Randomized comparison of the effectiveness of nasal intubation using a GlideScope video laryngoscope with Magill forceps versus vascular forceps in patients with a normal airway

A study to evaluate nasotracheal intubation using Airtraq laryngoscope with a bougie and without a bougie

Background and Aims

Airtraq has been found to be useful in improving the view of the glottis. However, directing the tube tip into the glottis can be challenging during nasotracheal intubation. This problem gets resolved if the bougie is placed first. The present study was conducted for the evaluation of nasotracheal intubation using a nasal Airtraq laryngoscope with and without a bougie.

Methods

Fifty patients of either gender, aged between 18 and 60 years, who belonged to the American Society of Anesthesiologists physical status (PS) I or II, requiring nasotracheal intubation were included. In group I (number (n) = 25), nasotracheal intubation was performed with a bougie, and in group II (n = 25), it was performed without a bougie. The primary objective was a comparison of the time taken to achieve successful nasotracheal intubation. Secondary objectives were ease of intubation and additional manoeuvres required for intubation.

Results

The mean (± standard deviation) for time for intubation in group I was 59.24 ± 9.98 s and that in group II was 41.00 ± 4.23 s (P = 0.001). Two patients (8%) in group I and ten patients (40%) in group II required additional manoeuvres for intubation (P = 0.008). Twenty-three patients (92%) in group I and 15 patients (60%) in group II had easy intubation (P = 0.030). In group I, no patient had trauma, whereas, in group II, four patients (16%) had trauma (P = 0.030) during intubation.

Conclusion

The time taken for nasotracheal intubation using an Airtraq laryngoscope was more with the use of a bougie as compared to the non-bougie technique. However, bougie-guided intubation was easier with less requirement of additional manoeuvres. In addition, trauma was also significantly less with the bougie technique.

Cuff inflation technique is better than Magill forceps technique to facilitate nasotracheal intubation guiding by GlideScope® video laryngoscope

Video laryngoscopy is often selected to assist nasotracheal intubation in allowing better laryngeal visualization, although there is no comparative study evaluating the effectiveness between auxiliary techniques by using Magill forceps and inflated cuff in GlideScope video laryngoscopy for nasotracheal intubation. Fifty-one of 100 patients in a Magill forceps group and 47 of 100 patients in a cuff inflation group were included in the final analysis in this randomized, single-blind, parallel, clinical trial study. Induction agents were routinely administered according to body weight, while intubation time spent, attempts, and related side effects were recorded. Compared to the Magill forceps group, the cuff inflation technique shortened the total intubation time (70.0 ± 24.5 s vs. 87.0 ± 25.0 s, p = 0.001) and the time of advancing the nasotracheal tube from oropharyngeal space into the trachea (25.9 ± 16.4 s vs. 42.3 ± 21.2 s, p < 0.001). However, the number of intubation attempts was not significantly different between groups. During tube advancement, the tube was rotated to accommodate the glottis and trachea more frequently in the cuff inflation group (p = 0.009), but the blade of the laryngoscope shifted and was adjusted to the proper position more frequently in the Magill forceps group (p < 0.001). In the Magill forceps group, the tube cuff might be clipped incidentally and the intubator might shift their gaze away from the screen during intubation, although there was no significant difference in intubation-related side effects between groups. Unlike the conventional approach, nasotracheal intubation with the GlideScope® video laryngoscope using the auxiliary technique of cuff inflation could be more suited than using Magill forceps.

A Comparison of McGrath Videolaryngoscope versus Macintosh Laryngoscope for Nasotracheal Intubation: A Systematic Review and Meta-Analysis

