A New Maneuver for Endotracheal Tube Insertion During Difficult Glidescope Intubation

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

OBJECTIVE

The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic.

METHODS

We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization.

RESULTS

We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73-3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58-2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001).

CONCLUSIONS

VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

Effects of tip-manipulated stylet angle on intubation using the GlideScope® videolaryngoscope in children: A prospective randomized controlled trial

BACKGROUND

An optimal endotracheal tube curve can be a key factor in successful intubation using the GlideScope videolaryngoscope.

AIMS

This study aimed to evaluate the effects of tube tip-modified stylet curve on the intubation time in children.

METHODS

Children aged 1-5 years were randomly assigned to either the standard curve (group S, n = 60) or tip-modified curve (group T, n = 60) groups. In group S, the endotracheal tube curve was similar to that in the GlideScope. In group T, a point approximately 1.5 cm from the tube tip was additionally angled to the left by 15°-20°. The primary outcome was the total intubation time, and the secondary outcomes were incidence of successful intubation in the first attempt, number of additional manipulations of the stylet curve, and visual analog scale (VAS) score for the easiness of intubation.

RESULTS

The mean total intubation time was significantly longer in group S than that in group T (13.9 [10.8] vs. 9.0 [3.4] sec, mean difference, 4.9 s; 95% confidence interval [CI], 2.0-7.8; p = .001). All patients in group T were successfully intubated in the first attempt, whereas those in group S were not (100% vs. 93.3%, relative risk [RR], 0.11; 95% CI, 0.01-2.02; p = .1376). Three patients in group S could be intubated after modifying the ETT curve similar to that in group T. Operators reported that tracheal intubation was easier in group T than in group S (median [interquartile range] for VAS; 1 [1-2] vs. 2 [1-3]; p < .001).

CONCLUSIONS

Having additional angle of the endotracheal tube tip to the left could be a useful technique to facilitate directing and advancing endotracheal tube into the vocal cords.

Difficult Intubation in Pediatric Patient with a Large Lymphangioma at the Tongue Base

Lymphangioma is a congenital malformation of lymphatic system and often involves the oral cavity. When lymphangioma is located on the mouth floor and enlarges, it can compress the airway and make intubation difficult. The GlideScope(®) video laryngoscope is sometimes used in routine intubation, but is most commonly used in difficult or failed intubation. We report a pediatric patient with a difficult intubation due to a large tongue base mass. The airway was compromised due to limited intraoral space, large mass at the tongue base, and glottis distortion. Oral approach was not successful with the Macintosh laryngoscope. In this case, a rigid stylet was made to match the GlideScope(®) curve and the endo-tracheal tube was inserted through the glottis under GlideScope(®) guidance. We believe that, even in pediatric patients, a rigid stylet is necessary when intubation at a sharp posterior angulation to the trachea is difficult during GlideScope(®) approach.

Comparison of the Airtraq laryngoscope and the GlideScope for double-lumen tube intubation in patients with predicted normal airways: a prospective randomized trial

BACKGROUND

The Airtraq laryngoscope and the GlideScope are commonly used in many airway scenarios. However, their features have not been fully described for double-lumen tube intubation. A prospective randomized study was designed to compare their intubation performances in thoracic surgery patients.

METHODS

Seventy ASA physical status I and II patients with predicted normal airway were scheduled for thoracic surgeries with double-lumen tube intubation. They were randomly assigned to one of two groups and intubated with either the Airtraq laryngoscope (group A, n = 35) or the GlideScope (group G, n = 35). Airway assessments were performed prior to anesthesia, and all patients were induced with a standard anesthetic regimen. The Cormack-Lehane grades were initially evaluated with a Macintosh laryngoscope and subsequently with the group-specific laryngoscope before intubation. Intubation time was recorded as the primary outcome. The Cormack-Lehane grade, the success of the first intubation attempt, the intubation difficulty scales and ease of tube advancement were noted. Hemodynamic variables during intubation and incidence of post-operative sore throat were documented as well.

RESULTS

The intubation time of group A was shorter than that of group G (36.6 ± 20.2 s vs. 54.6 ± 25.7 s, p = 0.002). The Cormack-Lehane grade (I/II/III/IV) was significantly better in group A (33/2/0/0 vs. 28/7/0/0, p = 0.042). The mean arterial pressure and heart rate rose to higher levels during intubation with the GlideScope than with the Airtraq laryngoscope. The success of the first intubation attempt and the intubation difficulty scales were comparable between the two groups. The numbers of patients who experienced postoperative sore throat were similar (6 vs. 8) in the two groups.

