Less postoperative sore throat after nasotracheal intubation using a fiberoptic bronchoscope than using a Macintosh laryngoscope: A double-blind, randomized, controlled study

Effectiveness of nasotracheal intubation in anterior cervical surgery including C3 lesions

OBJECTIVE

Anterior approach cervical surgery is widely used for accessing C3 lesions. When operating with an anterior approach, the surgical field is obstructed by mandible. Neck extension is popular method to secure better surgical field but risk devastating neurological damage. To overcome this limited surgical field without neck extension, we adopted nasotracheal intubation and evaluated its efficiency.

METHODS

We retrospectively analyzed 16 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via nasotracheal intubation. We enrolled an additional 29 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via orotracheal intubation as a control group. All patients had been diagnosed with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament. We measured the mandibular-cervical angle, which is the angle between the lower mandibular line and anterior vertebral line.

RESULTS

The mandibular-cervical angle was increased by 7.3 with nasotracheal intubation compared to orotracheal intubation.

CONCLUSIONS

Nasotracheal intubation is an effective surgical option for securing the surgical field without neck extension in anterior cervical surgery including C3 lesions.

Does Increasing the Bend Angle of a Stylet to 90° Increase the Nasotracheal Intubation Success Rate?

BACKGROUND

Video-stylet-guided nasotracheal intubation (NTI) is an effective technique for airway management. However, the impact of the bend angle on the success rate of intubation remains unclear.

PURPOSE

Does increasing the bend angle of a stylet to 90° increase NTI success rate?.

STUDY DESIGN, SETTING, SAMPLE

This prospective randomized controlled trial was conducted in the operating room of a population-based hospital. Adult patients requiring NTI were recruited.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The primary predictor variable is the choice of stylet bend angle (90° vs 70° bend) in NTI.

MAIN OUTCOME VARIABLE(S)

The primary outcome variables were success rates of NTI, defined as the proportion of successful intubation cases to total cases.

COVARIATES

Demographics, intubation time, the distance from the thyroid prominence to the nostril, additional maneuvers applied during intubation, and cases of epistaxis were recorded.

ANALYSES

The student's t-test was used to compare continuous variables between groups. Ordinal data (intubation attempts, head extension, and epistaxis) were analyzed using the Wilcoxon rank-sum test. As appropriate, frequency (external pharyngeal pressure) was analyzed using the χ2 test or Fisher's exact test. A P value of <.05 was considered statistically significant.

RESULTS

Of the 103 subjects assessed for eligibility, 98 were enrolled in the study. The mean age (27.0 ± 6.9 years vs 27.0 ± 4.1 years, P = .972) and sex differences (male/female: 9/40 vs 7/42, P = .136) were comparable between groups. The overall success rate in the 70° group was significantly lower than that in the 90° group (91.8 vs 100%, P < .001). The intubation time in the 70° group was significantly longer than that in the 90° group (43.2 ± 15.8 s vs 33.7 ± 7.3 s, P < .001).

CONCLUSIONS AND RELEVANCE

A 90° bend angle of the stylet significantly improves the likelihood of successful NTI.

Slow advancement of the endotracheal tube during fiberoptic-guided tracheal intubation reduces the severity of postoperative sore throat

Although fiberoptic-guided tracheal intubation is a gentler method than using a direct laryngoscope, injury may occur owing to impingement between the distal edge of the endotracheal tube and the glottis. This study aimed to investigate the effects of endotracheal tube advancement speed during fiberoptic-guided intubation on airway symptoms postoperatively. We randomized patients scheduled for laparoscopic gynecological surgery to either Group C or S. When advancing the tube over the bronchoscope, the operator advanced the tube at a normal speed in Group C and at a slower speed in Group S. The speed in Group S was approximately half that in Group C. The target outcomes were the severity of postoperative sore throat, hoarseness, and cough. Patients in Group C experienced a more severe sore throat than those in Group S at 3 and 24 h postoperatively (p = 0.001 and p = 0.012, respectively). However, the severity of hoarseness and cough postoperatively were not significantly different between the groups. In conclusion, the slow advancement of the endotracheal tube during fiberoptic-guided intubation can reduce sore throat severity.

Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial

BACKGROUND

During fiberoptic-guided tracheal intubation, impingement between the distal tip of the endotracheal tube and the airway tissue can cause difficulties in tube insertion or tissue damage during the tube advancement over the bronchoscope. This randomized controlled study aimed to investigate the effects of the endotracheal tube's bevel direction on the complications associated with airway injury when performing fiberoptic-guided tracheal intubation.

METHODS

The study subjects were divided into 2 groups: L (control) and D (study). When advancing the tube over the bronchoscope, the tube's bevel was facing the patients' left in Group L and the dorsal direction in Group D. According to the degree of resistance at the time of tube advancement, the insertion score was graded in 3 stages; the severity of the patients' sore throat and hoarseness was evaluated and recorded postoperatively.

RESULTS

The severity of postoperative sore throat was higher in Group L than in Group D 3 hours and 24 hours after surgery. (P = .008, P = .023, respectively). The tube insertion score was comparable between the groups. The severity of postoperative hoarseness did not vary significantly between the groups.

CONCLUSION

Endotracheal tube insertion with the bevel facing the dorsal direction of the patient during fiberoptic-guided tracheal intubation reduced the severity of postoperative sore throat in patients undergoing laparoscopic gynecologic surgery.

Alternative Technique for Nasotracheal Intubation Using a Flexible Fiberoptic Scope

In oral maxillofacial surgery, the endotracheal tube (ETT) is often inserted nasotracheally to provide surgeons a better view and easier access to the oral cavity. Use of a flexible fiberoptic scope is an effective technique for difficult intubation. While the airway anatomy can be observed as the scope is advanced, the ETT tip cannot be observed with the traditional method. It is occasionally difficult to advance the ETT beyond the glottis as impingement of the ETT tip may occur. We devised a new nasotracheal intubation technique using a fiberoptic scope. In this novel technique, the ETT and fiberoptic scope are inserted into the pharyngeal space separately through the right and left nasal cavities. This permits continuous observation of the glottis as the ETT is advanced into the trachea. The main advantage of this technique is that the ETT tip is visualized as it is advanced, which helps avoid impingement of the ETT. If resistance is noted, the ETT can easily be rotated or withdrawn without causing laryngeal damage, leading to safe and smooth intubation. This novel technique allows advancement of the ETT under continuous indirect vision, thus minimizing contact of the ETT with the laryngeal structures and aiding in unhindered passage into the glottis.

Risk Factors for Postoperative Sore Throat After Nasotracheal Intubation

OBJECTIVE

Postoperative sore throat is relatively frequent complication after orotracheal intubation. However, there are few reports about postoperative sore throat in nasotracheal intubation. In this retrospective study, we investigated the risk factors of postoperative sore throat in nasotracheal intubation.

METHODS

Anesthesia records of patients 16 to 80 years of age who underwent nasotracheal intubation were included. Patients underwent oral and maxillofacial surgery from February 2015 until September 2018. Airway device (Macintosh laryngoscope, Pentax-AWS, or McGRATH video laryngoscope, or fiberoptic scope), sex, age, height, weight, American Society of Anesthesiologists classification, intubation attempts, duration of intubation, intubation time, tube size, and fentanyl and remifentanil dose were investigated. Fisher exact test, Wilcoxon rank sum test, Welch t test, and Steel-Dwass multiple test were used, and a multivariable analysis was performed using stepwise logistic regression to determine the risk factors of postoperative sore throat.

RESULTS

A total of 169 cases were analyzed, and 126 patients (74.6%) had a postoperative sore throat. Based on the univariate analysis of the data, 12 factors were determined to be potentially related to the occurrence of a postoperative sore throat. However, after evaluation using stepwise logistic regression analysis, the 2 remaining variables that correlated with postoperative sore throat were airway device (P &lt; .05) and intubation attempts (P = .04). In the model using logistic regression analysis, the fiberoptic scope had the strongest influence on the incidence of sore throat with reference to Pentax-AWS (odds ratio = 5.25; 95% CI = 1.54-17.92; P &lt; .05).