Background: In this study, it was shown that the routine use of McGrath videolaryngoscopy may improve intubation success rates. The benefits to using a videolaryngoscope in nasotracheal intubation were also demonstrated. However, no solid evidence concerning the effectiveness of the use of McGrath videolaryngoscopes in nasotracheal intubation has previously been reported. As a result, we questioned whether, in adult patients who underwent oral and maxillofacial surgeries with nasotracheal intubation (P), the use of a McGrath videolaryngoscope (I) compared with a Macintosh laryngoscope (C) could reduce the intubation time, improve glottis visualization to a score of classification 1 in the Cormack–Lehane classification system, and improve the first-attempt success rate (O). The secondary outcomes measured were the rate of the use of Magill forceps and the external laryngeal pressure (BURP) maneuver used. Methods: An extensive literature search was conducted using databases. Only randomized controlled trials that compared the McGrath videolaryngoscopy and Macintosh laryngoscopy techniques in nasotracheal intubation in adult patients were included. Results: Five articles met the inclusion criteria and were included in the final analysis (n = 331 patients). The results showed a significant decrease in intubation time and a higher rate of classification 1 scores in the Cormack–Lehane classification system, but no difference in the first-attempt success rates were found between the McGrath group and the Macintosh group. Decreases in the rate of the use of Magill forceps and the use of the external laryngeal pressure maneuver were also found in the pooled analysis. With regard to the overall risk of bias, the selected trials were classified to have at least a moderate risk of bias, because none of the trials could blind the operator to the type of laryngoscope used. Conclusions: Our analysis suggests that the use of a McGrath videolaryngoscope in nasotracheal intubation resulted in shorter intubation times, improved views of the glottis and similar first-success rates in adult patients who received general anesthesia for dental, oral, maxillofacial, or head and neck cancer surgery, and also reduced the use of Magill forceps and the BURP maneuver.

A comparison of intubating conditions for nasotracheal intubation with standard direct Macintosh laryngoscope versus C-MAC® video laryngoscope employing cuff inflation technique in adult patients

Background and Aims:

While performing laryngoscopy during nasotracheal intubation (NTI), the tip of the advancing endotracheal tube (ETT) generally lies along the posterior pharyngeal wall. The inflation of the ETT cuff brings it anterior towards the glottis. The present study was planned to compare the intubating conditions for NTI with standard direct Macintosh laryngoscope versus C-MAC^® video laryngoscope (VL) employing ETT cuff inflation technique.

Methods:

This prospective randomised study was carried out on 50 patients, American Society of Anesthesiologists physical status I–II, age 18–60 years of either sex with an indication for NTI under general anaesthesia. They were randomly divided into two groups: group VL (n = 25): C-MAC^® VL and group ML (n = 25): Macintosh laryngoscope. The primary outcome was to compare the total duration of NTI (T), while the secondary outcomes were to compare the need for cuff inflation or assistance with Magill forceps for successful NTI, the total number of attempts to achieve successful NTI, haemodynamic effects and complications.

Results:

T was significantly higher in group ML than group VL (P < 0.001). The intubation was successful with cuff inflation in all the patients in group VL, however, six patients of group ML required assistance with Magill forceps (P = 0.022). The haemodynamic parameters were all significantly higher at 3 min in group ML in comparison to group VL.

Conclusion:

The cuff inflation technique when used along with C-MAC^® VL had more success rate, required lesser time and had minimal postoperative complications in comparison to the Macintosh laryngoscope.

Comparison of a tube core and Magill forceps for nasotracheal intubation: a randomised controlled trial

Background

Magill forceps are frequently used to complete nasotracheal intubation (NTI). We aimed to identify a tube core that could conveniently facilitate the NTI process without using Magill forceps.

Methods

Sixty patients scheduled for oral and maxillofacial surgeries were enrolled in our study and divided into two groups (30 per group) with no differences with regard to demographic data. In the Magill forceps group (Group M), a wire-reinforced endotracheal catheter was inserted into the trachea using Magill forceps. However, in the tube core group (Group T), a tube core bent to the physiological curve of the nasal cavity and lubricated with aseptic paraffin oil was inserted into the endotracheal catheter and was then withdrawn after the endotracheal catheter was advanced through the glottis under direct vision.

Results

All NTIs were completed successfully, and Magill forceps were not used on any patient in Group T. There was a significant difference in total NTI time between the two groups (Group M, 59.7 (5.1) s vs Group T, 52.4 (3.1) s). Mild epistaxis was observed in 6 patients in Group M and 5 patients in Group T (6/30 vs 5/30, respectively). No damage to oral tissue or teeth was observed in either group.

Conclusions

We conclude that using a tube core, consisting of a disposable sterilised stylet, is a convenient choice for NTI.

Trial registration

Patient enrolment was conducted after registration in the Chinese Clinical Trial Registry (www.Chictr.org.cn, ChiCTR190002 7387). This trial was prospectively registered on 11 November 2019.

Total control introducer-aided nasotracheal intubation using a videolaryngoscope in an anticipated difficult airway: a novel technique

Nasotracheal intubation can be challenging due to undesirable incidence of nasal bleeding and soft tissue injuries. The bleeding can obscure glottis visualisation, increase the total intubation time, the risk of aspiration and oxygen desaturation. Total control introducer is a new airway adjunct with a flexible shaft, articulating tip and an intuitive depth control system, which can be used in difficult airway scenarios to improve the success of nasal intubations.