CONCLUSIONS

Compared with the GlideScope, the specially designed Airtraq laryngoscope might be more suitable for double-lumen tube intubations in patients with predicted normal airway.

TRIAL REGISTRATION

www.chictr.org Identifier: ChiCTR-TRC-11001628.

A new twist in the pediatric difficult airway

Difficult intubation of a 2.4 kg ex premature, suspected Pierre Robin Sequence with upper airway obstruction causing respiratory failure. Multiple failed intubation attempts by an experienced pediatric anesthetist using described techniques and adjuncts. A description of a simple new maneuvre using a GlideScope and a stylet. By twisting the stylet into a spiral shape, the endotracheal tube was given improved maneuverability that allowed the intubator to place the endotracheal tube tip to the glottis opening. Then by rotating the tube in a clockwise direction it could be manipulated past the vocal cords into the trachea.

Improvement in GlideScope® Video Laryngoscopy performance over a seven-year period in an academic emergency department

To evaluate the outcomes in first pass success (FPS) of GlideScope (GVL) intubations over a seven-year period in an academic ED. Data were prospectively collected on all patients intubated in an academic ED with a level 1 trauma center over the seven-year period from July 1, 2007 to June 30, 2014. Following each intubation, the operator completed a standardized data collection form that included information on patient, operator and procedure characteristics. The primary outcome was first pass success, defined as successful intubation with a single laryngoscope blade insertion. The secondary outcome was the Cormack-Lehane (CL) view of the airway. To adjust for important confounders, a logistic regression model was used to determine the association between academic year and first pass success. In the first year of the study, the first pass success with the GVL was 75.6% (68/90; 95% CI 65.4-84.0%) and the percentage of patients with CL I/II views was 95.6% (86/90; 95% CI 89.0-98.8%). By the seventh year of the study, the first pass success with the GVL increased to 92.1% (128/139; 95% CI 86.3-96.0%) and the percentage of patients with CL I/II views was 94.2% (131/139; 95% CI 89.0-97.5%). In the logistic regression model, first pass success improved during the seven-year period (aOR 3.1; 95% CI 1.3-7.1; p = 0.008). Over the seven-year period, there was significant improvement in the first pass success of the GVL, without any change in the Cormack-Lehane view, suggesting that there was improvement in the skill of tube delivery with use of the GVL over time.

Comparing the novel GlideScope Groove videolaryngoscope with conventional videolaryngoscopy: a randomized mannequin study of novice providers

STUDY OBJECTIVE

To compare the GlideScope Groove (GG) with conventional GlideScope videolaryngoscopy (GVL) and direct laryngoscopy (DL) on intubation times, intubation attempts, and glottic visualization of an airway mannequin by medical students.

DESIGN

Randomized crossover trial.

SETTING

Intensive care unit of an academic tertiary-care hospital.

PARTICIPANTS

34 medical students with no airway management experience.

MEASUREMENTS

Each participant received standardized video instruction on all three laryngoscopes and was given 10 minutes to practice with each device. The participants had two attempts using DL, and then had two attempts each with either the GG or GVL in random order.

MEASUREMENTS

Time-to-intubate the mannequin in seconds was recorded. Secondary outcomes were Cormack-Lehane grade and number of intubation attempts, also recorded.

MAIN RESULTS

The median number of seconds required to successfully intubate the mannequin with DL, GVL, and GG were 17.4 seconds [interquartile range (IQR) 13.2 - 22.1)], 17.7 seconds (IQR 14.9 - 21.0), and 21.7 seconds (IQR 15.4 - 37.0), respectively. No differences in time-to-intubate was noted among the three devices (P = 0.45). A Cormack-Lehane grade 1 view was obtained for 25 of 34 participants (74%) with DL, 32 of 34 participants (94%) with GVL, and 34 of 34 participants (100%) with GG. First-attempt intubation success was 30 of 34 participants (88%) with DL, 34 of 34 participants (100%) with GVL, and 11 of 34 participants (32%) with GG. Using the GG, 6 of 24 participants (18%) required three attempts. More attempts were required for the GG than for DL (P < 0.001) or GVL (P < 0.001).

CONCLUSIONS

GG was not superior to DL or GVL in time-to-intubate an airway mannequin.

Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial

PURPOSE

Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers.

METHODS

Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures.

RESULTS

Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04).

CONCLUSIONS

Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.