CONCLUSION

Use of a fiberoptic scope was identified as an independent risk factor for postoperative throat discomfort. Compared with direct laryngoscopy and other video laryngoscopes, the use of a fiberoptic scope had a significantly higher incidence of sore throat.

Combined Video Laryngoscope and Fiberoptic Nasal Intubation

Techniques for facilitating nasal intubation and reducing associated airway trauma are well documented in the literature. This case series describes an additional technique that combines the use of the video laryngoscope and fiberoptic bronchoscope for intubation. Rather than first starting with the fiberoptic bronchoscope, an endotracheal tube is passed through the nasopharynx and lined up with the glottis using video laryngoscopy. Subsequently, the fiberoptic bronchoscope is used only to guide the endotracheal tube through the glottis. The two perspectives simultaneously provide enhanced guidance to the operator, which can, in turn, reduce the burden of fiberoptic navigation through blood, secretions, and/or altered airway anatomy. Additionally, our report demonstrates that this procedure can be used as a rescue measure when Magill forceps are unsuccessful.

Post operative sore throat: Comparison between Macintosh versus Video Laryngoscope in patients intubated by trainee anaesthetists - A Randomised Control Trial

Objectives:

Postoperative sore throat (POST) is a common complication related to endotracheal intubation. The aim of this study was to compare the incidence of POST in patients intubated by trainee anaesthetist using Video Laryngoscope™ (VDL) or Conventional Macintosh Laryngoscope (CL).

Methods:

Total 110 patient scheduled for elective laparoscopic cholecystectomy were included from main operating room of Aga Khan University Hospital between June 2017-2018. The standardized perioperative protocol was used for general anaesthesia. Selected patients were randomly allocated into conventional laryngoscopy (CL) group or video laryngoscopy (VDL) group. The evaluation of sore throat was done at 1st, 12th and 24th hour postoperatively using a ten-point visual analogue scale.

Results:

The demographic characteristics, including intubation time, related complications or any other maneuver required were similar between the groups. The incidence of POST at 1st hour was 47% patients in CL group and 38% in VDL group (p=0.335). At 12th hour, 34.5% patients in CL and 38% in VDL reported POST (p=0.692). Similarly at 24th hour, 25% patients in CL and 16% in VDL group reported POST (p=0.669).

Conclusions:

There was no significant difference in incidence of POST for patients intubated by trainee anaesthetists using either CL or VDL. Objective evidence of training and laryngoscope technique can impact of POST.

A randomized trial to evaluate a modified tracheal catheter with upper and lower balloons for anesthetic administration: effect on the cardiovascular, stress response, and comfort in patients undergoing laparoscopic cholecystectomy

Background

We aimed to evaluate a modified endotracheal tube containing upper and lower balloons for anesthetic administration among patients undergoing laparoscopic cholecystectomy.

Methods

Ninety patients scheduled to undergo laparoscopic cholecystectomy were randomly allocated to 3 equal groups: group A (conventional tracheal intubation without endotracheal anesthesia); B (conventional tracheal intubation with endotracheal anesthesia); and C (tracheal intubation using a modified catheter under study). Blood pressure, heart rate, angiotensin II level, blood glucose level, airway pressure before anesthesia (T1) were measured immediately after intubation (T2), 5 min after intubation (T3), and immediately after extubation (T4). The post-extubation pain experienced was evaluated using the Wong-Baker Face Pain scale. Adverse reactions within 30 min after extubation were recorded.

Results

Systolic blood pressure, diastolic blood pressure, angiotensin II, and blood sugar level in group C at T2, T3 and T4, and heart rate at T2 and T4 were significantly lower than those in group A (P < 0.05); systolic blood pressure and blood sugar at T4, and angiotensin II levels at T2, T3, and T4 were significantly lower than those in group B (P < 0.05). Patients in group C reported the lowest post-extubation pain (P < 0.05 vs. Group A), and the lowest incidence of adverse events such as nausea, vomiting, and sore throat than that in groups A and B (P < 0.05).

