate). Improvements in the following were reported: patient safety 100%; ability to see whether laryngoscopy is difficult 98%; ability to anticipate the 'next step' 98%; team-working and human factors 96%; ability to call a senior anaesthetist more quickly 94%; assessment or adjustment of cricoid force application 92%, understanding of laryngeal anatomy 92%; training in intubation 98%; training in cricoid force application 87%. Concerns were primarily about local issues such as decontamination and blade availability. Ninety percent reported that the clinical benefit outweighed any additional workload. In conclusion, the C-MAC^© videolaryngoscope is judged by anaesthetic assistants to confer numerous advantages for their working practice and training.

Should the Glidescope video laryngoscope be used first line for all oral intubations or only in those with a difficult airway? A review of current literature

The purpose of this study was to review literature that looked into the efficacy of the Glidescope video laryngoscope versus the Macintosh laryngoscope in oral endotracheal intubations. We aimed to answer the question 'Should the Glidescope video laryngoscope laryngoscopes be used as first line intubation aids or only in the difficult airway?' A systematic search of electronic databases was made. The inclusion criteria included: Glidescope, video laryngoscope, and Macintosh laryngoscope in human studies. The study aimed to compare first attempt success rate, glottic view and intubation time in papers dating between 2009 and 2017. Eleven trials with a total of 7,919 patients with both difficult and normal airways were included. The trials showed an improvement in first attempt success rate and glottic view with the Glidescope video laryngoscope especially in those with difficult airways. Overall time to intubate showed no significant differences between the Glidescope video laryngoscope and the Macintosh laryngoscope although it was identified that with increased training and experience with the Glidescope video laryngoscope, intubation time was reduced. Glidescope video laryngoscopes show advantages over the Macintosh laryngoscopes in obtaining better glottic views in those with difficult airways. However its use is not supported in all routine intubations.

Current Evidences for the Use of UEscope in Airway Management

Objective:

UEscope is a new angulated videolaryngoscope (VL). This review aimed to describe the features of UEscope and provide clinical evidences regarding the efficacy and safety of this video device in adult tracheal intubation and its roles in airway management teaching.

Data Sources:

The Wan Fang Data, CNKI, PubMed, Embase, Cochrane Library, and Google Scholar were searched for relevant English and Chinese articles published up to January 15, 2017, using the following keywords: “HC video laryngoscope”, “UE videolaryngoscope”, “video laryngoscope”, and “videolaryngoscopy”.

Study Selection:

Human case reports, case series, observable studies, and randomized controlled clinical trials were included in our search. The results of these studies and their reference lists were cross-referenced to identify a common theme.

Results:

UEscope features the low-profile portable design, intermediate blade curvatures, all-angle adjustable monitor, effective anti-fog mechanisms, and built-in video recording function. During the past 5 years, there have been a number of clinical studies assessing the application and roles of UEscope in airway management and education. As compared with direct laryngoscope, UEscope improves laryngeal visualization, decreases intubation time (IT), and increases intubation success rate in adult patients with normal and difficult airways. These findings are somewhat different from the previous results regarding the other angulated VLs; they can provide an improved laryngeal view, but no conclusive benefits with regard to IT and intubation success rate. Furthermore, UEscope has extensively been used for intubation teaching and shown a number of advantages.

Conclusions:

UEscope can be used as a primary intubation tool and may provide more benefits than other VLs in patients with normal and difficult airways. However, more studies with large sample are still needed to address some open questions about clinical performance of this new VL.