Conclusion

The modified endotracheal anesthesia tube under study is effective in reducing cardiovascular and tracheal stress response, and increasing patient comfort, without inducing an increase in airway resistance.

Trial registration

The clinical trial was retrospectively registered at the Chinese Clinical Trial Registry with the Registration Number ChiCTR1900020832 at January 20th 2019.

A comparison between the Disposcope endoscope and fibreoptic bronchoscope for nasotracheal intubation: a randomized controlled trial

Background

Nasotracheal intubation (NTI) is frequently performed for oral and maxillofacial surgeries. This study evaluated whether NTI is easier when guided by Disposcope endoscopy or fibreoptic bronchoscopy.

Methods

Sixty patients (30 per group) requiring NTI were randomly assigned to undergo fibreoptic bronchoscopy-guided (fibreoptic group) or Disposcope endoscope-guided (Disposcope group) NTI. The NTI time, which was defined as the time from when the fibreoptic bronchoscope or aseptic suction catheter was inserted into the nasal cavity to the time at which the tracheal tube was correctly inserted through the glottis, was recorded. Epistaxis was evaluated by direct laryngoscopy five minutes after completing NTI and was scored as one of four grades according to the following modified criteria: no epistaxis, mild epistaxis, moderate epistaxis, and severe epistaxis.

Results

The time to complete NTI was significantly longer in the fibreoptic group than in the Disposcope group (38.4 s vs 24.1 s; mean difference, 14.2 s; 95% confidence interval (CI), 10.4 to 18.1). Mild epistaxis was observed in 8 patients in the fibreoptic group and in 7 patients in the Disposcope group (26.7% vs 23.3%, respectively; relative risk, 1.2; 95% CI, 0.4 to 3.9), though no moderate or severe epistaxis occurred in either group. Furthermore, no obvious nasal pain was reported by any of the patients at any time point after extubation (P = 0.74).

Conclusion

NTI can be completed successfully using either fibreoptic bronchoscopy or Disposcope endoscope as a guide without any severe complications. However, compared to fibreoptic bronchoscopy, Disposcope endoscope requires less execution time (the NTI time).

Trial registration

This clinical research was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPR-17011462, date of registration, May 2017).

Effect of C-MAC Video Laryngoscope-aided intubations Using D-Blade on Incidence and Severity of Postoperative Sore Throat

Background:

Video laryngoscope-aided intubations require less force to align oral, pharyngeal, and laryngeal planes to visualize the glottis opening during intubation.

Aim:

The primary objective of the study was to assess the incidence and severity of postoperative sore throat (POST) in patients who were intubated with C-MAC video laryngoscope using D-blade versus traditional Macintosh laryngoscope.

Settings and Design:

This prospective, randomized, open label study was conducted in a tertiary care institution.

Subjects and Methods:

A total of 130 patients undergoing short elective laparoscopic surgeries lasting <2 h were recruited. All patients received general anesthesia as per a standardized protocol. Laryngoscopy was performed using traditional Macintosh laryngoscope in Group M and with Storz^® C-MAC video laryngoscope using D-Blade in Group V. The endotracheal tube cuff pressure was maintained at 20–22 cm of H2O intraoperatively.

Statistical Analysis Used:

Pearson's Chi-square test, Fisher's exact test, and Independent sample t-test were used in this study.

Results:

As compared to Group M, number of patients who had POST, hoarseness of voice, and cough was significantly low in Group V at 2, 6, 12, and 24 h. Severity, as well as the incidence of all these symptoms, showed a downward trend in both groups with time. Significantly more number of patients in Group M required rescue therapy for POST (44.6% as compared to 7.7%, P < 0.001).

Conclusion:

C-MAC video laryngoscope-aided intubations using D-blade significantly reduced the incidence and severity of POST, hoarseness of voice, and cough following orotracheal intubation as compared to use of traditional Macintosh laryngoscope.